Chapter 3.1: Diagnosis of CKD–MBD: biochemical abnormalities   Kidney International  Volume 76, Pages S22-S49 (August 2009) DOI: 10.1038/ki.2009.191 Copyright © 2009 International Society of Nephrology Terms and Conditions

Figure 4 Prevalence of abnormal mineral metabolism in CKD. (a) The prevalence of hyperparathyroidism, hypocalcemia, and hyperphosphatemia by eGFR levels at 10-ml/min per 1.73 m2 intervals. (b) Median values of serum Ca, P, and iPTH by eGFR levels. (c) Median values of 1,25 (OH)2D3, 25(OH)D3, and iPTH by GFR levels. CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; GFR, glomerular filtration rate; iPTH, intact parathyroid hormone. Reprinted with permission from Levin et al.28 Kidney International 2009 76, S22-S49DOI: (10.1038/ki.2009.191) Copyright © 2009 International Society of Nephrology Terms and Conditions

Figure 5 Changes in serum calcium, phosphorus, and iPTH with time in hemodialysis patients of DOPPS countries. Distribution of baseline serum calcium (a), phosphorus (b), and PTH (c) by country and the DOPPS phase. See text for details. DOPPS, Dialysis Outcomes and Practice Pattern Study; PTH, parathyroid hormone. Reprinted with permission from Tentori et al.33 Kidney International 2009 76, S22-S49DOI: (10.1038/ki.2009.191) Copyright © 2009 International Society of Nephrology Terms and Conditions

Figure 6 PTH assays. The figure shows the entire parathyroid hormone molecule, composed of 84 amino acids. Mid/C-PTH, mid/carboxyl-terminus of parathyroid hormone; N-PTH, amino-terminus of parathyroid hormone; PTH, parathyroid hormone; RIA, radioimmunoassay. Reprinted with permission from Moe and Sprague.70 Kidney International 2009 76, S22-S49DOI: (10.1038/ki.2009.191) Copyright © 2009 International Society of Nephrology Terms and Conditions

Figure 7 Prevalence of types of bone disease as determined by bone biopsy in patients with CKD–MBD. Bone formation (turnover) is high in those with osteitis fibrosa and mild disease, and low in those with osteomalacia and adynamic bone disease. Mineralization is abnormal in those with osteomalacia and mixed disease. AD, adynamic bone; OF, osteitis fibrosa; OM, osteomalacia. Kidney International 2009 76, S22-S49DOI: (10.1038/ki.2009.191) Copyright © 2009 International Society of Nephrology Terms and Conditions

Figure 8 Prevalence of histological types of renal osteodystrophy in children with CKD stages 5–5D. AD, adynamic bone; OF, osteitis fibrosa; OM, osteomalacia. Kidney International 2009 76, S22-S49DOI: (10.1038/ki.2009.191) Copyright © 2009 International Society of Nephrology Terms and Conditions

Figure 9 Types of renal osteodystrophy before and after 1995. OF, osteitis fibrosa; OM, osteomalacia. Kidney International 2009 76, S22-S49DOI: (10.1038/ki.2009.191) Copyright © 2009 International Society of Nephrology Terms and Conditions

Figure 10 Prevalence of bone histology types by symptoms in patients with CKD stage 5D receiving HD treatment. CKD, chronic kidney disease; HD, hemodialysis; mixed, mixed renal osteodystrophy; OF, osteitis fibrosa; OM, osteomalacia. Kidney International 2009 76, S22-S49DOI: (10.1038/ki.2009.191) Copyright © 2009 International Society of Nephrology Terms and Conditions

Figure 11 Distribution of osteoporosis, osteopenia, and normal bone density by creatinine clearance in general US population. Reprinted with permission from Klawansky et al.122 Kidney International 2009 76, S22-S49DOI: (10.1038/ki.2009.191) Copyright © 2009 International Society of Nephrology Terms and Conditions

Figure 12 Overlap between osteoporosis and CKD stages 3–4. This graph shows the overlap between osteoporosis and CKD stages 3–4 in women from the United States, using data from the NHANES III survey. The kidney function was estimated using the Cockcroft–Gault equation, which results in a greater prevalence of CKD stage 3–4 than when other methods are used.123 CKD, chronic kidney disease; NHANES III survey, The Third National Health and Nutrition Examination Survey. Kidney International 2009 76, S22-S49DOI: (10.1038/ki.2009.191) Copyright © 2009 International Society of Nephrology Terms and Conditions

Figure 13 Bone mineral density in patients with CKD stage 5D. The graph is a summary of studies arranged in chronological order; each point is the mean value for a study. When more than one skeletal site or gender was measured in a study, the points are connected by a vertical line. If data from men and women were reported separately, the points for women are in a lighter shade. The size of points is larger in studies with greater numbers of individuals. Data from studies that reported g/cm2 were converted to Z-scores (hip and forearm) using the average age of the group of individuals and published normal reference ranges. Overall, the average cortical bone density for patients with CKD stage s.d. was about 0.5–1 s.d. below that expected for age and gender, but at the spine, the bone density measurements were closer to the average in persons without known CKD.115,128–182CKD, chronic kidney disease. Kidney International 2009 76, S22-S49DOI: (10.1038/ki.2009.191) Copyright © 2009 International Society of Nephrology Terms and Conditions

Figure 14 Correlation coefficients between bone formation rate as seen on bone biopsies and serum markers of PTH, bone-specific ALP (BAP), osteocalcin (OC), and collagen cross-linking molecules (x-link) in patients with CKD stages 5–5D. Each point represents a study, and they are arranged in chronological order from 1981 to 2006 from left to right. Studies that measured more than one marker are joined by a vertical line. The small symbols are studies of 20–50 patients, medium symbols 51–100 patients, and large symbols >100 patients. CKD, chronic kidney disease; PTH, parathyroid hormone. Kidney International 2009 76, S22-S49DOI: (10.1038/ki.2009.191) Copyright © 2009 International Society of Nephrology Terms and Conditions

Kidney International 2009 76, S22-S49DOI: (10.1038/ki.2009.191) Copyright © 2009 International Society of Nephrology Terms and Conditions

Kidney International 2009 76, S22-S49DOI: (10.1038/ki.2009.191) Copyright © 2009 International Society of Nephrology Terms and Conditions

Kidney International 2009 76, S22-S49DOI: (10.1038/ki.2009.191) Copyright © 2009 International Society of Nephrology Terms and Conditions