When should the assessment of CKD-MBD biochemical parameters start?
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Rania Mahmoud
The most significant changes in the CKD-MBD biochemical parameters currently occur in patients in CKD stage 3b; consequently, systematic evaluation of CKD biochemical parameters should begin in stages 2-3a.The frequency of assessments, the pattern of decline of the GFR and the type, severity and duration of the identified abnormalities, should be evaluated individually to adapt the frequency of the assessments and the non-pharmacological and pharmacological interventions
The pathogenesis of CKD-MBD starts as early as stage2.
it become evident biochemically in stage 3b to 4
routine assessment of the biochemical changes must begins in stage 3a
the frequency of investigations should be individualized based on the presence and severity of abnormalities, in addition to the stage of CKD and speed of eGFR decline
The pathogenesis of CKD-MBD starts as early as stage2.
it become evident biochemically in stage 3b to 4
routine assessment of the biochemical changes must begins in stage 3a
the frequency of investigations should be individualized based on the presence and severity of abnormalities, in addition to the stage of CKD and speed of eGFR decline
CKD MBD pathogenesis starts as early as CKD G2, so lab monitoring should start early in stage 3a, by evaluating base line Ca & phosphorus& ALP- total or BSAP-& PTH& calcidiol& VBG. regular follow up will be based on initial results, clinical assessment and concurrent medications.
The assessment of CKD-MBD biochemical parameters start:since some patients of CKD stage 3 already CKD-MBD abnormalities
the assessment should start in stage 3
the most important cahnges occur in stage 3b.
the biochemical assessment include srum calcium, phosphorus, iPTH, calcidiol, alkaline phosphatase and acid base
Klotho and FGF measurement still limited
The more important changes in the CKD-MBD biochemical parameters currently start in patients CKD stage 3b, thus, the routine assessment of the biochemical parameters of CKD should begin in stages 2–3a. The frequency of assessments, the pattern of decline of the GFR and the type, severity and duration of the identified abnormalities, should be evaluated individually to adapt the frequency of the assessments and the non-pharmacological and pharmacological interventions.
Biochemical parameter should be assessment in early stag of CKD
((reference KIDIGO guideline ))
Chapter 3.1: Diagnosis of CKD-MBD: biochemical abnormalities
3.1.1: We recommend monitoring serum levels of calcium, phosphate, PTH, and alkaline phosphatase activity beginning in CKD G3a (1C). In children, we suggest such monitoring beginning in CKD G2 (2D).
3.1.2: In patients with CKD G3a–G5D, it is reasonable to base the frequency of monitoring serum calcium, phosphate, 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 G3a–G3b: for serum calcium and phosphate, every 6–12 months; and for PTH, based on baseline level and CKD progression. In CKD G4: for serum calcium and phosphate, every 3–6 months; and for PTH, every 6–12 months. In CKD G5, including G5D: for serum calcium and phosphate, every 1–3 months; and for PTH, every 3–6 months. In CKD G4–G5D: for alkaline phosphatase activity, every 12 months, or more frequently in the presence of elevated PTH (see Chapter 3.2). In CKD patients 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).
3.1.3: In patients with CKD G3a–G5D, we suggest that 25(OH)D (calcidiol) levels 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).
3.1.4: In patients with CKD G3a–G5D, 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).
3.1.5: In patients with CKD G3a–G5D, we suggest that individual values of serum calcium and phosphate, evaluated together, be used to guide clinical practice rather than the mathematical construct of calcium-phosphate product (Ca 3 P) (2D).
3.1.6: In reports of laboratory tests for patients with CKD G3a–G5D, 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), or handling specifications to facilitate the appropriate interpretation of biochemistry data (1B.
In practice, an initial evaluation of Ca/P/PTH/ALP is done. with stable patients the frequency of monitoring lab. parameters can be set individually according to observed changes, and needed treatments. The frequency and start of an initial evaluation in accordance with KDIGO guidelines should start with the CKD IIIa stage. In dialysis patients, the evaluation of Ca/P is done monthly while PTH is done each 3 months
The routine assessment of the biochemical parameters of CKD should begin in stages 2–3a. That is because the more important changes in the CKD-MBD biochemical parameters currently start in patients CKD stage 3b.
According to kdigo guide line start monitoring S2 in children and s3a in adult
serum levels of calcium, phosphate, PTH, and alkaline phosphatase activity
s3a–s3b
serum calcium and phosphate every 6–12 months
for PTH based on baseline level and CKD progression
S4:for serum calcium and phosphate every 3–6 months for PTH every 6–12 months s5, including Gs5D for serum calcium and phosphate every 1–3 months for PTH every 3–6 months.
S4–s5D:for alkaline phosphatase activity every 12 months, or more frequently in the presence of high PTH
In patients with CKD G3a–G5D:
For 25(OH)D (calcidiol) levels might be measured, and repeated testing determined by baseline values and therapeutic interventions.
The routine assessment of the biochemical parameters of CKD should begin in stages 2–3a. That is because the more important changes in the CKD-MBD biochemical parameters currently start in patients CKD stage 3b.
Assessment and management should be individuallized to adapt the frequency of the assessments and the non-pharmacological and pharmacological interventions
Here is the time and frequancy of investigation according to KDIGO 2017 with grading
We recommend monitoring serum levels of calcium, phosphate, PTH, and alkaline phosphatase activity beginning in CKD G3a (1C). In children, we suggest such monitoring beginning in CKD G2 (2D).
In patients with CKD G3a–G5D, it is reasonable to base the frequency of monitoring serum calcium, phosphate, 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 G3a–G3b: for serum calcium and phosphate, every 6–12 months; and for PTH, based on baseline level and CKD progression.
In CKD G4: for serum calcium and phosphate, every 3–6 months; and for PTH, every 6–12 months.
In CKD G5, including G5D: for serum calcium and phosphate, every 1–3 months; and for PTH, every 3–6 months.
In CKD G4–G5D: for alkaline phosphatase activity, every 12 months, or more frequently in the presence of elevated PTH (see Chapter 3.2).
In CKD patients 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).
In patients with CKD G3a–G5D, we suggest that 25(OH)D (calcidiol) levels might be measured, and repeated testing determined by baseline values and therapeutic interventions (2C).
In patients with CKD G3a–G5D, 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).
The routine assessment of the biochemical parameters of CKD should begin in stages 2–3a. That is because the more important changes in the CKD-MBD biochemical parameters currently start in patients CKD stage 3b.
A) At beginning in CKD G3a in adult and G2 in children serum levels of calcium, phosphate, PTH, and alkaline phosphatase activity B) In CKD G3a–G3b 1- serum calcium and phosphate every 6–12 months 2- for PTH based on baseline level and CKD progression C) In CKD G4: 1- for serum calcium and phosphate every 3–6 months 2- for PTH every 6–12 months D) In CKD G5, including G5D 1- for serum calcium and phosphate every 1–3 months 2- for PTH every 3–6 months. F) In CKD G4–G5D: for alkaline phosphatase activity every 12 months, or more frequently in the presence of high PTH G) In patients with CKD G3a–G5D: For 25(OH)D (calcidiol) levels might be measured, and repeated testing determined by baseline values and therapeutic interventions.
ACCORDING TO KDIGO GUIDELINE 2017
1-with CKD G3A (when egfr <60 ml/min ain adult )recommend for evaluation of
ca ,po4 ,PTH
2-frequency of monitoring depend on baseline abnormalities and progression of ckd
3-CKD G3a–b CALCIUM /PO4 EVERY 6–12 MONTH AND PTH ACCORDING TO BASE LINE LEVEL AND PROGRESSION OF CKD
4-CKD G4 CA AND PO4 /3–6 MONTH AND PTH EVERY 6 –12 MONTH
5-CKD G5 ND –D
CALCIUM AND PO4 /1–3 MONTH AND PTH EVERY 3—6 MONTH
=================
ADVICE FOR ALP on CKD G4 and yearly
=============
25 (OH )d3 TO BE EVALUATED
The important changes in CKD-MBD biochemical parameters usually start in ckd stage 3b, but the routine biochemical parameters assessment should begin in ckd stage 2-3a .
Then the frequency of assessment depends on the degree of the decrease in GFR, type, severity and duration of progression of kidney disease which should be individualized.
Studies that use a cross-sectional approach have shown patterns of abnormalities in the most important biochemical indicators of CKD-MBD at various phases of the disease. Serum calcium and phosphate readings typically stay within the normal range up to glomerular filtration rates (GFR) of around 30–40 ml/min; however, the respective decline and rise of both are shown with GFR that falls below 20–30 ml/min.
On the other hand, calcitriol levels start to drop early on in the progression of CKD (when GFR is between 70 and 80 ml/min), whereas calcidiol and PTH levels start to rise a little bit later (when GFR is between 60 and 70 ml/min).
Since PTH hyporesponsiveness is already apparent in CKD stages 3b–4, PTH levels should be maintained in the upper normal range or slightly above. In CKD stage 4–5 patients before dialysis, levels conspicuously over the upper range of normal levels enable a required phosphaturic impact.
CKD stage 5D patients have more difficult criteria. In the late stages of CKD (stages 4–5), biochemical measures, including PTH, should be taken every 1–3 months to identify growing increases in PTH, calcium, phosphate, and calcidiol and correct them to normal.
The routine assessment of the biochemical parameters of CKD should begin in stages 2–3a. That is because the more important changes in the CKD-MBD biochemical parameters currently start in patients CKD stage 3b.
(for Diagnosis of CKD-MBD: biochemical abnormalities)
A) At beginning in CKD G3a in adult and G2 in children
serum levels of calcium, phosphate, PTH, and alkaline phosphatase activity
B) In CKD G3a–G3b
1- serum calcium and phosphate every 6–12 months
2- for PTH based on baseline level and CKD progression
C) In CKD G4:
1- for serum calcium and phosphate every 3–6 months
2- for PTH every 6–12 months
D) In CKD G5, including G5D
1- for serum calcium and phosphate every 1–3 months
2- for PTH every 3–6 months.
F) In CKD G4–G5D:
for alkaline phosphatase activity every 12 months, or more frequently in the presence of high PTH
G) In patients with CKD G3a–G5D:
For 25(OH)D (calcidiol) levels might be measured, and repeated testing determined by baseline values and therapeutic interventions.
Diagnosis of CKD-MBD: bone
1- In patients with CKD G3a–G5D vitamin D deficiency and insufficiency be corrected using treatment strategies recommended for the general population
2- In CKD G3a–G5D, therapeutic decisions be based on trends rather than on a single laboratory value
3- In CKD G3a–G5D with evidence of CKD-MBD and/or risk factors for osteoporosis, BMD test could assess fracture risk if results will impact treatment decisions
4- In CKD G3a–G5D, perform a bone biopsy if knowledge of the type of renal osteodystrophy will impact treatment decisions
5- In patients with CKD G3a–G5D, 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
6- In patients with CKD G3a–G5D, 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) .
important changes in bone and mineral metabolism appear mostly in stage 3b , so assessment of biochemical changes should start in stage 2 to 3a as change in calcium and phosphate metabolism appear at GFR between 20 and 30 but decreased active vit D start to appear earlier at GFR between 70 and 80
-When should the assessment of CKD-MBD biochemical parameters start?
CKD 2G to CKD 3aG
Should be individualized = precision medicine
Check Ca, PO4, PTH, vitamin D, ALP, and acid base balance status
The diagnosis & management of CKD-MBD should be based mainly on the trend of changes in these markers. This is very important specially in the interpretation of PTH
The more important changes in the CKD-MBD biochemical parameters currently start in patients CKD stage 3b, thus, the routine assessment of the biochemical parameters of CKD should begin in stages 2–3a.
According to KDIGO 2017:Reasonable monitoring intervals would be:
In CKD G3a–G3b: for serum calcium and phosphate, every 6–12 months; and for PTH, based on baseline level and CKD progression.
In CKD G4: for serum calcium and phosphate, every 3–6 months; and for PTH, every 6–12 months.
In CKD G5, including G5D: for serum calcium and phosphate, every 1–3 months; and for PTH, every 3–6months.
In CKD G4–G5D: for alkaline phosphatase activity, every 12 months, or more frequently in the presence of elevated PTH
Studies that use a cross-sectional approach have shown patterns of abnormalities in the most important biochemical indicators of CKD-MBD at various phases of the disease. Serum calcium and phosphate readings typically stay within the normal range up to glomerular filtration rates (GFR) of around 30–40 ml/min; however, the respective decline and rise of both are shown with GFR that falls below 20–30 ml/min.
On the other hand, calcitriol levels start to drop early on in the progression of CKD (when GFR is between 70 and 80 ml/min), whereas calcidiol and PTH levels start to rise a little bit later (when GFR is between 60 and 70 ml/min).
Since PTH hyporesponsiveness is already apparent in CKD stages 3b–4, PTH levels should be maintained in the upper normal range or slightly above. In CKD stage 4–5 patients before dialysis, levels conspicuously over the upper range of normal levels enable a required phosphaturic impact.
CKD stage 5D patients have more difficult criteria. In the late stages of CKD (stages 4–5), biochemical measures, including PTH, should be taken every 1–3 months to identify growing increases in PTH, calcium, phosphate, and calcidiol and correct them to normal.
The routine assessment of the biochemical parameters of CKD should begin in stages 2–3a. That is because the more important changes in the CKD-MBD biochemical parameters currently start in patients CKD stage 3b.
Calcitriol begins to reduce the level at the early stages of CKD (GFR between 70-80 ml/min), while calcidiol and PTH increase later from GFR 60-70 ml/min.
Up to GFR 30-40 ml/min calcium and phosphorus usually within the normal value.
So, routine assessment of MBD should start at stages 2-3a, and the frequency of assessment should be determined in an individualized way based on:
A pattern of the decline of GFR.
Types, severity, and duration of abnormality.
The laboratory diagnosis of CKD-MBD includes:
Serum Ca.
Serum PO4.
PTH.
Calcidol.
ALP.
Acid-base status.
VitD level.
FGF23-Klotho= very limited use in clinical practice.
Recommended cutt-off values from KDIGO for metabolic abnormality for each CKD stage:
Serum PO4:
CKD stage 3-5, = keep high P level to near normal range.
CKD stage 5D, = keep high P level to near normal range.
2. Serum Calcium:
CKD stage 3-5 = avoid hypercalcemia.
CKD stage 5D = avoid hypercalcemia.
3. Serum PTH:
CKD stage 3-5 = maintain the level within normal range or slightly elevated in CKD 4-5
CKD stage 5D = maintain PTH level within 2-9 times more than the normal range.
4. Serum calcidiol:
CKD stage 3-5 = keep within the safest and optimal range 20-40 pglml.
CKD stage 5D = keep within the safest and optimal range 20-4- pg/ml.
The routine assessment of the biochemical parameters of CKD should begin in stages 2–3a. That is because the more important changes in the CKD-MBD biochemical parameters currently start in patients CKD stage 3b.
The most significant changes in the CKD-MBD biochemical parameters currently occur in patients in CKD stage 3b; consequently, systematic evaluation of CKD biochemical parameters should begin in stages 2-3a. The frequency of assessments, the pattern of decline of the GFR and the type, severity and duration of the identified abnormalities, should be evaluated individually to adapt the frequency of the assessments and the non-pharmacological and pharmacological interventions
it should start as early as stage2 tho it can be identified biochemically in stage 3b.
monitoring should be done as per KDIGO guidelines
The pathogenesis of CKD-MBD starts as early as stage2.
it become evident biochemically in stage 3b to 4
routine assessment of the biochemical changes must begins in stage 3a
the frequency of investigations should be individualized based on the presence and severity of abnormalities, in addition to the stage of CKD and speed of eGFR decline
The pathogenesis of CKD-MBD starts as early as stage2.
it become evident biochemically in stage 3b to 4
routine assessment of the biochemical changes must begins in stage 3a
the frequency of investigations should be individualized based on the presence and severity of abnormalities, in addition to the stage of CKD and speed of eGFR decline
CKD MBD pathogenesis starts as early as CKD G2, so lab monitoring should start early in stage 3a, by evaluating base line Ca & phosphorus& ALP- total or BSAP-& PTH& calcidiol& VBG. regular follow up will be based on initial results, clinical assessment and concurrent medications.
The assessment of CKD-MBD biochemical parameters start:since some patients of CKD stage 3 already CKD-MBD abnormalities
the assessment should start in stage 3
It should start at stage 2-3a
early changes include changes in vit D, FGF 23 and klotho
the most important cahnges occur in stage 3b.
the biochemical assessment include srum calcium, phosphorus, iPTH, calcidiol, alkaline phosphatase and acid base
Klotho and FGF measurement still limited
The more important changes in the CKD-MBD biochemical parameters currently start in patients CKD stage 3b, thus, the routine assessment of the biochemical parameters of CKD should begin in stages 2–3a. The frequency of assessments, the pattern of decline of the GFR and the type, severity and duration of the identified abnormalities, should be evaluated individually to adapt the frequency of the assessments and the non-pharmacological and pharmacological interventions.
Great Dr. Asmaa
Biochemical parameter should be assessment in early stag of CKD
((reference KIDIGO guideline ))
Chapter 3.1: Diagnosis of CKD-MBD: biochemical abnormalities
3.1.1: We recommend monitoring serum levels of calcium, phosphate, PTH, and alkaline phosphatase activity beginning in CKD G3a (1C). In children, we suggest such monitoring beginning in CKD G2 (2D).
3.1.2: In patients with CKD G3a–G5D, it is reasonable to base the frequency of monitoring serum calcium, phosphate, 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 G3a–G3b: for serum calcium and phosphate, every 6–12 months; and for PTH, based on baseline level and CKD progression. In CKD G4: for serum calcium and phosphate, every 3–6 months; and for PTH, every 6–12 months. In CKD G5, including G5D: for serum calcium and phosphate, every 1–3 months; and for PTH, every 3–6 months. In CKD G4–G5D: for alkaline phosphatase activity, every 12 months, or more frequently in the presence of elevated PTH (see Chapter 3.2). In CKD patients 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).
3.1.3: In patients with CKD G3a–G5D, we suggest that 25(OH)D (calcidiol) levels 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).
3.1.4: In patients with CKD G3a–G5D, 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).
3.1.5: In patients with CKD G3a–G5D, we suggest that individual values of serum calcium and phosphate, evaluated together, be used to guide clinical practice rather than the mathematical construct of calcium-phosphate product (Ca 3 P) (2D).
3.1.6: In reports of laboratory tests for patients with CKD G3a–G5D, 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), or handling specifications to facilitate the appropriate interpretation of biochemistry data (1B.
Thanks Dr. Elsayed
In practice, an initial evaluation of Ca/P/PTH/ALP is done. with stable patients the frequency of monitoring lab. parameters can be set individually according to observed changes, and needed treatments. The frequency and start of an initial evaluation in accordance with KDIGO guidelines should start with the CKD IIIa stage. In dialysis patients, the evaluation of Ca/P is done monthly while PTH is done each 3 months
Thanks Dr. Mahmud
The routine assessment of the biochemical parameters of CKD should begin in stages 2–3a. That is because the more important changes in the CKD-MBD biochemical parameters currently start in patients CKD stage 3b.
According to kdigo guide line start monitoring S2 in children and s3a in adult
serum levels of calcium, phosphate, PTH, and alkaline phosphatase activity
s3a–s3b
serum calcium and phosphate every 6–12 months
for PTH based on baseline level and CKD progression
S4:for serum calcium and phosphate every 3–6 months for PTH every 6–12 months s5, including Gs5D for serum calcium and phosphate every 1–3 months for PTH every 3–6 months.
S4–s5D:for alkaline phosphatase activity every 12 months, or more frequently in the presence of high PTH
In patients with CKD G3a–G5D:
For 25(OH)D (calcidiol) levels might be measured, and repeated testing determined by baseline values and therapeutic interventions.
Thanks Dr./ Rabab
The routine assessment of the biochemical parameters of CKD should begin in stages 2–3a. That is because the more important changes in the CKD-MBD biochemical parameters currently start in patients CKD stage 3b.
Assessment and management should be individuallized to adapt the frequency of the assessments and the non-pharmacological and pharmacological interventions
Here is the time and frequancy of investigation according to KDIGO 2017 with grading
We recommend monitoring serum levels of calcium, phosphate, PTH, and alkaline phosphatase activity beginning in CKD G3a (1C). In children, we suggest such monitoring beginning in CKD G2 (2D).
In patients with CKD G3a–G5D, it is reasonable to base the frequency of monitoring serum calcium, phosphate, 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 G3a–G3b: for serum calcium and phosphate, every 6–12 months; and for PTH, based on baseline level and CKD progression.
In CKD G4: for serum calcium and phosphate, every 3–6 months; and for PTH, every 6–12 months.
In CKD G5, including G5D: for serum calcium and phosphate, every 1–3 months; and for PTH, every 3–6 months.
In CKD G4–G5D: for alkaline phosphatase activity, every 12 months, or more frequently in the presence of elevated PTH (see Chapter 3.2).
In CKD patients 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).
In patients with CKD G3a–G5D, we suggest that 25(OH)D (calcidiol) levels might be measured, and repeated testing determined by baseline values and therapeutic interventions (2C).
In patients with CKD G3a–G5D, 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).
Thanks Dr. Rola
CKD G3a–G5D as per KDIGO.
Great Dr. Amna
The routine assessment of the biochemical parameters of CKD should begin in stages 2–3a. That is because the more important changes in the CKD-MBD biochemical parameters currently start in patients CKD stage 3b.
According to KDIGO CKD-MBD recommendation 2017:
A) At beginning in CKD G3a in adult and G2 in children
serum levels of calcium, phosphate, PTH, and alkaline phosphatase activity
B) In CKD G3a–G3b
1- serum calcium and phosphate every 6–12 months
2- for PTH based on baseline level and CKD progression
C) In CKD G4:
1- for serum calcium and phosphate every 3–6 months
2- for PTH every 6–12 months
D) In CKD G5, including G5D
1- for serum calcium and phosphate every 1–3 months
2- for PTH every 3–6 months.
F) In CKD G4–G5D:
for alkaline phosphatase activity every 12 months, or more frequently in the presence of high PTH
G) In patients with CKD G3a–G5D:
For 25(OH)D (calcidiol) levels might be measured, and repeated testing determined by baseline values and therapeutic interventions.
Great Dr. Ahmed
ACCORDING TO KDIGO GUIDELINE 2017
1-with CKD G3A (when egfr <60 ml/min ain adult )recommend for evaluation of
ca ,po4 ,PTH
2-frequency of monitoring depend on baseline abnormalities and progression of ckd
3-CKD G3a–b CALCIUM /PO4 EVERY 6–12 MONTH AND PTH ACCORDING TO BASE LINE LEVEL AND PROGRESSION OF CKD
4-CKD G4 CA AND PO4 /3–6 MONTH AND PTH EVERY 6 –12 MONTH
5-CKD G5 ND –D
CALCIUM AND PO4 /1–3 MONTH AND PTH EVERY 3—6 MONTH
=================
ADVICE FOR ALP on CKD G4 and yearly
=============
25 (OH )d3 TO BE EVALUATED
Great Dr. Emad
According to KDIGO CKD-MBD recommendation: (2017)
At beginning in CKD G3a
In CKD G4:
D) In CKD G5, including G5D
Great Dr./ Ashraf
As per KDIGO guidelines, assessment should start in CKD-3a
Good answer, Dr Mahmoud
When should the assessment of CKD-MBD biochemical parameters start?
Great Dr. Ibrahim
The important changes in CKD-MBD biochemical parameters usually start in ckd stage 3b, but the routine biochemical parameters assessment should begin in ckd stage 2-3a .
Then the frequency of assessment depends on the degree of the decrease in GFR, type, severity and duration of progression of kidney disease which should be individualized.
Excellent Dr. Israa
Studies that use a cross-sectional approach have shown patterns of abnormalities in the most important biochemical indicators of CKD-MBD at various phases of the disease. Serum calcium and phosphate readings typically stay within the normal range up to glomerular filtration rates (GFR) of around 30–40 ml/min; however, the respective decline and rise of both are shown with GFR that falls below 20–30 ml/min.
On the other hand, calcitriol levels start to drop early on in the progression of CKD (when GFR is between 70 and 80 ml/min), whereas calcidiol and PTH levels start to rise a little bit later (when GFR is between 60 and 70 ml/min).
Since PTH hyporesponsiveness is already apparent in CKD stages 3b–4, PTH levels should be maintained in the upper normal range or slightly above. In CKD stage 4–5 patients before dialysis, levels conspicuously over the upper range of normal levels enable a required phosphaturic impact.
CKD stage 5D patients have more difficult criteria. In the late stages of CKD (stages 4–5), biochemical measures, including PTH, should be taken every 1–3 months to identify growing increases in PTH, calcium, phosphate, and calcidiol and correct them to normal.
Thanks Dr. Rihab
The routine assessment of the biochemical parameters of CKD should begin in stages 2–3a. That is because the more important changes in the CKD-MBD biochemical parameters currently start in patients CKD stage 3b.
According to KDIGO CKD-MBD recommendation 2017:
(for Diagnosis of CKD-MBD: biochemical abnormalities)
A) At beginning in CKD G3a in adult and G2 in children
serum levels of calcium, phosphate, PTH, and alkaline phosphatase activity
B) In CKD G3a–G3b
1- serum calcium and phosphate every 6–12 months
2- for PTH based on baseline level and CKD progression
C) In CKD G4:
1- for serum calcium and phosphate every 3–6 months
2- for PTH every 6–12 months
D) In CKD G5, including G5D
1- for serum calcium and phosphate every 1–3 months
2- for PTH every 3–6 months.
F) In CKD G4–G5D:
for alkaline phosphatase activity every 12 months, or more frequently in the presence of high PTH
G) In patients with CKD G3a–G5D:
For 25(OH)D (calcidiol) levels might be measured, and repeated testing determined by baseline values and therapeutic interventions.
Diagnosis of CKD-MBD: bone
1- In patients with CKD G3a–G5D vitamin D deficiency and insufficiency be corrected using treatment strategies recommended for the general population
2- In CKD G3a–G5D, therapeutic decisions be based on trends rather than on a single laboratory value
3- In CKD G3a–G5D with evidence of CKD-MBD and/or risk factors for osteoporosis, BMD test could assess fracture risk if results will impact treatment decisions
4- In CKD G3a–G5D, perform a bone biopsy if knowledge of the type of renal osteodystrophy will impact treatment decisions
5- In patients with CKD G3a–G5D, 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
6- In patients with CKD G3a–G5D, 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) .
Great Dr. Ahmed
The assessment should start in stages 2- 3a
But the most important changesin ckd MBD will be seen at stage 3b.
Decrease in vitamin D appear earlier at Gfr 70-80
Great Dr. Nour
important changes in bone and mineral metabolism appear mostly in stage 3b , so assessment of biochemical changes should start in stage 2 to 3a as change in calcium and phosphate metabolism appear at GFR between 20 and 30 but decreased active vit D start to appear earlier at GFR between 70 and 80
Great Dr. Mark
-When should the assessment of CKD-MBD biochemical parameters start?
Good answer. Dr. Ben
Thnxs, prof
The more important changes in the CKD-MBD biochemical parameters currently start in patients CKD stage 3b, thus, the routine assessment of the biochemical parameters of CKD should begin in stages 2–3a.
According to KDIGO 2017:Reasonable monitoring intervals would be:
In CKD G3a–G3b: for serum calcium and phosphate, every 6–12 months; and for PTH, based on baseline level and CKD progression.
In CKD G4: for serum calcium and phosphate, every 3–6 months; and for PTH, every 6–12 months.
In CKD G5, including G5D: for serum calcium and phosphate, every 1–3 months; and for PTH, every 3–6months.
In CKD G4–G5D: for alkaline phosphatase activity, every 12 months, or more frequently in the presence of elevated PTH
Great Answer. Thanks Dr. Alaa
Studies that use a cross-sectional approach have shown patterns of abnormalities in the most important biochemical indicators of CKD-MBD at various phases of the disease. Serum calcium and phosphate readings typically stay within the normal range up to glomerular filtration rates (GFR) of around 30–40 ml/min; however, the respective decline and rise of both are shown with GFR that falls below 20–30 ml/min.
On the other hand, calcitriol levels start to drop early on in the progression of CKD (when GFR is between 70 and 80 ml/min), whereas calcidiol and PTH levels start to rise a little bit later (when GFR is between 60 and 70 ml/min).
Since PTH hyporesponsiveness is already apparent in CKD stages 3b–4, PTH levels should be maintained in the upper normal range or slightly above. In CKD stage 4–5 patients before dialysis, levels conspicuously over the upper range of normal levels enable a required phosphaturic impact.
CKD stage 5D patients have more difficult criteria. In the late stages of CKD (stages 4–5), biochemical measures, including PTH, should be taken every 1–3 months to identify growing increases in PTH, calcium, phosphate, and calcidiol and correct them to normal.
Thanks Dr. Weam
The routine assessment of the biochemical parameters of CKD should begin in stages 2–3a. That is because the more important changes in the CKD-MBD biochemical parameters currently start in patients CKD stage 3b.
Starting CKD-MBD assessment:
A cross-sectional study shows that:
So, routine assessment of MBD should start at stages 2-3a, and the frequency of assessment should be determined in an individualized way based on:
The laboratory diagnosis of CKD-MBD includes:
Recommended cutt-off values from KDIGO for metabolic abnormality for each CKD stage:
2. Serum Calcium:
3. Serum PTH:
4. Serum calcidiol:
Thanks Dr. Kamal
The routine assessment of the biochemical parameters of CKD should begin in stages 2–3a. That is because the more important changes in the CKD-MBD biochemical parameters currently start in patients CKD stage 3b.