Therapeutic interventions for chronic kidney disease-mineral and bone disorders: focus on mortality

Purpose of review Chronic kidney disease-mineral and bone disorder (CKD-MBD) encompasses a broad spectrum of abnormalities related to bone and cardiovascular health. Many reports related to therapeutic interventions specifically aimed at these disorders describe an effect only on surrogate outcomes. This review will focus on recent literature pertaining to interventions directed at CKD-MBDs that emphasize the clinical outcome of mortality. Recent findings Higher levels of serum phosphorus (including those within the normal range) and its regulatory hormone, fibroblast growth factor 23 (FGF-23), are associated with increased mortality in patients with all stages of CKD. Reports investigating specific interventions that affect dietary intake of phosphorus, as well as serum levels of phosphorus, FGF-23, calcium, and parathyroid hormone have recently been published which support the hypothesis that abnormal mineral metabolism is directly linked to increased mortality. Unfortunately, with the exception of altered dialysis prescription, no intervention has been subject to the scrutiny of placebo-controlled randomized clinical trials. Summary Observational evidence continues to accumulate relating specific therapeutic interventions to improved survival in patients with kidney disease including phosphate binders, calcimimetics, and altered dietary and dialysis prescription patterns. It is time for randomized clinical trials to definitively establish whether or not interventions directed at CKD-MBD effect improvement in hard clinical outcomes in patients with kidney disease.