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CKD Mineral Bone Disorder (CKD-MBD) - Dr. Gawad
The document discusses chronic kidney disease mineral bone disorder (CKD-MBD), focusing on the regulation of calcium, phosphorus, parathyroid hormone (PTH), and vitamin D. It outlines pathophysiology, lab abnormalities, and the classification and management of related bone diseases, including renal osteodystrophy. Additionally, it addresses treatment options such as phosphate binders, vitamin D analogues, and cinacalcet, emphasizing the importance of monitoring biochemical targets over time.
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CKD Mineral Bone Disorder (CKD-MBD) - Dr. Gawad
- 1. CKD Mineral BoneDisorder (CKD-MBD) Mohammed Abdel Gawad Nephrology Consultant - Alexandria - Egypt MD Nephrology - Mansoura University NephroTube Founder/Admin drgawad@gmail.com NephroTube Webinar September 2020
- 2. To download thelecture with full animations contact me drgawad@gmail.com For more Nephrology lectures visit www.NephroTube.com
- 4. Mineral & BoneDisorder (MBD) General Definition PTH – Vit D – Ca – Pi Axis Mineral and bone disorder (MBD)
- 5. Mineral & BoneDisorder (MBD) General Definition PTH – Vit D – Ca – Pi Axis Mineral and bone disorder (MBD)
- 6. Mineral & BoneDisorder (MBD) Lab Abnormalities Back to Basics (1) : PTH – Vit D – Ca – Pi Axis Increase serum Ca Increase serum Pi Increase Ca reabsorption PTH Increase Pi excretion Decrease serum Pi M.Gawad. www.nephrotube.blogspot.com
- 7. Mineral & BoneDisorder (MBD) Lab Abnormalities Back to Basics (1) : PTH – Vit D – Ca – Pi Axis Increase serum Ca Increase serum Pi Increase Ca reabsorption PTH Increase Pi excretion Decrease serum Pi M.Gawad. www.nephrotube.blogspot.com So low serum Ca & high serum Pi will stimulate PTH release & vise verca PTH Action: increase serum Ca and decrease serum Pi
- 8. Mineral & BoneDisorder (MBD) Lab Abnormalities Back to Basics (1) : PTH – Vit D – Ca – Pi Axis Increase serum Ca Increase serum Pi Increase Ca reabsorption PTH Increase Pi excretion Vit D Calcidiol 25-OH-D Calcitriol 1,25-(OH)2-D α1 hydroxylase Increase Ca & Pi reabsorption Decrease serum Pi M.Gawad. www.nephrotube.blogspot.com
- 9. Mineral & BoneDisorder (MBD) Lab Abnormalities Back to Basics (1) : PTH – Vit D – Ca – Pi Axis Increase serum Ca Increase serum Pi Increase Ca reabsorption PTH Increase Pi excretion Vit D Calcidiol 25-OH-D Calcitriol 1,25-(OH)2-D α1 hydroxylase Increase Ca & Pi reabsorption Decrease serum Pi Active vit D Action: increase serum Ca & Pi M.Gawad. www.nephrotube.blogspot.com
- 10. Increase serum Ca Increase serum Pi IncreaseCa reabsorption PTH Increase Pi excretion Vit D Calcidiol 25-OH-D Calcitriol 1,25-(OH)2-D α1 hydroxylase Increase Ca & Pi reabsorption Decrease serum Pi Mineral & Bone Disorder (MBD) Lab Abnormalities Pathogenesis (1) : PTH – Vit D – Ca – Pi Axis M.Gawad. www.nephrotube.blogspot.com
- 11. Increase Ca reabsorption PTH Increase Pi excretion VitD Calcidiol 25-OH-D Calcitriol 1,25-(OH)2-D α1 hydroxylase Mineral & Bone Disorder (MBD) Lab Abnormalities Pathogenesis (1) : PTH – Vit D – Ca – Pi Axis Bone Disease Fractures Bone pain Marrow fibrosis Erythropoietin resistance Decrease serum Ca Increase serum Pi 2ry hyperPTH M.Gawad. www.nephrotube.blogspot.com
- 12. Increase Ca reabsorption PTH Increase Pi excretion Mineral& Bone Disorder (MBD) Lab Abnormalities Pathogenesis (1) : Tertiary Hyperparathyroidism Decrease serum Ca Increase serum Pi Persistent untreated Persistent parathyroid stimulation Formation of parathyroid adenoma Increase serum Pi & Ca M.Gawad. www.nephrotube.blogspot.com
- 13. Mineral & BoneDisorder (MBD) Lab Abnormalities Summary PTH Ca Pi ALK Phosphatase Secondary Hyperparathyroidism ↑ ↓ ↑ ↑ Tertiary Hyperparathyroidism ↑↑↑ ↑ ↑↑ ↑
- 14. Decrease serum Ca Increase serum Pi IncreaseCa reabsorption PTH Increase Pi excretion Vit D Calcidiol 25-OH-D Calcitriol 1,25-(OH)2-D α1 hydroxylase Fibroblast Growth Factor 23 (FGF 23) Mineral & Bone Disorder (MBD) Lab Abnormalities Back to Basics (2): FGF 23 2ry hyperPTH
- 15. Decrease serum Ca Increase serum Pi IncreaseCa reabsorption PTH Increase Pi excretion Vit D Calcidiol 25-OH-D Calcitriol 1,25-(OH)2-D α1 hydroxylase Fibroblast Growth Factor 23 (FGF 23) Mineral & Bone Disorder (MBD) Lab Abnormalities Back to Basics (2): FGF 23 2ry hyperPTH
- 16. Decrease serum Ca Increase serum Pi IncreaseCa reabsorption PTH Increase Pi excretion Vit D Calcidiol 25-OH-D Calcitriol 1,25-(OH)2-D α1 hydroxylase Fibroblast Growth Factor 23 (FGF 23) Mineral & Bone Disorder (MBD) Lab Abnormalities Pathogenesis (2): FGF 23 Still ↑ Pi serum level Persistent very high level of FGF 23 in CKD Strong independent predictor of mortality in CKD in CKD
- 17. Mineral & BoneDisorder (MBD) General Definition PTH – Vit D – Ca – Pi Axis Mineral and bone disorder (MBD)
- 18. Mineral & BoneDisorder (MBD) Bone Abnormalities – Renal Osteodystrophy Back to Basics – TMV Classification System Turnover High Normal Low Mineralization Normal Abnormal Volume High Normal Low
- 19. Mineral & BoneDisorder (MBD) Bone Abnormalities – Renal Osteodystrophy Spectrum iPTH < 150 pg/ml iPTH 150-300 pg/ml iPTH > 300 pg/ml Low turn over bone disease (Adynamic bone Normal bone formation High turn over bone disease (Ostetis fibrosa cystica) Mixed lesion KEITH A et al. July 20, 1995. Vol. 333 No. 3
- 20. Mineral & BoneDisorder (MBD) Bone Abnormalities – Renal Osteodystrophy High turn over - Osteitis Fibrosa Cystica iPTH < 150 pg/ml iPTH 150-300 pg/ml iPTH > 300 pg/ml Low turn over bone disease Normal bone formation High turn over bone disease (Ostetis fibrosa cystica) KEITH A et al. July 20, 1995. Vol. 333 No. 3 Mixed lesion Increased bone resorption and formation Increased numbers of osteoclasts and osteoblasts Increased of woven bone, and peritrabecular fibrosis.
- 21. Mineral & BoneDisorder (MBD) Bone Abnormalities – Renal Osteodystrophy High turn over - Osteitis Fibrosa Cystica
- 22. Mineral & BoneDisorder (MBD) Bone Abnormalities – Renal Osteodystrophy High turn over - Osteitis Fibrosa Cystica
- 23. Mineral & BoneDisorder (MBD) Bone Abnormalities – Renal Osteodystrophy High turn over - Osteitis Fibrosa Cystica Salt & Pepper Appearance
- 24. Mineral & BoneDisorder (MBD) Bone Abnormalities – Renal Osteodystrophy High turn over - Osteitis Fibrosa Cystica Rugger jersey Spine
- 25. Mineral & BoneDisorder (MBD) Bone Abnormalities – Renal Osteodystrophy High turn over - Osteitis Fibrosa Cystica
- 26. Mineral & BoneDisorder (MBD) Bone Abnormalities – Renal Osteodystrophy High turn over - Osteitis Fibrosa Cystica
- 27. Mineral & BoneDisorder (MBD) Bone Abnormalities – Renal Osteodystrophy High turn over - Osteitis Fibrosa Cystica Clinically Bone fractures Bone pain and discomfort Metastatic calcification
- 28. Mineral & BoneDisorder (MBD) Bone Abnormalities – Renal Osteodystrophy Low turn over – Adynamic Bone Disease iPTH < 150 pg/ml iPTH 150-300 pg/ml iPTH > 300 pg/ml Low turn over bone disease Normal bone formation High turn over bone disease (Ostetis fibrosa cystica) Mixed lesion KEITH A et al. July 20, 1995. Vol. 333 No. 3 low or absent bone formation paucity of bone-forming osteoblasts and bone-resorbing osteoclasts. High incidence of tissue calcification What is the cause?? 1- In the past it was attributed to Al toxicity 2- Over treated hyperparathyroidism Laboratory?? Low PTH Low ALK Phosphatase High Ca & Pi
- 29. Mineral & BoneDisorder (MBD) Management – Biochemical Targets
- 32. Mineral & BoneDisorder (MBD) Management – Follow Up Therapeutic decisions must base on trends rather than on a single laboratory value. It is reasonable to base the frequency of monitoring on the presence and magnitude of abnormalities, and the rate of progression of CKD and also to monitor for trends and treatment efficacy and side-effects
- 33. Mineral & BoneDisorder (MBD) Bone Abnormalities – Renal Osteodystrophy Spectrum S Moe et al. Kidney International (2006) 69, 1945–1953
- 35. Mineral & BoneDisorder (MBD) General Definition PTH – Vit D – Ca – Pi Axis Mineral and bone disorder (MBD)
- 36. Mineral & BoneDisorder (MBD) Ca-Phosphate Product PTH – Vit D – Ca – Pi Axis ↑ Ca X Pi 1- Vascular, articular, and extra-articular soft tissue 2- Pruritis (deposition under skin) Deposition of Ca & Pi
- 37. Mineral & BoneDisorder (MBD) Vascular & Soft tissue Classification PTH – Vit D – Ca – Pi Axis
- 38. Mineral & BoneDisorder (MBD) Management – Drugs Used 1- Phosphate binders. 2- Vit D analogues. 3- Cinacalcet.
- 39. Mineral & BoneDisorder (MBD) Management – Drugs 1- Phosphate binders. 2- Vit D and Vit D analogues. 3- Cinacalcet.
- 40. Mineral & BoneDisorder (MBD) Management – Drugs Phosphate Binders
- 41. Mineral & BoneDisorder (MBD) Management – Drugs Phosphate Binders
- 42. Mineral & BoneDisorder (MBD) Management – Drugs Phosphate Binders
- 43. Mineral & BoneDisorder (MBD) Management – Drugs Used 1- Phosphate binders. 2- Vit D analogues. 3- Cinacalcet.
- 44. Mineral & BoneDisorder (MBD) Management – Drugs Used 1- Phosphate binders. 2- Vit D analogues. 3- Cinacalcet.
- 45. Mineral & BoneDisorder (MBD) Management – Drugs Vit D Analogues Liver
- 46. Mineral & BoneDisorder (MBD) Management – Drugs Vit D Analogues
- 47. Mineral & BoneDisorder (MBD) Management – Drugs Used 1- Phosphate binders. 2- Vit D analogues. 3- Cinacalcet.
- 48. Mineral & BoneDisorder (MBD) Management – Drugs Used 1- Phosphate binders. 2- Vit D and Vit D analogues. 3- Cinacalcet.
- 49. Mineral & BoneDisorder (MBD) Management – Drugs Cinacalcet
- 50. Mineral & BoneDisorder (MBD) Management
- 51. Mineral & BoneDisorder (MBD) Native Vitamin D
- 52. Mineral & BoneDisorder (MBD) Native Vitamin D
- 53.