Saturday, November 15, 2008


bill goodman talking on KDIGO. Goodman wrote the article that interested me in the topic of vascular calcification and binder choice.

What is KDIGO

Kidney Disease Improving Global Outcomes
established in 2003

Independent non-profit, established by the NKF
The concept was to take K/DOQI and generalize the guidelines for a global audience.

The KDIGO mission is to provide:
  • Clinical Practice Guidelines
  • Guideline database
  • Work groups
  • Controversy conferences
  • Mineral and bone inititative (in draft)
  • Hepatitis C in kidney disease (coming)
  • Care of transplant patient (coming)
  • Acute kidney disease (coming)

CKD Mineral and Bone Disease
A rose from the perception that international perspective needed to define renal osteodystrophy

use the phrase ROD exclusively to define: alterations in bone morphology in patients with CKD
classification based on bone histology, bone turnover, mineralization and volume.

CKD-MBD is a systemic disorder of mineral and bone metabolism due to ckd manifested by either one or a combination of the following:
  • abnormalities of Ca, Phos, PTH, Vitamin D
  • abnormal bone turnover, mineralization, volume, linear growth or strength
  • vascular or soft tissue calcification
KDIGO revisited the concept of guidelines
They graded evidence and created their guidelines by limitting the data to:
  • RCT of at least six months in duration
  • N>50 excepts for pediatrics and bone biopsy
  • Intermediate endpoints including: BMD, bone biopsy, vascular calcification and biochemical endpoints are not considered unless they have been validated prospectively [unclear if any surrogates have been validated]
  • Observational studies acceptable if a clinical outcome examined conducted with a high methodological quality and had a relative risk of >2.0 or <0.5
treatment of CKD-MBD
  • lowering high phos
  • abnormal PTH levels in CKD-MBD
  • treatment of bone and bisphosphonates, other osteoporosis medication and growth hormone
  • evaluation and treatment of kidney transplant bone disease
there is little evidence to provide guidance for a specific therapeutic target range for any biochemical parameter
  • extreme values are associated with greater mortality risk
  • little evidence to support preferred treatments
KDIGO concluded that PTH guidelines are mainly opinion based and not informed by randomized clinical trials

150-300 is based on evidence just not rct and outdated

phos and calcium guidelines are loose

repeated emphasis through out document on the lack of evidence from RCT with hard outcomes

Data Gaps

Evolve is really important, largest prospective clinical trial on dialysis population
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