Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease: An Overview

George R. Bailie, PharmD, PhD, FCCP; Shaul G. Massry, MD


Pharmacotherapy. 2005;25(12):1687-1707. 

In This Article

Overview of Guidelines

Most patients with advanced kidney disease (stage 3 [GFR 30-59 ml/min/1.73 m2] through stage 5) will exhibit some degree of aberrations in bone and mineral metabolism. Appropriate management of bone disease is complex and requires balanced use of diet, phosphorus binders, vitamin D analogs, and calcimimetic agents. The following clinical practice guidelines were developed to provide an integrated clinical action plan to the management of this complex problem throughout the course of CKD. The guidelines were based on a systematic review of the evidence in the literature through January 1, 2001. The guidelines were published before the United States Food and Drug Administration (FDA) approved cinacalcet in April 2004 and lanthanum carbonate in October 2004; therefore, recommendations pertaining to these drugs are not included. In addition, because sevelamer was approved in late 1998, only relatively few data were available for this phosphorus-binding agent, and limited recommendations about its role were incorporated. Throughout the guidelines, references are made to non, non-aluminum-containing phosphorus binders. Until such time that lanthanum carbonate enjoys widespread use, sevelamer is the predominant available agent in this category.

The following describes some of the guidelines that are pertinent to pharmacy practice. The method used to produce the evidence-based guidelines has been previously discussed.[1] Table 1 summarizes the results of the literature retrieval and review process used for creating the document.[3] The document contains 16 clinical practice guidelines ( Table 2 ). Some of these are briefly reviewed here. An indication is given as to whether each guideline reviewed is based on evidence (E) or opinion (O). About one third of the guidelines are evidence based, and two thirds are opinion based. In each of the guidelines, reference is made to the staging of kidney disease from stages 1-5. These correspond to concentrations of kidney function estimated by the following GFRs: stage 1, presence of kidney damage with GFR of 90 ml/minute/1.73 m2 or greater; stage 2, presence of kidney damage with GFR of 60-89 ml/minute/1.73 m2; stage 3, GFR of 30-59 ml/minute/1.73 m2; stage 4, GFR of 15-29 ml/minute/1.73 m2; and stage 5, GFR less than 15 ml/minute/1.73 m2 (or undergoing dialysis).

Dissemination of these guidelines to as many individuals in the primary care areas as possible is particularly important. Although nephrologists should be very familiar with the content of these recommendations and may use them to guide practice, for most patients in the United States, kidney disease is unfortunately diagnosed late in the process, and referral to a nephrologist is late for many of these patients. A consequence is that primary care providers, unaware perhaps of the existence of these guidelines, may not optimally treat their patients. Pharmacists can assist with educational activities that may correct these problems, and throughout this review we provide commentary regarding aspects that may be of particular relevance to pharmacists.