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                                COMMENTARY

       Canadian Society of Nephrology Commentary on the 2009 KDIGO
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  1. 1. CSN COMMENTARY Canadian Society of Nephrology Commentary on the 2009 KDIGO Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of CKD–Mineral and Bone Disorder (CKD-MBD) Braden J. Manns, MD, MSc,1 Anthony Hodsman, MB, FRCPC,2 Deborah L. Zimmerman, MD, MSc,3 David C. Mendelssohn, MD, FRCPC,4 Steven D. Soroka, BMus, MD, MSc, FRCPC, CHE,5,6,7 Chris Chan, MD, FRCPC,8 Kailash Jindal, MD, FRCPC,9 and Scott Klarenbach, MD, MSc, FRCPC9 INTRODUCTION Bone Disorder (CKD-MBD) represents a 2-year Professional societies throughout the world, comprehensive effort to review the relevant evi- including the Canadian Society of Nephrology dence in CKD-MBD.6 The CSN congratulates (CSN), agree there is a need for developing KDIGO on an excellent review of the available clinical practice guidelines for patients with evidence. chronic kidney disease (CKD). However, as illus- Although the CSN welcomes the KDIGO trated by the case of the plethora of anemia evidence synthesis and global clinical practice guidelines for CKD that have been completed guidelines initiative, the CSN1 and other pro- (and updated) by many national professional fessional societies, including Kidney Disease societies since 2000,1-5 creation of guidelines by Outcomes Quality Initiative (KDOQI),7 be- individual professional societies results in signifi- lieve that local factors require consideration cant duplication of effort. In this context, KDIGO when making recommendations to guide care. (Kidney Disease: Improving Global Outcomes) As such, the CSN guidelines committee formed was established in 2003 with its stated mission to a work group to evaluate the KDIGO CKD- “improve the care and outcomes of kidney dis- MBD guidelines and determine the extent to ease patients worldwide through promoting coor- which they were relevant within a Canadian dination, collaboration, and integration of initia- context. This CSN work group believes that tives to develop and implement clinical practice any limitations of these guidelines relate not to guidelines.”6 the effort of the KDIGO work group, but to the The KDIGO Clinical Practice Guideline for lack of information for the significance of the Diagnosis, Evaluation, Prevention, and Treat- mineral metabolism abnormalities in early- ment of Chronic Kidney Disease–Mineral and stage CKD, and more specifically, to the lack of conclusive information about how to guide management throughout CKD stages 3-5. From the 1Foothills Medical Centre, Calgary, Alberta; The KDIGO CKD-MBD guidelines focus 2 Department of Medicine, University of Western Ontario, St. on the management of children and adults with Joseph’s Health Centre, London, Ontario; 3Kidney Re- nondialysis and dialysis CKD and patients search Centre, Ottawa Hospital Research Institute, Univer- with kidney transplants. Given that the focus sity of Ottawa, Ottawa Hospital; 4Humber River Regional Hospital, University of Toronto; 5Dalhousie University; of the CSN is adults with CKD and the Cana- 6 Capital Health Hemodialysis, PreDialysis Program, and dian Society of Transplantation is preparing a Nephrology Clinical Trials; 7Nova Scotia Provincial Dialy- commentary on the transplant-specific CKD- sis Program; 8Home Hemodialysis, Toronto General Hospi- MBD guidelines, this commentary focuses on tal/University Health Network, University of Toronto; and 9 University of Alberta, Edmonton, Alberta, Canada. KDIGO guidelines relevant to adults with non- Address correspondence to Braden J. Manns, MD, MSc, dialysis and dialysis CKD. While preparing Foothills Medical Centre, 1403–29th St NW, Calgary, this commentary, the CSN work group care- Alberta, Canada T2N 2T9. E-mail: braden.manns@ fully considered 2 recent Canadian sets of albertahealthservices.ca © 2010 by the National Kidney Foundation, Inc. guidelines that have addressed mineral metab- 0272-6386/10/5505-0003$36.00/0 olism in CKD. These include: (1) the 2006 doi:10.1053/j.ajkd.2010.02.339 CSN hemodialysis guidelines,8 which had a 800 American Journal of Kidney Diseases, Vol 55, No 5 (May), 2010: pp 800-812
  2. 2. CSN Commentary 801 target audience of Canadian nephrologists and should be made available, by reimbursement, addressed the management of mineral metabo- to Canadian patients. lism in dialysis patients with CKD; and (2) the Having said that, an alternate point of view 2008 CSN guidelines focusing on the overall expressed within the CSN is that as nephrolo- management of patients with nondialysis CKD gists, we are advocates for our patients, and targeting general practitioners.9 Although the failure to champion promising therapeutic in- present commentary focuses on the KDIGO terventions will lead to inadequate access to guidelines, important differences between the novel strategies.13,14 This viewpoint may be KDIGO CKD-MBD recommendations and the influenced by the poor outcomes for dialysis relevant CSN guidelines, as well as the reasons patients and the belief that strict adherence to for these discrepancies, are noted when appli- principles of evidence-based medicine is lim- cable. ited by the paucity of well-performed random- Although this commentary is most relevant ized controlled trials.15 In the opinion of this to Canadian nephrologists and specialists who CSN workforce, the KDIGO guidelines in gen- care for patients with dialysis and nondialysis eral considered these issues and crafted recom- CKD, some of the commentary may be rel- mendations that generally were acceptable, evant for general practitioners who care for avoiding overly prescriptive recommendations patients with CKD. In general, the CSN work when evidence was not definitive. Although group is of the opinion that CKD-MBD care this approach may be criticized, the reality should not be undertaken by general practitio- is that nephrology has the fewest randomized ners; rather, their focus should continue to be trials of any medical subspeciality,15 leading on therapies that have proven efficacy in pa- to a slim evidence base available to guide tients with CKD, including cardiovascular risk therapy. There is a lack of definitive evidence reduction. Across the Canadian health care jurisdic- for potentially promising therapies, and this tions, there is variable but highly restricted has led to variation in perspectives of Cana- access to public funding for expensive medica- dian nephrologists, as well as variation in tions (including non–calcium-based phosphate access to therapies in Canada. The workforce binders and calcimimetics), reflecting their high strongly believes that nephrology as a commu- cost and limited outcome data beyond putative nity needs to focus its academic pursuits on surrogate end points.10 Acknowledging this improving the nephrology evidence base, and reality and to maintain consistency with previ- this should be done in partnership with indus- ous CSN guidelines, the resource implications try and nonindustry funding agencies. of guidelines were considered when preparing this commentary.1 The rationale for this is as REVIEW AND APPROVAL PROCESS FOR CSN follows. Given that the budget for health care GUIDELINES AND COMMENTARIES is finite, directing excessive resources toward expensive marginally effective therapies limits The development and review of this com- the resources available to be used for other mentary were consistent with CSN policies set effective therapies.11,12 In many Canadian ju- out for the conduct of clinical practice guide- risdictions, renal programs are responsible for lines. The CSN guideline committee deter- caring for a defined group of dialysis and mined that this commentary was of priority, selected nondialysis patients with CKD with a and a Chair was selected to guide the commen- finite pool of resources.10 Careful consider- tary process. Individual members were se- ation of both an intervention’s effectiveness lected based on their interest and expertise, (and the magnitude of effect) and cost is needed taking into consideration relevant conflicts of to deploy resources to maximize health out- interest. Commentary development took place comes for our patients. Because physicians during fall 2009 using the original KDIGO often are in a position to compare the benefits CKD-MBD guidelines,6 as well as the primary and risks of specific therapies, they should take documents referenced within this report; addi- an active role in deciding which therapies tional literature searching was left to the discre-
  3. 3. 802 Manns et al Box 1. KDIGO Recommendations Concerning Diagnosis of CKD-MBD: Biochemical Abnormalities 3.1.1. We recommend monitoring serum levels of calcium, phosphorus, PTH, and alkaline phosphatase activity beginning in CKD stage 3 (1C). [see comments] In children, we suggest such monitoring beginning in CKD stage 2 (2D). 3.1.2. In patients with CKD stages 3-5D, it is reasonable to base the frequency of monitoring serum calcium, phosphorus, and PTH on the presence and magnitude of abnormalities and the rate of progression of CKD (not graded). Reasonable monitoring intervals would be: in CKD stage 3: for serum calcium and phosphorus, every 6-12 months; and for PTH, based on baseline level and CKD progression. In CKD stage 4: for serum calcium and phosphorus, every 3-6 months; and for PTH, every 6-12 months. In CKD stage 5, including 5D: for serum calcium and phosphorus, every 1-3 months; and for PTH, every 3-6 months. In CKD stages 4-5D: for alkaline phosphatase activity, every 12 months or more frequently in the presence of increased PTH levels (see Chapter 3.2). In patients with CKD receiving treatments for CKD-MBD or in whom biochemical abnormalities are identified, it is reasonable to increase the frequency of measurements to monitor for trends and treatment efficacy and side effects (not graded). [see comments] 3.1.3. In patients with CKD stages 3-5D, we suggest that 25(OH)D (calcidiol) might be measured, and repeated testing determined by baseline values and therapeutic interventions (2C). We suggest that vitamin D deficiency and insufficiency be corrected using treatment strategies recommended for the general population (2C). [see comments] 3.1.4. In patients with CKD stages 3-5D, we recommend that therapeutic decisions be based on trends rather than on a single laboratory value, taking into account all available CKD-MBD assessments (1C) [CSN work group concurs] 3.1.5. In patients with CKD stages 3-5D, we suggest that individual values of serum calcium and phosphorus evaluated together be used to guide clinical practice, rather than the mathematical construct of calcium-phosphorus product (2D). 3.1.6. In reports of laboratory tests for patients with CKD stages 3-5D, we recommend that clinical laboratories inform clinicians of the actual assay method in use and report any change in methods, sample source (plasma or serum), and handling specifications to facilitate the appropriate interpretation of biochemistry data (1B) [CSN work group concurs] Abbreviations: CKD, chronic kidney disease; CKD-MBD, chronic kidney disease–mineral and bone disorder; CSN, Canadian Society of Nephrology; KDIGO, Kidney Disease: Improving Global Outcomes; PTH, parathyroid hormone. Reproduced with permission of KDIGO from chapter 3.1 of the KDIGO Clinical Practice Guideline for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease–Mineral and Bone Disorder.6 tion of individual members. After repeated REVIEW OF KDIGO RECOMMENDATIONS teleconferences, all authors approved the final Diagnosis of CKD-MBD: text of the commentary. Because this was a commentary rather than a guideline, consensus Biochemical Abnormalities was sought, and when it could not be achieved, Commentary on Chapter 3.1 both perspectives are raised. The final docu- In chapter 3.1, there are 3 level 1 recommenda- ment was sent out for peer review by the CSN tions (Box 1). Our work group believed that one guidelines committee. The reviews were con- recommendation deserved further discussion; sidered and responded to, with incorporation namely, the statement “We recommend monitor- of further revisions before ratification by the ing serum levels of calcium, phosphorus, PTH CSN guidelines committee and CSN execu- [parathyroid hormone], and alkaline phosphatase tive. activity beginning in CKD stage 3 (1C)” and the suggested monitoring intervals of every 6-12 STRUCTURE OF THIS COMMENTARY months in stage 3 CKD. Given that the frequency This commentary does not seek to discuss all of abnormalities in serum calcium and phospho- KDIGO recommendations; rather, it was our rus levels is rare at a glomerular filtration rate intent to focus commentary on recommendations (GFR) 40 mL/min (almost no patients with that are based on better quality evidence (ie, GFR 40 mL/min in a cross-sectional analysis level 1 in the guideline6) or are more controver- of more than 1,800 patients with CKD stages 3-5 sial. The KDIGO recommendations are provided patients had abnormal calcium or phosphorus in boxes, with CSN concurrence indicated. Impli- levels16), it is difficult to present a substantive cations and commentary relevant for Canadian argument in favor of routine measurement of health care are offered in the text when appropri- calcium and phosphorus in patients with stage 3 ate. For some recommendations (typically those CKD. This is particularly true given that the that are opinion based), specific comments are impact of managing abnormalities in mineral not provided in italics. metabolism in patients with stage 3 CKD is
  4. 4. CSN Commentary 803 unknown, and most patients will not go on to practitioners should prompt nephrology require dialysis, but instead will die of other assessment. causes.17 Moreover, when one considers that 2. Vascular risk reduction must remain the 95% of Canadian patients with stages 3-5 focus of all physicians, particularly pri- nondialysis CKD have stage 3 CKD,18 this rec- mary care physicians, in patients with ommendation may inadvertently direct attention stage 3 CKD because cardiovascular risk to a cohort of patients without identifiable labora- reduction strategies have improved clini- tory abnormalities. cal outcomes in patients with stage 3 Of note, one other recommendation (level CKD. In contrast, assessment and manage- 2C) suggested that “25(OH)D (calcidiol) lev- ment of mineral metabolism in this group els might be measured, and repeated testing of patients has not been shown to improve determined by baseline values and therapeutic outcomes and might interfere with the interventions.” It was noted that the cost of primary focus on vascular risk reduction. laboratory tests, particularly measurement of PTH and vitamin D, is significant, and given Diagnosis of CKD-MBD: Bone budget limitations within publicly funded Ca- Commentary on Chapter 3.2 nadian health care, this could direct resources away from other treatments for which better Fractures are more prevalent in patients with evidence of benefit is available. For example, CKD stage 5 contrasted with the nonuremic the cost of a serum 25-hydroxyvitamin D assay population.6 This is particularly true of hip is Can $100 locally. Until the clinical benefit fractures in elderly dialysis patients, particu- of correcting nutritional vitamin D “insuffi- larly those with diabetes. The KDIGO working ciency” has been established within the dialy- group found little evidence that future fracture sis population or for patients with stages 4 and risk might be linked specifically to identifiable 5 CKD, it would seem premature to suggest risk factors or modified by specific therapy. screening with vitamin D assays. For patients The CSN work group agrees that it is not with stage 3 CKD without biochemical evi- possible to generalize the extensive epidemio- dence of MBD, it is reasonable to expect that logic characteristics of fractures (and evidence- the overall benefits of vitamin D supplementa- based therapy) in the general population to tion in the general population (800-2,000 U/d) patients with CKD. would apply, and Osteoporosis Canada does The diverse spectrum of the metabolic bone not recommend screening 25-hydroxyvitamin disease associated with renal osteodystrophy D assays in the general population for individu- ranges from extensive deposits of woven bone als already using routine supplementation.19 in hyperparathyroidism to excessive unminer- alized osteoid associated with osteomalacia; Implications Within Canadian Health Care “adynamic” bone is more normal in structure. 1. Patients with stage 3 CKD usually are Not surprisingly, both bone mass and bone managed by primary care practitioners quality within the skeleton can vary widely rather than nephrologists. Our work group according to the underlying pathobiological believed that routine laboratory monitor- process. For this reason, the KDIGO working ing for calcium, phosphate, PTH, and group emphasized at several points that bone alkaline phosphatase is not warranted in biopsy with histomorphometric evaluation is stage 3 CKD, particularly in patients being the only certain method of classifying the managed exclusively within a general prac- underlying bone disease. tice. An initial evaluation of laboratory Bone mineral density (BMD) measurements markers of mineral metabolism should assume a stable ratio of calcium hydroxyapa- occur as GFR approaches 30 mL/min and tite to organic matrix within bone to assess could occur upon referral to a nephrologist “bone mass.” In the general population, this because referral is recommended at GFR relationship is valid enough that a diagnosis of of 30 mL/min. Abnormalities in mineral osteoporosis can be made using the World metabolism that are detected by general Health Organization T score of 2.5 standard
  5. 5. 804 Manns et al Box 2. KDIGO Recommendations Concerning Diagnosis of CKD-MBD: Bone 3.2.1. In patients with CKD stages 3-5D, it is reasonable to perform a bone biopsy in various settings, including, but not limited to, unexplained fractures, persistent bone pain, unexplained hypercalcemia, unexplained hypophosphatemia, possible aluminum toxicity, and before treatment with bisphosphonates in patients with CKD-MBD (not graded). [see comments] 3.2.2. In patients with CKD stages 3-5D with evidence of CKD-MBD, we suggest that BMD testing not be performed routinely because BMD does not predict fracture risk as it does in the general population and BMD does not predict type of renal osteodystrophy (2B). [see comments] 3.2.3. In patients with CKD stages 3-5D, we suggest that measurements of serum PTH or bone-specific alkaline phosphatase can be used to evaluate bone disease because markedly high or low values predict underlying bone turnover (2B). [see comments] 3.2.4. In patients with CKD stages 3-5D, we suggest not to routinely measure bone-derived turnover markers of collagen synthesis (such as procollagen type I C-terminal propeptide) and breakdown (such as type I collagen cross-linked telopeptide, cross-laps, pyridinoline, or deoxypyridinoline) (2C). [CSN work group concurs] Abbreviations: BMD, bone mineral density; CKD, chronic kidney disease; CKD-MBD, chronic kidney disease–mineral and bone disorder; CSN, Canadian Society of Nephrology; KDIGO, Kidney Disease: Improving Global Outcomes; PTH, parathyroid hormone. Reproduced with permission of KDIGO from chapter 3.2 of the KDIGO Clinical Practice Guideline for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease–Mineral and Bone Disorder.6 deviations less than “peak adult bone mass.”20 might still occur in the minority of patients Moreover, the combination of age, BMD, and using aluminum-based binders, bone histo- specific additional risk factors (particularly logic evaluation may provide little addi- prevalent osteoporotic fractures) allows some tional relevant information that will change prediction of the probability of future fractures management in a way known to improve in the next 10 years, as recommended by clinical outcomes. Osteoporosis Canada.21 However, BMD gener- 2. Except in patients with stage 3 CKD ally is lower in the dialysis population, particu- without biochemical evidence of MBD, larly at cortical measurement sites (distal ra- bone densitometry should not be used dius and hip), and the ability of BMD to routinely in CKD stages 3-5D by Cana- predict fractures or other clinical outcomes in dian nephrologists to form the basis of dialysis patients is weak and inconsistent. diagnostic and therapeutic decisions. Moreover, in patients with nondialysis CKD 3. Although opinion based, it is routine prac- stages 3-5 associated with abnormalities in tice in Canada to measure both intact PTH mineral metabolism and dialysis CKD, BMD and serum total alkaline phosphatase in measurements do not distinguish between his- dialysis patients, and many nephrologists tologic types of underlying renal osteodystro- measure these in nondialysis patients with phy. For these reasons, we agree that BMD CKD as well. It is likely that markedly measurements should not be used as a diagnos- high or low values predict underlying tic tool in CKD stages 3-5 (Box 2). However, it bone turnover. is reasonable to conclude that decreased BMD in patients with stage 3 CKD without biochemi- Diagnosis of CKD-MBD: Vascular Calcification cal evidence of MBD can still be used to Commentary on Chapter 3.3 diagnose underlying osteoporosis. The CSN work group noted that chapter 3.3 referred to patients with stages 3-5 nondialysis Implications Within Canadian Health Care and dialysis CKD (Box 3).6 However, it is impor- 1. In clinical practice, bone biopsy in dialysis tant to emphasize that the level of evidence, patients rarely is performed in Canada. In prevalence, and therapeutic strategies are hetero- part, this is due to the very limited labora- geneous among the various CKD stages, and tory services with the ability to process most evidence exists for dialysis CKD. undecalcified bone specimens. With the With respect to the first recommendation, it exception of severe osteomalacia associ- is true that a lateral abdominal radiograph and ated with aluminum intoxication, which 2-dimensional echocardiogram may be used to
  6. 6. CSN Commentary 805 Box 3. KDIGO Recommendations Concerning Diagnosis of CKD-MBD: Vascular Calcification 3.3.1. In patients with CKD stages 3-5D, we suggest that a lateral abdominal radiograph can be used to detect the presence or absence of vascular calcification, and an echocardiogram can be used to detect the presence or absence of valvular calcification as reasonable alternatives to computed tomography– based imaging (2C). [see comments] 3.3.2. We suggest that patients with CKD stages 3-5D with known vascular/valvular calcification be considered at highest cardiovascular risk (2A). [see comments] Abbreviations: CKD, chronic kidney disease; CKD-MBD, chronic kidney disease–mineral and bone disorder; KDIGO, Kidney Disease: Improving Global Outcomes. Reproduced with permission of KDIGO from chapter 3.3 of the KDIGO Clinical Practice Guideline for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease–Mineral and Bone Disorder.6 detect vascular and valvular calcification. How- peutic strategies are available. At present, ever, it is important to note that population there is a lack of conclusive evidence in screening is not recommended by KDIGO or support of any therapeutic strategy that existing CSN guidelines because there are many may regress vascular calcification or im- unanswered questions regarding the utility of prove clinical outcomes in CKD. screening and lack of therapies conclusively b) With respect to intentional case finding in shown to improve clinical outcomes in pa- patients believed to be at high risk of tients with vascular calcification or even treat vascular calcification, this also is not and/or prevent vascular and valvular calcifica- recommended given that predicting vas- tion. cular calcification accurately is not pos- With regard to the second recommendation, sible based on clinical characteristics. we note that all patients with CKD have in- c) It is likely that vascular calcification will creased cardiovascular risk. We agree that pa- be detected incidentally in many patients tients with vascular/valvular calcification carry who are evaluated with x-rays or echocar- an added adverse cardiovascular risk, although diography during routine care. Although there is a large range of risk profile in patients the work group agrees that the presence of with nondialysis and dialysis stages 3-5 CKD. vascular calcification identifies patients who are at higher risk of mortality, the Implications Within Canadian Health Care work group was unable to find consensus 1. The issue of vascular calcification, particu- on whether management should be altered larly given how common it is (as many as in these patients given the lack of un- 70% of patients with CKD stage 5D have equivocal evidence of benefit for any vascular calcification6), is important. Al- management strategy (see commentary on though it is associated with higher cardiovas- chapter 4.1). cular risk, all patients with CKD are at high Treatment of CKD-MBD Targeted at Lowering cardiovascular risk and aggressive risk reduc- High Serum Phosphorus and Maintaining tion should be undertaken. However, there Serum Calcium presently is a lack of information to direct management in such patients (see commen- Commentary on Chapter 4.1 tary on chapter 4.1). Most recommendations in Chapter 4.1 are 2. With respect to screening for vascular calcifi- opinion based (Box 4). With respect to the recom- cation, our work group believed there were 3 mendation regarding dialysate calcium concentra- issues: (a) screening, (b) “intentional case tion, the work group believed there may be finding” in groups believed to be at high risk selected situations in which a lower or higher of vascular calcification, and (c) incidental dialysate calcium concentration may be consid- detection of vascular calcification: ered after careful assessment of risks and ben- a) We agree that screening for vascular calci- efits. For example, a low (1.0 mmol/L) bath fication is not recommended. This is espe- may be considered in selected patients with hy- cially true given that effective screening percalcemia, although the risks associated with implies that appropriate and effective thera- hypercalcemia need to be balanced against the
  7. 7. 806 Manns et al Box 4. KDIGO Recommendations Concerning Treatment of CKD-MBD Targeted at Lowering High Serum Phosphorus and Maintaining Serum Calcium 4.1.1 In patients with CKD stages 3-5, we suggest maintaining serum phosphorus levels in the reference range (2C). In patients with CKD stage 5D, we suggest decreasing increased phosphorus levels toward the reference range (2C). [see comments] 4.1.2 In patients with CKD stages 3-5D, we suggest maintaining serum calcium levels in the reference range (2D). [see comments] 4.1.3 In patients with CKD stage 5D, we suggest using a dialysate calcium concentration between 1.25 and 1.50 mmol/L (2.5 and 3.0 mEq/L) (2D). [see comments] 4.1.4 In patients with CKD stages 3-5 (2D) and 5D (2B), we suggest using phosphate-binding agents in the treatment of hyperphosphatemia. It is reasonable that the choice of phosphate binder takes into account CKD stage, presence of other components of CKD-MBD, concomitant therapies, and side-effect profile (not graded). [see comments] 4.1.5 In patients with CKD stages 3-5D and hyperphosphatemia, we recommend restricting the dose of calcium-based phosphate binders and/or the dose of calcitriol or vitamin D analogue in the presence of persistent or recurrent hypercalcemia (1B). In patients with CKD stages 3-5D and hyperphosphatemia, we suggest restricting the dose of calcium-based phosphate binders in the presence of arterial calcification (2C) and/or adynamic bone disease (2C) and/or if serum PTH levels are persistently low (2C). [see comments] 4.1.6 In patients with CKD stages 3-5D, we recommend avoiding the long-term use of aluminum-containing phosphate binders and, in patients with CKD stage 5D, avoiding dialysate aluminum contamination to prevent aluminum intoxication (1C). [CSN work group concurs] 4.1.7 In patients with CKD stages 3-5D, we suggest limiting dietary phosphate intake in the treatment of hyperphos- phatemia alone or in combination with other treatments (2D). [CSN work group concurs] 4.1.8 In patients with CKD stage 5D, we suggest increasing dialytic phosphate removal in the treatment of persistent hyperphosphatemia (2C). [see comments] Abbreviations: CKD, chronic kidney disease; CKD-MBD, chronic kidney disease–mineral and bone disorder; CSN, Canadian Society of Nephrology; KDIGO, Kidney Disease: Improving Global Outcomes; PTH, parathyroid hormone. Reproduced with permission of KDIGO from chapter 4.1 of the KDIGO Clinical Practice Guideline for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease–Mineral and Bone Disorder.6 potential risks of intradialytic hypotension and the best strategy to achieve such a recommen- propensity toward arrhythmia.22 Also, higher dation (discussed next). calcium concentration could be considered in There is a clear epidemiologic association nocturnal dialysis patients, who are more likely and biological plausibility among hyperphos- to have a net negative calcium balance,23 or after phatemia, net calcium intake, and important parathyroidectomy, when “hungry” bones can negative health consequences for patients with cause refractory hypocalcemia. It should be noted CKD that was shown first in a study of pediat- that the impact of these strategies on clinical ric dialysis patients.24 However, there is a lack outcomes and the safety of low calcium baths of randomized trial evidence to suggest that ( 1.25 mmol/L) are uncertain (as for all strate- maintaining serum calcium and phosphorus gies discussed next), although selecting a differ- levels within the reference range is associated ent calcium dialysate typically will have no im- with improvements in clinically important out- pact on costs. comes.25 Additionally, randomized controlled One level 1 recommendation (to restrict the trials and meta-analyses performed to date do dose of calcium-based phosphate binders and/or not conclusively support the use of one type of dose of calcitriol or vitamin D analogue in the phosphate binder in preference to another for presence of persistent hypercalcemia) stimu- important patient outcomes.25-28 lated much discussion (Box 4). Although level Specifically, controversy exists about the 1, this recommendation is based on more com- efficacy of non–calcium-based phosphate bind- mon sense and observational data than random- ers (ie, sevelamer and lanthanum) on relevant ized trials. The CSN work group acknowl- clinical outcomes (cardiovascular events, mor- edged that based on the available evidence, tality, and hospitalization). The largest clinical limiting calcium intake in the scenarios de- trial to date, the Dialysis Clinical Outcomes scribed is likely to be more beneficial than Revisited (DCOR) study, enrolled 2,103 preva- harmful, although there was no consensus about lent dialysis patients, allocating patients to
  8. 8. CSN Commentary 807 sevelamer or calcium therapy.25 Although fol- The recommendation by KDIGO to limit the use low-up lasted for 20 months on average, this of calcium-based binders in the scenarios outlined study had significant method limitations, in- (and presumably use non–calcium-based binders) cluding a differential loss to follow-up of ap- generated significant discussion, and our work group proximately 50% in both groups and lack of could not reach consensus. Given the lack of con- patient blinding. The primary analysis showed clusive evidence of benefit, the lack of randomized no difference in patient survival between study trials that have assessed morbidity and mortality in groups (hazard ratio, 0.93 [95% confidence patients with vascular calcification, and the ex- interval, 0.79-1.10]), although secondary anal- pense of sevelamer and lanthanum, several mem- yses suggested a decrease in mortality in pa- bers believed that use of these agents was not tients older than 65 years.25 Reanalysis of this justified until further evidence of clinical benefit data set using Medicare claims data (thus ensur- could be established in valid randomized trials. ing complete follow-up for the primary out- Moreover, these members believed that such a come) showed no difference in mortality over- recommendation would make it less likely that the all or in any patient subgroup.29 One small randomized trials needed to investigate the efficacy randomized study of incident dialysis patients of these agents would be performed. Given the suggested improved survival, although this was recent drawn-out experience with hemoglobin nor- noted in only adjusted analyses and after ex- malization in patients with end-stage renal dis- tended follow-up after active treatment and the ease,32 largely supported by similar lines of obser- planned study period had ended.30 Three meta- vational evidence, this situation is far from optimal. analyses have compared the impact of non– Alternatively, other members believed that the calcium-based phosphate binders and calcium- use of non–calcium-based binders in the situations recommended or suggested by KDIGO was justi- based phosphate binders on mortality. One fied on theoretical grounds, the existing random- found no difference in survival,26 whereas 2 ized controlled trials were underpowered to show found a non–statistically significant 30% de- statistically significant benefit, recent meta-analy- crease in mortality.27,28 Given the methodologi- ses suggest clinical benefit, and calcium-based phos- cal limitations and therefore concern for study phate binders are likely to cause positive calcium validity for the largest trials contributing weight balance in late stages of CKD and have never been to these meta-analyses (including significant proven to be safe. loss to follow-up; ie, 50% in the largest sevelamer and lanthanum trials,25,31 and lack Implications Within Canadian Health Care of patient blinding), the impact of non–calcium- 1. Although recommendations regarding the based binders on clinically relevant outcomes use of dialysate calcium concentrations of is uncertain. 1.25-1.5 mmol/L are reasonable, there may Given how common vascular calcification is be scenarios in which higher or lower cal- in dialysis patients, many cases are likely to be cium concentrations may be considered. detected incidentally. In patients with arterial 2. The work group recommendations are simi- calcification and hyperphosphatemia, KDIGO lar to the recent Canadian guidelines noted recommends restricting the dose of calcium- previously,8,9 with the exception that non– based phosphate binders. Presumably, implemen- calcium-containing phosphate binders were tation of this recommendation may require the not recommended within the CSN guide- use of more frequent dialysis or of much longer lines for nondialysis patients because of a duration or the use of non–calcium-based phos- lack of morbidity and mortality data. phate binders, which are more than 20-fold more 3. Variation in access and practice currently expensive than calcium carbonate. If the cost of exists in Canada with respect to the poten- non–calcium-based phosphate binders was simi- tial strategies mentioned, including noctur- lar to that of calcium-based binders, our work nal or extended-hours hemodialysis and group believed that use of such binders would be use of non–calcium-based binders. Within much less controversial. However, this is not the Canada, other mechanisms to decrease case. serum phosphate levels and the amount of
  9. 9. 808 Manns et al Box 5. KDIGO Recommendations Concerning Treatment of Abnormal PTH Levels in CKD-MBD 4.2.1. In patients with CKD stages 3-5 not on dialysis therapy, the optimal PTH level is not known. However, we suggest that patients with iPTH levels higher than the upper reference limit of the assay are first evaluated for hyperphosphatemia, hypocalcemia, and vitamin D deficiency (2C). It is reasonable to correct these abnormalities with any or all of the following: decreasing dietary phosphate intake and administering phosphate binders, calcium supplements, and/or native vitamin D (not graded). [see comments] 4.2.2. In patients with CKD stages 3-5 not on dialysis therapy in whom serum PTH levels are progressively increasing and persistently remain higher than the upper reference limit for the assay despite correction of modifiable factors, we suggest treatment with calcitriol or vitamin D analogues (2C). [see comments] 4.2.3. In patients with CKD stage 5D, we suggest maintaining iPTH levels in the range of approximately 2-9 times the upper reference limit for the assay (2C). We suggest that marked changes in PTH levels in either direction within this range prompt an initiation or change in therapy to avoid progression to levels outside of this range (2C). [see comments] 4.2.4. In patients with CKD stage 5D and increased or increasing PTH levels, we suggest calcitriol, vitamin D analogues, calcimimetics, or a combination of calcimimetics and calcitriol or vitamin D analogues be used to decrease PTH levels (2B). [see comments] It is reasonable that the initial drug selection for the treatment of increased PTH levels be based on serum calcium and phosphorus levels and other aspects of CKD-MBD (not graded). It is reasonable that calcium-based or non– calcium-based phosphate-binder dosage be adjusted so that treatments to control PTH levels do not compromise levels of phosphorus and calcium (not graded). We recommend that in patients with hypercalcemia, calcitriol or another vitamin D sterol be reduced or stopped (1B). [CSN work group concurs] We suggest that in patients with hyperphosphatemia, calcitriol or another vitamin D sterol be reduced or stopped (2D). [CSN work group concurs] We suggest that in patients with hypocalcemia, calcimimetics be reduced or stopped depending on severity, concomitant medications, and clinical signs and symptoms (2D). We suggest that if iPTH levels decrease to less than 2 times the upper reference limit for the assay, calcitriol, vitamin D analogues, and/or calcimimetics be reduced or stopped (2C). [CSN work group concurs] 4.2.5. In patients with CKD stages 3-5D with severe hyperparathyroidism that fail to respond to medical/pharmacologic therapy, we suggest parathyroidectomy (2B). [see comments] Abbreviations: CKD, chronic kidney disease; CKD-MBD, chronic kidney disease–mineral and bone disorder; CSN, Canadian Society of Nephrology; iPTH, intact parathyroid hormone; KDIGO, Kidney Disease: Improving Global Outcomes; PTH, parathyroid hormone. Reproduced with permission of KDIGO from chapter 4.2 of the KDIGO Clinical Practice Guideline for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease–Mineral and Bone Disorder.6 calcium-containing phosphate binders in scriptive and do not provide specific targets for hypercalcemic patients with CKD stage therapy other than to suggest an intact PTH level of 5D may need to be explored until better 2-9 times the reference range. The KDIGO guide- quality evidence in support of more expen- lines are similar to the CSN guidelines,8 emphasiz- sive options is available. This might in- ing the importance of increased phosphate and clude intensive dietary intervention includ- calcium levels rather than PTH levels. ing avoidance of processed foods, lower Although some clinicians may believe that the dialysate calcium, longer dialysis duration present KDIGO guidelines are not helpful in pa- (nocturnal, in center, or at home), use of tient management, the following points should be magnesium-based phosphate binders, and emphasized: (1) the level or range of intact PTH parathyroidectomy. levels that are associated with or determine bone health or cardiovascular health are unknown; (2) Treatment of Abnormal PTH Levels in CKD–MBD increased PTH levels have been associated with Commentary on Chapter 4.2 cardiovascular events, but the association is not as Within this section, there is only one relatively strong as for hyperphosphatemia and there are no strong recommendation, that “vitamin D sterols or randomized trials that have shown decreasing PTH calcitriol be reduced or stopped in patients with levels to be associated with better clinical out- hypercalcemia,” with the rest of the recommenda- comes; (3) low PTH levels seem to be as common, tions being based on weak evidence (Box 5). In if not more common, than increased levels, and contrast to previous KDOQI guidelines on mineral options for reversing this or the implications of metabolism,33 these guidelines are much less pre- such a reversal are not well worked out; and (4)
  10. 10. CSN Commentary 809 previous studies of vitamin D, vitamin sterols, and dilemma because fractures are common and there calcimimetics in patients with CKD have either is no evidence to date that any therapy decreases been of poor quality and/or have used biomarkers the risk of fracture in dialysis patients. With as the study outcomes, rather than clinical end respect to nondialysis CKD, the CSN work group points. noted that post hoc analyses of the pivotal clini- cal trials evaluating antiresorptive therapies al- Implications Within Canadian Health Care low some recommendations concerning these 1. The KDIGO intact PTH targets are simi- agents in managing osteoporosis in patients with lar to those recommended by the CSN impaired kidney function. In patients with CKD (10.6-53 pmol/L)8 and seem reasonable stages 1-2, there is good evidence that the effi- pending further evidence. Treatment cacy of bisphosphonates and raloxifene is not when iPTH level increases to 53 impaired. The same can be said of these agents in pmol/L with symptoms of hyperparathy- patients with CKD stage 3, provided that these roidism should be considered. individuals have no underlying biochemical evi- 2. The CSN work group believes that parathy- dence of CKD-MBD. These recommendations roidectomy remains a reasonable alternative follow from the post hoc analyses of pivotal for patients with severe hyperparathyroid- phase 3 randomized clinical trials of these agents, ism that fails to respond to other therapy, in which patients were enrolled with various although the work group believes that the degrees of kidney disease (though all partici- indication for parathyroidectomy should be pants were required to have normal biochemical based on symptoms or signs associated with parameters of vitamin D and parathyroid func- an increased PTH level, such as resistant tion). Thus, the CSN work group agrees that anemia, intractable pruritis, or other manifes- management of future fracture risk reduction tations, rather than PTH level alone. This should be no different in these patients than for decision needs to integrate information about the general population (Box 6). the individual patient’s perioperative risk In patients with advanced stage 3 CKD with because studies suggest a mean 30-day mor- evidence of biochemical abnormalities in min- tality risk after parathyroidectomy of 3.1%, eral metabolism, as for patients with stages 4 which can be substantially greater in some and 5 CKD, the work group could find little patient subgroups (eg, those with diabe- evidence on which to base therapeutic recom- tes).34 mendations (Box 6). There are no data to 3. In current clinical practice, calcitriol, vita- support either the safety or the efficacy of min D analogues, calcimimetics, or a combi- bisphosphonates, estrogens, or selective estro- nation of calcimimetics and calcitriol or gen receptor modulators to prevent fractures in vitamin D analogues are used to medically this population. decrease PTH levels. However, there is Implications Within Canadian Health Care variable but highly restricted access to pub- lic funding for calcimimetics across Canada 1. In patients with stages 1 and 2 CKD, to- as a result of their high cost and limited gether with those with stage 3 CKD without outcome data beyond PTH lowering. As evidence of abnormalities of mineral metab- such, the options available to most Canadian olism, it is reasonable to assess and treat patients with end-stage renal disease include patients for their risk of osteoporosis accord- dietary modification, phosphate binders, and ing to the current guidelines established for vitamin D analogues alone. the general population by Osteoporosis Can- ada (www.osteoporosis.ca). Management would include assessment of future fragility Treatment of Bone With Bisphosphonates, Other fracture risk based on age, sex, prior osteopo- Osteoporosis Medications, and Growth Hormone rotic fracture, BMD and other significant Commentary on Chapter 4.3 risk factors, including glucocorticoid use. Dialysis patients who present with intercur- Management would include routine supple- rent fractures present a particular therapeutic mentation with vitamin D (1,000-2,000 U/d)
  11. 11. 810 Manns et al Box 6. KDIGO Recommendations Concerning Treatment of Bone With Bisphosphonates, Other Osteoporosis Medications, and Growth Hormone 4.3.1 In patients with CKD stages 1-2 with osteoporosis and/or high risk of fracture, as identified by World Health Organization criteria, we recommend management as for the general population (1A). [CSN work group concurs] 4.3.2 In patients with CKD stage 3 with PTH levels in the reference range and osteoporosis and/or high risk of fracture, identified using World Health Organization criteria, we suggest treatment as for the general population (2B). [see comments] 4.3.3 In patients with CKD stage 3 with biochemical abnormalities of CKD-MBD and low BMD and/or fragility fractures, we suggest that treatment choices take into account the magnitude and reversibility of the biochemical abnormalities and progression of CKD, with consideration of a bone biopsy (2D). 4.3.4 In patients with CKD stages 4-5D with biochemical abnormalities of CKD-MBD and low BMD and/or fragility fractures, we suggest additional investigation with bone biopsy before therapy with antiresorptive agents (2C). [see comments] Abbreviations: BMD, bone mineral density; CKD, chronic kidney disease; CKD-MBD, chronic kidney disease–mineral and bone disorder; CSN, Canadian Society of Nephrology; KDIGO, Kidney Disease: Improving Global Outcomes; PTH, parathyroid hormone. Reproduced with permission of KDIGO from chapter 4.3 of the KDIGO Clinical Practice Guideline for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease–Mineral and Bone Disorder.6 and calcium (1,000-15,00 mg/d total elemen- tional trials because the number of clinical tal calcium intake) and specific pharmaco- trials is limited and existing clinical trials therapy, including bisphosphonates when often are underpowered or use nonclinical out- appropriate. comes. 2. For patients with stage 3 CKD who have Future changes in care should be driven by abnormalities in mineral metabolism adequately powered randomized trials with and those with more advanced CKD clinical end points. The challenge is to create stages, there is no evidence to support an environment that promotes advances in CKD the safety or therapeutic efficacy of the care, stimulates randomized trials, increases therapies currently used to reduce the evidence-based nephrology practice, and en- risk of fractures in the general popula- courages industry and public research funders tion. Although nutritional vitamin D to support this. Moreover, it important to sat- insufficiency/deficiency is common in isfy provincial health ministries that nephrolo- the dialysis population, the clinical harm gists are reasonable in terms of balancing resulting from this has not been defined, access to promising new treatments while ac- and there is no evidence for benefits knowledging that resources directed to thera- resulting from supplementation to “suffi- pies with an incomplete evidence-base might cient” levels of serum 25-hydroxyvita- direct resources away from other effective min D ( 75 nmol/L). It is not reason- therapies. Perhaps a more general discussion able to generalize the clear benefits of of how to accomplish these goals for our bisphosphonates to reduce fracture risk data-impoverished discipline should take prior- in the nonuremic population to the dialy- ity over the production of specific guidelines sis population. for the time being. Specifically, the nephrology community must be a willing partner in con- CONCLUSION ducting randomized trials and create a culture that stimulates and values the production and In many ways, nephrologists should be cha- implementation of such research. grined by the situation we find ourselves in when attempting to care for dialysis patients in ACKNOWLEDGEMENTS general and in particular with respect to min- eral metabolism. It is clear that abnormalities Support: No financial support was required for the devel- opment of this commentary. in mineral metabolism are associated with ad- Financial Disclosure: In the interest of transparency and verse clinical outcomes. However, our manage- full disclosure, the Appendix includes conflict-of-interest ment is driven largely by results of observa- information for all members of the work group.
  12. 12. CSN Commentary 811 REFERENCES 18. Hemmelgarn B, Manns B, Lloyd A, et al. Relation between kidney function, proteinuria, and adverse out- 1. Manns BJ, White CT, Madore F, et al. Introduction to comes. JAMA. 2010;303:423-429. the Canadian Society of Nephrology clinical practice guide- 19. Brown JP, Josse RG. 2002 Clinical Practice Guide- lines for the management of anemia associated with chronic lines for the Diagnosis and Management of Osteoporosis in kidney disease. Kidney Int Suppl. 2008;110:S1-3. Canada. CMAJ. 2002;167(10 suppl):S1-34. 2. National Kidney Foundation. IV. K/DOQI Clinical Prac- 20. Kanis JA; WHO Study Group. Assessment of fracture tice Guidelines for Anemia of Chronic Kidney Disease: update risk and its application to screening for postmenopausal 2000. Am J Kidney Dis. 2001;37(1 suppl 1):S182-238. osteoporosis: synopsis of a WHO report. Osteoporosis Int. 3. National Kidney Foundation. KDOQI Clinical Prac- 1994;4:368-381. tice Guidelines and Clinical Practice Recommendations for 21. Siminoski KG, Leslie WD, Frame H. Recommenda- Anemia in Chronic Kidney Disease. Am J Kidney Dis. tions for bone mineral density reporting in Canada. Can 2006;47(suppl 3):S1-146. Assoc Radiol J. 2007;56:178-188. 4. McMahon L. The CARI guidelines. Biochemical and 22. Toussaint N, Cooney P, Kerr PG. Review of dialysate haematological targets. Haemoglobin. Nephrology (Carl- calcium concentration in hemodialysis. Hemodial Int. 2006;10(4): ton). 2008;13(suppl 2):S44-56. 326-337. 5. Locatelli F, Aljama P, Barany P, et al. Revised Euro- 23. Al-Hejaili F, Kortas C, Leitch R, et al. Nocturnal but not pean Best Practice Guidelines for the management of anae- short hours quotidian hemodialysis requires an elevated dialysate mia in patients with chronic renal failure. Nephrol Dial calcium concentration. J Am Soc Nephrol. 2003;14(9):2322-2328. Transplant. 2004;19(suppl 2):ii1-47. 24. Goodman WG, Goldin J, Kuizon BD, et al. Coronary- 6. Kidney Disease: Improving Global Outcomes (KDIGO) artery calcification in young adults with end-stage renal disease CKD-MBD Work Group. KDIGO Clinical Practice Guide- who are undergoing dialysis. N Engl J Med. 2000;342(20):1478- line for the Diagnosis, Evaluation, Prevention, and Treat- 1483. ment of Chronic Kidney Disease-Mineral and Bone Disor- 25. Suki WN, Zabaneh R, Cangiano JL, et al. Effects of der (CKD-MBD). Kidney Int Suppl. 2009;113:S1-130. sevelamer and calcium-based phosphate binders on mortality in 7. Rocco MV, Berns JS. KDOQI in the era of global hemodialysis patients. Kidney Int. 2007;72(9):1130-1137. guidelines. Am J Kidney Dis. 2009;54(5):781-787. 26. Tonelli M, Wiebe N, Culleton B, et al. Systematic review 8. Jindal K, Chan CT, Deziel C, et al. Hemodialysis of the clinical efficacy and safety of sevelamer in dialysis patients. clinical practice guidelines for the Canadian Society of Nephrol Dial Transplant. 2007;22(10):2856-2866. Nephrology. J Am Soc Nephrol. 2006;17(3 suppl 1):S1-27. 27. Jamal SA, Fitchett D, Lok CE, Mendelssohn DC, 9. Levin A, Hemmelgarn B, Culleton B, et al. Guidelines Tsuyuki RT. The effects of calcium-based versus non- for the management of chronic kidney disease. CMAJ. calcium-based phosphate binders on mortality among pa- 2008;179(11):1154-1162. tients with chronic kidney disease: a meta-analysis. Nephrol 10. Manns BJ, Mendelssohn DC, Taub KJ. The econom- Dial Transplant. 2009;24(10):3168-3174. 28. Navaneethan SD, Palmer SC, Craig JC, Elder GJ, ics of end-stage renal disease care in Canada: incentives and Strippoli GF. Benefits and harms of phosphate binders in impact on delivery of care. Int J Health Care Finance Econ. CKD: a systematic review of randomized controlled trials. 2007;7(2-3):149-169. Am J Kidney Dis. 2009;54(4):619-637. 11. Klarenbach SW. Economic evaluation in renal dis- 29. St. Peter WL, Liu J, Weinhandl E, Fan Q. A compari- ease. J Nephrol. 2007;20(3):251-259. son of sevelamer and calcium-based phosphate binders on 12. Klarenbach S, Manns B. Economic evaluation of mortality, hospitalization, and morbidity in hemodialysis: a dialysis therapies. Semin Nephrol. 2009;29(5):524-532. secondary analysis of the Dialysis Clinical Outcomes Revis- 13. Mendelssohn DC. The evolution of nephrology guide- ited (DCOR) randomized trial using claims data. Am J lines: calling for a mid-course adjustment. Nephrol News Kidney Dis. 2008;51(3):445-454. Issues. 2009;23(9):41-44. 30. Block GA, Spiegel DM, Ehrlich J, et al. Effects of sevel- 14. Phillips N, Barrett B, Mendelssohn DC. The role of amer and calcium on coronary artery calcification in patients new physicians in political advocacy. Results of a Canadian to hemodialysis. Kidney Int. 2005;68(4):1815-1824. Society of Nephrology survey. Nephrol News Issues. 2008; 31. Finn WF. Lanthanum carbonate versus standard 22(13):6-7, 32-33. therapy for the treatment of hyperphosphatemia: safety and 15. Strippoli GF, Craig JC, Schena FP. The number, efficacy in chronic maintenance hemodialysis patients. Clin quality, and coverage of randomized controlled trials in Nephrol. 2006;65(3):191-202. nephrology. J Am Soc Nephrol. 2004;15(2):411-419. 32. Pfeffer MA, Burdmann EA, Chen CY, et al, for the 16. Levin A, Bakris GL, Molitch M, et al. Prevalence TREAT Investigators. A trial of darbepoetin alfa in type 2 of abnormal serum vitamin D, PTH, calcium, and phospho- diabetes and chronic kidney disease. N Engl J Med. 2009; rus in patients with chronic kidney disease: results of the 361(21):2019-2032. study to evaluate early kidney disease. Kidney Int. 2007; 33. National Kidney Foundation. K/DOQI Clinical Practice 71(1):31-38. Guidelines for Bone Metabolism and Disease in Chronic Kidney 17. Hemmelgarn BR, Manns BJ, Zhang J, et al. Associa- Disease. Am J Kidney Dis. 2003;42(4 suppl 3):S1-201. tion between multidisciplinary care and survival for elderly 34. Kestenbaum B, Andress DL, Schwartz SM, et al. patients with chronic kidney disease. J Am Soc Nephrol. Survival following parathyroidectomy among United States 2007;18(3):993-999. dialysis patients. Kidney Int. 2004;66(5):2010-2016.
  13. 13. 812 Manns et al APPENDIX Conflict of Interest Information for Work Group Members Type of Potential Conflict of CSN Member Interest Role Period Sponsora Chan None Hodsman Advisory Board Advisory Board 2006-2009 Shire Jindal Speaker Speaker 2006-2009 Novartis, Boehringer-Ingelheim Canada, Pfizer Industry clinical trial Site Investigator 2006-2009 Amgen Klarenbach Consultant Consultant 2006-2009 Canadian Agency for Drugs and Technology in Health Unrestricted research grant; Coinvestigator (Alberta Kidney 2006-2008 Amgen investigator initiated Disease Network) Manns Unrestricted research grant; Coinvestigator (Alberta Kidney 2006-2008 Amgen investigator initiated Disease Network) Mendelssohn Speaker Speaker 2006-2009 Amgen, Ortho Biotech, Genzyme, Shire, Roche, Baxter, Bayer Advisory Board Advisory Board 2006-2009 Amgen, Ortho Biotech, Genzyme, Shire, Roche, Baxter, Astra Zeneca Research grant, multicenter Principal Investigator 2006-2009 Ortho Biotech studies Research grant Site Investigator 2006-2009 Amgen Soroka Speaker Speaker 2006-2009 Amgen Canada, Genzyme, Shire Zimmerman Advisory Board/Speaker Speaker, Advisory Board 2006-2009 Amgen Speaker Speaker 2006-2009 Ortho Biotech, Aventis Note: Information provided concerns the past 3 years. Abbreviation: CSN, Canadian Society of Nephrology. a List restricted to companies that make products for the management of mineral metabolism and companies that make dialysis technology.

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