Mineral Metabolism Targets: Stage 5:  < 15 (mL/min/1.73m2) or renal replacement therapy

Guideline Organization

Recommendation (Evidence Level)

Evidence

Comments

CARI-Australia
2006

Predialysis serum phosphate level of 0.8–1.60 mmol/L is recommended as higher levels of serum phosphate have been shown to be associated with an increase in mortality. (Level III)

Biochemical Targets: Phosphate

Predialysis albumin-corrected serum calcium should be kept within the normal laboratory reference range, preferably towards the lower end (2.1–2.4 mmol/L) provided that keeping serum calcium at this level does not worsen hyperparathyroidism. (Opinion)

Biochemical Targets: Calcium

- Levels of intact-parathyroid hormone (iPTH) that are within or below the normal range of the assay are generally indicative of low bone turnover and levels of iPTH that are greater than 2–3 times the upper normal range of the assay are generally indicative of high bone turnover. (Level l)
- Normal bone turnover is generally associated with levels of iPTH that are 1–3 times the upper normal range of the assay. For bone, the suggested target iPTH is from 1–3 times the upper normal range of the assay, with most opinion favouring 2–3 times. (Opinion)
- Markedly elevated levels of iPTH are associated with an increased risk of cardiovascular mortality and sudden death. Values that are > 7 times the upper normal range of the iPTH assay should generally be avoided. (Level lll)
- When iPTH levels are below 7 times the assay upper range, therapies to achieve bone targets for PTH that compromise target levels of serum calcium, phosphate or the calcium x phosphate product should be used with caution. (Opinion)

Biochemical Targets: PTH

- PTH levels determined using assays for iPTH and PTH(1-84) correlate closely. However, iPTH assays vary in their detection of C-terminal PTH fragments and values may differ between assays (Level lll evidence). PTH(1–84) assays that measure the full length polypeptide are reported to be more directly comparable. (Level lll evidence) For comparison of PTH values in multicentre clinical trials, the use of a PTH(1–84) assay may be preferable. (Opinion)
- In assessing bone turnover, the value of the PTH(1–84)/ non-PTH(1–84) ratio remains uncertain. (Opinion)

Serum calcium (albumin-corrected) x phosphate product < 4.0 mmol/L is recommended. (Level III – cohort data; strong effect; consistent finding)

Biochemical Targets: Calcium X phosphate product

CSN-Canada
2006

 Serum phosphate levels should be maintained within the normal range. (Grade C)

Chapter 3: Mineral Metabolism

Pg 11 of 27 in linked pdf

Give priority to phosphate and calcium targets over management of PTH (Grade D, opinion)

 Serum calcium levels should be maintained within the normal range. (Grade D)

Avoid intact PTH (iPTH) levels < 100 pg/mL (10.6 pmol/L (Grade C); iPTH levels > 500 pg/mL (53 pmol/L) should be treated if accompanied by symptoms or clinical signs of hyperparathyroidism.

Europe A:  Clinical Algorithms presented by an expert panel not in the context of EBPG
2001

Phosph mg/dl (mmol/L)
2.5-4.6 (0.8-1.5)
Calcium mg/dl (mmol/L)
8.8-11 (2.2-2.7)
PTH pg/ml (pmol/L)
85-170 (9-18)

Page 5 of 19 website PDF 

EBPG
2002

Phosph 0.8-1.8 mmol/L (2.5-5.5 mg/dL)  (Level B)
 Ca x P product < 55 mg²/dL²(Level B)

Hemodialysis Guidelines: Vascular Disease and Risk Factors
VII. 3 Hyperphophaetemia and calcium-phosphorus ion product

KDOQI-US
2003

Phosph mg/dl (mmol/L)
3.5-5.5 (1.1-1.8)

Guideline 3. Evaluation of serum phosphorus levels

Calcium mg/dl (mmol/L)
< 10.2, preferably 8.4-9.5
(< 2.54, preferably 2.10-2.37) (OPINION)

Guideline 6. Serum calcium and calcium-phosphorus product

PTH pg/ml (pmol/L)
150-300 (16.5-33)

Guideline 8B. Vitamin therapy in CKD patients

UK-Guidelines
2007 (Draft)

Serum phosphate in dialysis patients (measured before a “short gap” dialysis session in HD patients) should be maintained between 1.1 and 1.8 mmol/L. (Evidence)

Complications of CKD – Section 2: Mineral Bone Disease

Measured before a “short gap” dialysis session in HD patients

Serum calcium, adjusted for albumin concentration, should be maintained within the normal reference range for the laboratory used (Evidence) and ideally kept below 2.5 mmol/L.  (Good Practice)

Measured before a “short gap” dialysis session in HD patients

The serum albumin corrected calcium phosphorus product should be kept below 4.8 mmol2/L2 and ideally below 4.2 mmol2/L2 in all CKD patients. (Evidence)

The target range for parathyroid hormone measured using an intact PTH assay should be between 2 and 4 times the upper limit of normal for the intact PTH assay used (Good Practice).  The same target range should apply when using the whole molecule PTH assay. (Good Practice)