Markus Ketteler, MD; Geoffrey A. Block, MD; Pieter Evenepoel, MD, PhD; Masafumi Fukagawa, MD, PhD; Charles A. Herzog, MD; Linda McCann, RD, CSR; Sharon M. Moe, MD; Rukshana Shroff, MD, PhD; Marcello A. Tonelli, MD, SM, MSc; Nigel D. Toussaint, MBBS, PhD; Marc G. Vervloet, MD, PhD; Mary B. Leonard, MD, MSCE
Acknowledgment: The Work Group thanks Bertram L. Kasiske and the KDIGO Co-Chairs, David C. Wheeler and Wolfgang C. Winkelmayer, for their invaluable guidance. The Work Group is also grateful for the rigorous evidence review performed by Dr. Karen A. Robinson and her evidence review team members. Finally, the Work Group acknowledges all who provided feedback during the public review of the draft guideline.
Financial Support: This guideline is supported by KDIGO, and no funding is accepted for the development of specific guidelines.
Disclosures: Dr. Ketteler reports grants from Amgen and personal fees from Amgen, Fresenius Medical Care, Medice, Sanofi, and Vifor Fresenius Medical Care Renal Pharma outside the submitted work. Dr. Block reports personal fees from Amgen, Kirin Corporation, OPKO, Daiichi Sankyo, ONO Pharmaceutical, Keryx, and Ardelyx; nonfinancial support from Amgen, OPKO, ONO Pharmaceutical, and Keryx; grants from Keryx; and other support from Ardelyx outside the submitted work. Dr. Evenepoel reports grants from Amgen and personal fees from Amgen, Sanofi, and Vifor Fresenius Medical Care during the conduct of the study. Dr. Fukagawa reports grants from Kyowa Hakko Kirin and Bayer Japan and personal fees from Kyowa Hakko Kirin, Bayer Japan, ONO Pharmaceutical, and Torii Pharmaceutical outside the submitted work. Dr. Herzog reports grants from Amgen and Zoll and personal fees from AbbVie, FibroGen, Relypsa, Sanifit, and ZS Pharma outside the submitted work. Ms. McCann reports other support from Amgen, Sanofi, and Relypsa outside the submitted work. Dr. Moe reports grants from Chugai, the National Institutes of Health, and the U.S. Department of Veterans Affairs and personal fees from Sanofi Genzyme and Amgen outside the submitted work. Dr. Toussaint reports grants and nonfinancial support from Amgen, Shire, and Sanofi during the conduct of the study. Dr. Vervloet reports grants from Fresenius Medical Care, Vifor Pharma, and Amgen and personal fees from Fresenius Medical Care, Vifor Pharma, Otsuka, Baxter, and Amgen outside the submitted work. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M17-2640. All Work Group members are required to complete, sign, and submit a financial disclosure and attestation form showing all such relationships that might be perceived as or are actual conflicts of interest. All reported information is published in the Work Group members' Biographic and Disclosure section, which can be found in the full-text guideline update (http://kdigo.org/wp-content/uploads/2017/02/2017-KDIGO-CKD-MBD-GL-Update.pdf).
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Requests for Single Reprints: Markus Ketteler, MD, Division of Nephrology, Klinikum Coburg GmbH, Ketschendorfer Street 33, 96450 Coburg, Germany (e-mail, firstname.lastname@example.org); Mary B. Leonard, MD, MSCE, Stanford University School of Medicine, 300 Pasteur Drive, Room G-306, Stanford, CA 94305 (e-mail, email@example.com).
Current Author Addresses: Dr. Ketteler: Division of Nephrology, Klinikum Coburg GmbH, Ketschendorfer Street 33, 96450 Coburg, Germany.
Dr. Block: Denver Nephrology, 130 Rampart Way, Suite 175, Denver, CO 80230.
Dr. Evenepoel: University Hospitals Leuven, Herestraat 49, Leuven 3000, Belgium.
Dr. Fukagawa: Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, 143 Shimo-kasuya, Isehara 2591193, Japan.
Dr. Herzog: Hennepin County Medical Center/University of Minnesota, 914 South 8th Street, Suite S-4.100, Minneapolis, MN 55404.
Ms. McCann: 1406 North Foresto Bello Way, Eagle, ID 83616.
Dr. Moe: Indiana University, 950 West Walnut Street, R2-202, Indianapolis, IN 46202.
Dr. Shroff: Great Ormond Street Hospital for Children, NHS Foundation Trust, Great Ormond Street, London WC1N 3JH, United Kingdom.
Dr. Tonelli: University of Calgary, TRW 7th Floor, 3280 Hospital Drive Northwest, Calgary, Alberta T6G 2G3, Canada.
Dr. Toussaint: The Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria 3050, Australia.
Dr. Vervloet: VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands.
Dr. Leonard: Stanford University School of Medicine, 300 Pasteur Drive, Room G-306, Stanford, CA 94305.
Author Contributions: Conception and design: M. Ketteler, G.A. Block, M. Fukagawa, S.M. Moe, R. Shroff, N.D. Toussaint, M.G. Vervloet.
Analysis and interpretation of the data: M. Ketteler, G.A. Block, P. Evenepoel, L. McCann, S.M. Moe, R. Shroff, M.A. Tonelli, N.D. Toussaint, M.G. Vervloet, M.B. Leonard.
Drafting of the article: M. Ketteler, G.A. Block, L. McCann, R. Shroff, N.D. Toussaint, M.G. Vervloet.
Critical revision of the article for important intellectual content: M. Ketteler, G.A. Block, P. Evenepoel, C.A. Herzog, L. McCann, S.M. Moe, R. Shroff, M.A. Tonelli, N.D. Toussaint, M.G. Vervloet.
Final approval of the article: M. Ketteler, G.A. Block, P. Evenepoel, M. Fukagawa, C.A. Herzog, L. McCann, S.M. Moe, R. Shroff, M.A. Tonelli, N.D. Toussaint, M.G. Vervloet, M.B. Leonard.
Administrative, technical, or logistic support: M.B. Leonard.
Collection and assembly of data: M. Ketteler, G.A. Block, P. Evenepoel, M. Fukagawa, L. McCann, N.D. Toussaint, M.G. Vervloet.
The Kidney Disease: Improving Global Outcomes (KDIGO) 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease–Mineral and Bone Disorder (CKD–MBD) is a selective update of the prior CKD–MBD guideline published in 2009. The guideline update and the original publication are intended to assist practitioners caring for adults with CKD and those receiving long-term dialysis.
Development of the guideline update followed an explicit process of evidence review and appraisal. The approach adopted by the Work Group and the evidence review team was based on systematic reviews of relevant trials, appraisal of the quality of the evidence, and rating of the strength of recommendations according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Searches of the English-language literature were conducted through September 2015 and were supplemented with targeted searches through February 2017. Final modification of the guidelines was informed by a public review process involving numerous stakeholders, including patients, subject matter experts, and industry and national organizations.
The update process resulted in the revision of 15 recommendations. This synopsis focuses primarily on recommendations for diagnosis of and testing for CKD–MBD and treatment of CKD–MBD that emphasizes decreasing phosphate levels, maintaining calcium levels, and addressing elevated parathyroid hormone levels in adults with CKD stage G3a to G5 and those receiving dialysis. Key elements include basing treatment on trends in laboratory values rather than a single abnormal result and being cautious to avoid hypercalcemia when treating secondary hyperparathyroidism.
Prognosis of CKD, by categories of GFR and albuminuria.
CKD is defined as abnormalities of kidney structure or function that are present for >3 mo and have health implications. CKD is classified on the basis of cause, GFR category (G1 to G5), and albuminuria category (A1 to A3). Green means low risk (no CKD if no other markers of kidney disease), yellow means moderately increased risk, orange means high risk, and red means very high risk. The suffix “D” denotes dialysis (e.g., CKD G5D refers to a patient with CKD stage G5 who is receiving dialysis). (Reproduced with permission of Kidney Disease: Improving Global Outcomes.) CKD = chronic kidney disease; GFR = glomerular filtration rate.
Table. Consolidated KDIGO Guideline Recommendations for Adults With CKD Stage G3a to G5D and CKD–MBD*
Appendix Table 1. GRADE Criteria Used for Grading the Strength of a Recommendation*
Appendix Table 2. GRADE Criteria Used for Grading the Overall Quality of Evidence
Appendix Table 3. Research Questions Addressing the Systematic Update of Selected Recommendations
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Ketteler M, Block GA, Evenepoel P, Fukagawa M, Herzog CA, McCann L, et al. Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease–Mineral and Bone Disorder: Synopsis of the Kidney Disease: Improving Global Outcomes 2017 Clinical Practice Guideline Update. Ann Intern Med. 2018;168:422–430. doi: 10.7326/M17-2640
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Published: Ann Intern Med. 2018;168(6):422-430.
Published at www.annals.org on 20 February 2018
Chronic Kidney Disease, Guidelines, Nephrology.
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