Kidney with bones and minerals

CKD-MBD Management: Are Global Guidelines Enough?

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Beau Callahan in Health & Wellness June 2025 • 4 min read.

"Bridging the Gap Between International Standards and Local Realities in Chronic Kidney Disease-Mineral Bone Disorder Treatment"


The term 'chronic kidney disease-mineral bone disorder' (CKD-MBD) highlights a systemic syndrome impacting cardiovascular health and overall survival. In response, numerous countries have established clinical guidelines to enhance patient outcomes. The Kidney Disease Outcome Quality Initiative (KDOQI) and Kidney Disease: Improving Global Outcomes (KDIGO) guidelines are globally recognized and used, but questions remain about their universal applicability.

The effectiveness of these global guidelines can be influenced by differences in healthcare systems and societal factors, which may limit their widespread application. Data from Korean registries and the Dialysis Outcomes and Practice Patterns Study (DOPPS) indicates that many dialysis patients do not consistently meet the KDOQI and KDIGO targets for serum calcium, phosphorus, and PTH levels. This discrepancy highlights a gap between global guidelines and local practices.

Addressing this gap necessitates studies comparing outcomes of Korean CKD-MBD patients under current practices against those suggested by global guidelines, and identifying region-specific mineral targets linked to improved outcomes.

Why One-Size-Fits-All Doesn't Work: Tailoring CKD-MBD Treatment

Kidney with bones and minerals

While international guidelines provide a foundation for CKD-MBD management, healthcare providers must consider patient populations' unique characteristics and needs. In Korea, the Korean Society of Nephrology has tracked end-stage renal disease (ESRD) since 1986, but comprehensive mineral data collection began in 2012. According to 2013 data, Korea had nearly 60,000 dialysis patients, with average phosphorus levels around 4.94±1.63 mg/dL in hemodialysis patients and 5.05±1.56 mg/dL in peritoneal dialysis patients. Average calcium levels were 8.87±0.89 mg/dL and 8.74±0.91 mg/dL, respectively. Although these averages seem acceptable, the wide standard deviations suggest considerable variability.

The need for tailored approaches arises from the understanding that CKD-MBD is more than just renal osteodystrophy; it's a systemic condition affecting cardiovascular health. Elevated serum calcium, phosphorus, and parathyroid hormone (PTH) levels are associated with increased cardiovascular and all-cause mortality. Therefore, effectively managing these levels is vital to improving patient outcomes. Clinical practice guidelines are created globally to help in this management, but their successful implementation locally depends on various factors.

  • KDOQI (2003): Recommends maintaining serum phosphorus between 3.5 and 5.5 mg/dL in CKD stages 5 and 5D, slightly above normal levels.
  • KDIGO (2009): Suggests lowering phosphorus levels toward the normal range in CKD stage 5D. Both guidelines have limited evidence.
Normal serum phosphorus levels typically range from 2.5 to 4.5 mg/dL. To assess the applicability of these guidelines to the Korean population, a study was conducted excluding individuals with an estimated glomerular filtration rate (eGFR) below 60 mL/min/1.73 m². Serum phosphorus concentrations from 6,131 adults participating in health check-ups were analyzed. The results indicated that the normal serum phosphorus concentration in this population ranged from 2.4 to 4.5 mg/dL, aligning with Western standards and suggesting no significant differences in normal phosphorus levels between Korean and Western patients.

Local Data, Global Impact: Optimizing CKD-MBD Care

Effectively managing CKD-MBD requires a nuanced approach, integrating global guidelines with regional data to achieve optimal health outcomes. As research continues and dialysis management evolves, healthcare strategies must be refined to reflect the unique needs of each population, ensuring that standardized practices translate into tangible benefits for patients.

About this Article -

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Everything You Need To Know

1

What exactly is Chronic Kidney Disease-Mineral Bone Disorder (CKD-MBD) and why is it important to manage?

Chronic Kidney Disease-Mineral Bone Disorder, or CKD-MBD, is a systemic syndrome associated with decreased cardiovascular health and overall survival in patients with chronic kidney disease. It involves abnormalities in calcium, phosphorus, parathyroid hormone (PTH), and vitamin D metabolism, leading to bone disease and cardiovascular complications. Managing CKD-MBD is vital because elevated levels of serum calcium, phosphorus, and PTH are linked to increased cardiovascular and all-cause mortality.

2

What are the KDOQI and KDIGO guidelines, and what role do they play in managing CKD-MBD?

The Kidney Disease Outcome Quality Initiative (KDOQI) and Kidney Disease: Improving Global Outcomes (KDIGO) guidelines are sets of clinical recommendations developed to standardize the management of CKD-MBD globally. They provide targets for serum calcium, phosphorus, and PTH levels. These guidelines serve as a foundation for healthcare providers, aiming to improve patient outcomes by ensuring consistent and evidence-based treatment approaches. However, they may not always be directly applicable due to variations in healthcare systems and patient populations.

3

Why is it necessary to tailor CKD-MBD treatment strategies instead of using a one-size-fits-all approach?

Tailoring CKD-MBD treatment is essential because patient populations have unique characteristics and needs that can influence the effectiveness of standardized guidelines. Factors such as genetic background, dietary habits, and access to healthcare resources can vary significantly. For instance, data from Korean registries reveals variability in achieving KDOQI and KDIGO targets, suggesting that a one-size-fits-all approach may not be optimal. Region-specific mineral targets linked to improved outcomes are needed.

4

Why are elevated serum calcium, phosphorus, and parathyroid hormone (PTH) levels a concern in CKD-MBD?

Elevated serum calcium, phosphorus, and parathyroid hormone (PTH) levels are significant because they are associated with increased cardiovascular and all-cause mortality in CKD-MBD patients. These abnormalities contribute to vascular calcification, cardiac dysfunction, and other cardiovascular complications. Effectively managing these levels through tailored treatment strategies is crucial to reducing the risk of adverse outcomes and improving the overall survival of patients.

5

How can healthcare providers ensure they are providing the best possible CKD-MBD care for their patients?

Healthcare providers can optimize CKD-MBD care by integrating global guidelines with regional data. This involves regularly collecting and analyzing local data on mineral levels, treatment practices, and patient outcomes to identify gaps and areas for improvement. By refining healthcare strategies to reflect the unique needs of each population, providers can ensure that standardized practices translate into tangible benefits for patients, ultimately leading to better health outcomes and quality of life.

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