Summary

Selective update of the 2009 KDIGO CKD-MBD guideline addressing diagnosis and treatment of mineral and bone disorders in CKD G3a–G5D and kidney transplant recipients. Key revisions: BMD testing is now recommended (rather than discouraged) because newer cohort data show DXA predicts fracture in CKD; phosphate-lowering therapy is reserved for overt/progressive hyperphosphatemia rather than preventive normalization; calcium-based phosphate binders should be restricted across all CKD stages (not only with hypercalcemia); routine calcitriol/vitamin D analogs are not recommended in CKD G3a–G5 non-dialysis due to hypercalcemia risk; and calcimimetics, calcitriol, or vitamin D analogs are all acceptable first-line PTH-lowering options in CKD G5D.

Key Recommendations

Monitor serum calcium, phosphate, PTH, and alkaline phosphatase starting at CKD G3a in adults (G2 in children), with frequency increasing as CKD progresses.
Base clinical decisions on trends across serial calcium, phosphate, and PTH values considered together rather than on a single value or the Ca×P product.
In CKD G3a–G5D, lower elevated phosphate toward the normal range, but do not initiate phosphate-lowering therapy preventively in normophosphatemic patients.
Restrict the dose of calcium-based phosphate binders in all adult CKD G3a–G5D patients receiving phosphate-lowering treatment, regardless of calcium or PTH level.
Avoid hypercalcemia in adults with CKD G3a–G5D; maintain age-appropriate normal serum calcium in children.
Avoid long-term aluminum-containing binders and aluminum-contaminated dialysate.
Do not routinely use calcitriol or vitamin D analogs in CKD G3a–G5 not on dialysis; reserve for CKD G4–G5 with severe, progressive hyperparathyroidism.
In CKD G5D, maintain iPTH at approximately 2–9× the upper normal limit of the assay; initiate or adjust therapy for marked trends within or beyond this range.
For PTH lowering in CKD G5D, calcimimetics, calcitriol, or vitamin D analogs (alone or in combination) are all acceptable first-line options.
Perform BMD (DXA) testing in CKD G3a–G5D when evidence of CKD-MBD or osteoporosis risk factors is present and results will alter management.
Consider bone biopsy when knowledge of renal osteodystrophy type will change treatment (e.g., before antiresorptive therapy, unexplained fractures, atypical PTH response).
Refer for parathyroidectomy in CKD G3a–G5D with severe hyperparathyroidism refractory to medical therapy; in immediate post-transplant period, monitor serum calcium and phosphate at least weekly until stable.

Thresholds & Doses

Monitoring intervals CKD G3a–G3b: Ca/PO4 every 6–12 months; PTH based on baseline.
Monitoring intervals CKD G4: Ca/PO4 every 3–6 months; PTH every 6–12 months.
Monitoring intervals CKD G5/G5D: Ca/PO4 every 1–3 months; PTH every 3–6 months; alkaline phosphatase annually (or more if PTH elevated).
Dialysate calcium concentration in CKD G5D: 1.25–1.50 mmol/L (2.5–3.0 mEq/L).
Target iPTH in CKD G5D: approximately 2–9× upper limit of normal for the assay (e.g., ~130–585 pg/mL or ~14–62 pmol/L).
Reduce/stop calcitriol, vitamin D analog, or calcimimetic if iPTH falls below 2× upper limit of normal.
Hold/reduce vitamin D sterols if hyperphosphatemia develops; reduce calcimimetics if hypocalcemia develops.
Post-transplant: measure serum Ca and PO4 at least weekly until stable in immediate post-transplant period.
Post-transplant first 12 months: consider antiresorptive therapy if eGFR > ~30 mL/min/1.73 m² and low BMD.
Pediatric growth monitoring: infants with CKD G2–G5D measured quarterly; children assessed for linear growth at least annually.
COSMOS data: best HD patient survival observed with serum phosphate ~4.4 mg/dL (1.42 mmol/L).

Citations

Chapter 3.2, Rec 3.2.1 — BMD testing in CKD G3a–G5D when results impact treatment.
Chapter 4.1, Rec 4.1.2–4.1.6 — phosphate lowering only for elevated phosphate; restriction of calcium-based binders.
Chapter 4.1, Rec 4.1.4 — dialysate calcium 1.25–1.50 mmol/L.
Chapter 4.2, Rec 4.2.2 — calcitriol/vitamin D analogs not routine in non-dialysis CKD G3a–G5.
Chapter 4.2, Rec 4.2.3–4.2.4 — iPTH target 2–9× ULN in G5D; calcimimetics, calcitriol, or vitamin D analogs as PTH-lowering options.
Chapter 5, Rec 5.1, 5.5, 5.6 — post-transplant monitoring, BMD testing, and treatment in first 12 months.
Table 1 — sensitivity/specificity of KDOQI and KDIGO PTH thresholds for bone turnover.
Summary and comparison of 2017 vs 2009 recommendations — rationale for updates including EVOLVE post hoc analyses.