Medical and Surgical Management (Including Diet)

Considerable advances in the understanding and management of CKD–MBD were made in the last years; however, mortality rates remain extremely high, and the optimal approach for preventing and/or treating the mineral bone disorders in patients with stages 3, 4, and 5 CKD remains frustratingly unclear. In an attempt to minimize the morbidity and mortality associated with abnormal mineral metabolism, several evidence-based clinical practice guidelines were published, including the 2009 KDIGO guideline. But, because of the lack of randomized clinical trials, these guidelines were not able to generate strong statements in an area where there is a great unmet medical need for “guidance.” The current paper is a mini review of the current treatment approach of CKD–MBD, which principally involves the administration of some combination of the following: dietary phosphate restriction, phosphate binders (either calcium or non-calcium-containing binders), vitamin D (oral, injectable, or topical into PT glands), calcimimetics, parathyroidectomy/parathyroid ablation with ethanol. However, our management is driven largely by results of observational trials because the number of prospective randomized clinical trials is limited and existing clinical trials often are underpowered or use non-clinical outcomes. Future changes in care should be driven by adequately powered randomized trials with clinical end points.