JULY/AUGUST 2004 VOLUME 1 ISSUE 1

CHRONIC KIDNEY DISEASE

BEST PRACTICE
Welcome to Best Practice
We hope you enjoy the first issue of this
new professional newsletter published by
the National Kidney Foundation (NKF).
With each bimonthly issue, we hope to
promote better outcomes for Stage 5
chronic kidney disease (CKD) patients by
sharing the experiences of clinicians around
the country, that have demonstrated
improved outcomes using “best practice”
clinical protocols.
Each issue will showcase examples of
successful implementation of the Kidney
Disease Outcomes Quality Initiative
(K/DOQI) guidelines (formerly known as
Dialysis Outcomes Quality Initiative [DOQI]
guidelines) in dialysis patients.
K/DOQI guidelines have revolutionized
dialysis care in the U.S. and abroad. Since
they were first published in 1997, delivered
Kt/V has increased in hemodialysis patients,
weekly creatinine clearance has increased in
peritoneal dialysis patients, mean monthly
hemoglobin levels have risen, and an
increase in arteriovenous (AV) fistula
insertion rates have been noted. Despite
these developments, dialysis patient
mortality rates remain high, albeit slightly
improved over the past decade, and
considerable variability in practice and
clinical outcomes persist.
Although it can be argued that there is
no single right way to manage specific
clinical problems, dissemination of “best
practices” should aid in furthering the NKF
mission of translating K/DOQI guidelines
into improved outcomes. Best Practice will
be distributed to dialysis units around the
country and through NKF meetings and
exhibits. It’s targeted to the entire dialysis
team, including medical directors, nursing
staff, pharmacists, dietitians, social workers,
and technicians.
This introductory issue contains an article
by Dr. Garabed Eknoyan, providing an
overview of K/DOQI that discusses its
profound impact on dialysis practice
patterns. An article by Dr. Friedrich Port
describes the Dialysis Outcomes and
Practice Patterns Study (DOPPS), an
international study of hemodialysis patients
that has already identified important
variations in practice and areas in need
of improvement. Subsequent issues will
each have a major theme, such as anemia
management, iron administration, vascular
access, bone disease, medications, nutrition,
dyslipidemia, peritoneal dialysis, and
hemodialysis adequacy.
Dialysis units are encouraged to contribute
protocols that will comprise articles for
future issues. To be considered, submit
a short description of your clinic’s best
practices for achieving K/DOQI goals,
using the enclosed Best Practice Submission
Form or go to NKF’s KLS Web site
(www.nkfkls.org). The editorial board will
review all submissions and invite a formal
article from selected units.
We are very excited about this new under-
taking and welcome your participation and
feedback.
Anton C. Schoolwerth, MD, MSHA
EDITOR IN CHIEF

K/DOQI: Making Lives Better for Patients

with Chronic Kidney Disease IN THIS ISSUE:
by Garabed Eknoyan, MD, Founding K/DOQI Co-Chair

Significant improvements and knowledge have favorably impacted survival on dialysis, DOPPS Findings Help Define
but many opportunities remain for further improvement. To make the most of these Best Practices in Dialysis
opportunities and improve outcomes for the more than 300,000 Americans who receive by Friedrich K. Port, MD PAGE 3
dialysis for the treatment of kidney failure, in 1995 the National Kidney Foundation
launched the Dialysis Outcomes Quality Initiative (DOQI), a project to develop clinical
practice guidelines. Update: What’s New in
Four guidelines were published in 1997, covering hemodialysis adequacy, peritoneal Managing Bone Disease in CKD
dialysis adequacy, vascular access and anemia of chronic kidney disease (CKD). by George R. Bailie, PharmD, PhD
Continued p.2 PAGE 4
This publication is supported by an educational grant from
JULY/AUGUST 2004 VOLUME I ISSUE I
CHRONIC KIDNEY DISEASE
BEST PRACTICE
A PUBLICATION OF THE
EDITOR IN CHIEF
Anton C. Schoolwerth, MD, MSHA
Senior Consultant on Chronic Kidney Disease
Centers for Disease Control and Prevention
Visiting Professor, Dartmouth-Hitchcock
Medical Center
EDITORIAL ADVISORY BOARD
George R. Bailie, PharmD, PhD
Professor of Pharmacy Practice
Albany College of Pharmacy
Marilyn M. Gammarino, RD, LD, CDE
Nutrition Consultant, Rockville, MD
Friedrich K. Port, MD, MS
President, URREA, Ann Arbor, MI, Professor
Emeritus of Medicine and Epidemiology
Christopher O. Simon, MSW, LCSW-C
Social Work Coordinator, Independent
Dialysis Foundation
Donna L. Mapes, DNSc, MS
Adjunct Senior Researcher, URREA
Adjunct Assistant Clinical Professor, UCSF
Descriptions of best practices in this newsletter
are intended to highlight and communicate
successful approaches to advancing the goals of
K/DOQI. They do not necessarily represent an
endorsement by NKF.
Best Practice is published bimonthly by the National
Kidney Foundation. The material is covered by
copyright. All rights reserved. Express written
permission is required to reproduce, in any manner,
the contents of this issue. For more information
write to National Kidney Foundation,
30 E. 33rd Street, New York, NY 10016.
© 2004 National Kidney Foundation
Additional guidelines are currently being developed and are due to be published within the next year. One K/DOQI work group is examining
issues related to cardiovascular disease among dialysis patients, while another group is developing guidelines on diagnosis and staging
of diabetic kidney disease. Each of these new guidelines will be accompanied by an implementation guide in an effort to translate the
recommendations into clinical practice.
AN INDIVIDUALIZED APPROACH
While extensive effort has gone into the guideline development process and attention has been paid to detail and scientific rigor, it is
essential to emphasize that these documents are guidelines, not standards or mandates. Each recommendation in the guidelines is accompanied
by a rationale, enabling caregivers to make informed decisions about the proper care plan for each individual patient. Variations in practice
are expected and appropriate. (Copies of K/DOQI guidelines may be ordered from the National Kidney Foundation or accessed online at
www.kdoqi.org)
K/DOQI: MAKING LIVES BETTER FOR PATIENTS WITH CHRONIC KIDNEY DISEASE
Continued from p.1
DOPPS Findings Help Define Best Practices in Dialysis
by Friedrich K. Port, MD, President of URREA
These were the first comprehensive efforts to provide evidence-based guidance to clinical care teams.
The guidelines, supported by an educational grant from Amgen, the Founding and Principal Sponsor of Despite the success of dialysis therapy in
K/DOQI, have been widely adopted in the United States and abroad. They have served as the basis for improving and lengthening the lives of
clinical performance measures developed by the Centers for Medicare and Medicaid Services (CMS). patients with kidney failure, hemodialysis
These guidelines are evolving documents; they were updated in 2000 and new updates are expected patients continue to have higher death and
for three of them in 2005 and for the fourth, on anemia management, in 2006. hospitalization rates and poorer quality of
life than the general population. To address
FROM DOQI TO K/DOQI this situation, the Dialysis Outcomes and
In the course of developing the DOQI guidelines, it became evident that, while it was necessary to Practice Patterns Study (DOPPS) was initiated
improve the health status of individuals who require maintenance dialysis, an even greater opportu- in 1996 with the aim of improving our
nity existed. This was to improve outcomes for all patients with CKD, beginning at the earliest stages understanding of which dialysis practices
of kidney injury through the entire course of progressive loss of kidney function, well before kidney achieve the best patient outcomes.
failure sets in and replacement therapy becomes necessary to sustain life.
Before the DOPPS, it was difficult to
There is growing evidence that it is possible to delay the progression of kidney disease to kidney determine the degree to which differences
failure and prevent complications such as cardiovascular disease. Yet, the application of these in patient outcomes were related to patient
characteristics (such as heart disease) or to
medical advances remains inconsistent, resulting in variation in clinical practice and, sadly, avoidable
poor outcomes. Therefore, a new and more ambitious program was initiated to encompass the entire variations in the care given to patients. It
spectrum of kidney disease. To reflect this expansion, reference to “dialysis” in the acronym was was also hard to discern which methods of
changed to “disease” and the new initiative was termed Kidney Disease Outcomes Quality Initiative performing dialysis treatment were most
(K/DOQI), launched in January 2000. helpful and which were potentially harmful.
CKD GUIDELINES The primary points of study for the DOPPS,
The centerpiece of K/DOQI is the CKD guidelines on evaluation, classification, and stratification. which is coordinated by the University Renal
The publication of these guidelines in February 2002 marked a milestone in the evolution of clinical Research and Education Association (URREA)
practice guidelines and the delivery of care in nephrology. Specifically, these guidelines defined CKD in Ann Arbor, Michigan, include risks of
and classified its stages, irrespective of underlying cause; determined laboratory measurements for hospitalization and death, vascular access
the clinical assessment of kidney function; associated the level of kidney function with systemic complications, quality of life, diseases
complications that develop during progressive kidney disease; and stratified the risk of loss of kidney that accompany kidney failure, patient
function and development of cardiovascular disease in CKD. characteristics, medication use, nutrition
and dialysis prescriptions.
INTERVENTIONAL GUIDELINES
The classification proposed in the CKD guidelines constitutes
DOPPS currently collects data on dialysis
the basis of K/DOQI interventional guidelines. The first of these
patients and facilities in 12 countries—
guidelines—the management of dyslipidemias in CKD—is
Australia, New Zealand, Belgium, Canada,
intended to guide practitioners as they manage their patients’
France, Germany, Italy, Japan, Spain, Sweden,
lipid levels to appropriate targets. It was published as a
the United Kingdom and the United States.
supplement to the American Journal of Kidney Diseases (AJKD)
The international scope of the DOPPS
in April 2003. maximizes the diversity of practices and
The second set of interventional guidelines, on the management patient characteristics that can be explored.
Dialysis units enrolled in the DOPPS collect a
of mineral and bone disorders in CKD (published as a supple-
ment to the AJKD in October 2003), addresses the significant wealth of data about their patients, such as
roles of serum phosphorus and calcium, parathyroid hormone, the cause of kidney disease, other medical
and vitamin D in the high incidence of bone disease and cardiac conditions, laboratory
disorders in patients with CKD. Another set of interventional values and medications.
(All information that
guidelines, published in May 2004, addresses the evaluation
dialysis units collect
and management of blood pressure in CKD.
about their patients is
kept strictly confidential.)
Characteristics of
participating facilities,
such as staffing
ratios for nurses and
technicians; preventive
care policies; and the
frequency of visits by
physicians, dietitians,
and social workers, are
also studied. Dots represent dialysis facilities collecting data for the DOPPS.
Because the DOPPS studies patients and
treatment over time, it can track trends
in dialysis practices. The DOPPS allows for
important observations of the impact of
dialysis practice guidelines and provides
support for their refinement and the
development of new guidelines.
In the U.S., for instance,
DOPPS data, along with
other medical evidence,
have been used by the
National Kidney
Foundation to
periodically update the
Kidney Disease
Outcomes Quality
Initiative (K/DOQI)
Clinical Practice
Guidelines. The K/DOQI
guidelines cover a wide
range of practices for
FIGURE 1: Vascular Access Use Among First-Time Hemodialysis Patients in
treating chronic kidney Europe, Japan, and the United States
disease.
Examples of K/DOQI guidelines that have
been confirmed by the DOPPS include (but
are not limited to) optimum hemodialysis
dose; control of anemia, phosphorus
(phosphate), calcium, and parathyroid
hormone (PTH); and choice of vascular
access. The DOPPS has shown that there
were improvements in dialysis dose and
control of anemia from 1999/2000 to
2002/2003. However, control of phosphorus
did not improve during this time.
TWO RECENT FINDINGS FROM THE DOPPS
VASCULAR ACCESS: The DOPPS revealed differ-
ent patterns of vascular access use in Europe,
Japan and the U.S., particularly the type of
access used by patients newly starting
chronic hemodialysis treatments. As Figure 1
shows, 65% to 75% of such patients in
Japan and Europe began their hemodialysis
treatment with an AV fistula, compared to
only 15% in the U.S. In the U.S., synthetic
grafts accounted for 24% of vascular
accesses in patients beginning hemodialysis.
In Europe and Japan, the percentage was
far lower (3% to 8%).
The DOPPS analysis also showed that
synthetic grafts were associated with nearly
twice the rate of having an intervention or
failure as compared with AV fistulae. About
half of the synthetic grafts required some
intervention during one year, compared to
32% for AV fistulae. Furthermore, use of a
catheter for vascular access was associated
with a 1.6-fold higher failure rate of a
subsequently used AV fistula.
This example highlights how the findings
of DOPPS researchers support the K/DOQI
guidelines. Those guidelines recommended
AV fistulae as the preferred access for
hemodialysis patients, and minimizing the
use of catheters.
QUALITY OF LIFE: Using the Kidney
Disease Quality of Life Short Form, a patient
questionnaire, the DOPPS analyzed a variety
of quality of life scores that reflected each
patient’s state of mental health and general
physical health. The quality of life summary
scores were compared with each patient’s
level of albumin as related to patient
outcomes. Low albumin levels have been
used to predict the likelihood of patient
hospitalization and/or death.
Continued p.4
JULY/AUGUST 2004 VOLUME I ISSUE I
CHRONIC KIDNEY DISEASE
BEST PRACTICE
A PUBLICATION OF THE
EDITOR IN CHIEF
Anton C. Schoolwerth, MD, MSHA
Senior Consultant on Chronic Kidney Disease
Centers for Disease Control and Prevention
Visiting Professor, Dartmouth-Hitchcock
Medical Center
EDITORIAL ADVISORY BOARD
George R. Bailie, PharmD, PhD
Professor of Pharmacy Practice
Albany College of Pharmacy
Marilyn M. Gammarino, RD, LD, CDE
Nutrition Consultant, Rockville, MD
Friedrich K. Port, MD, MS
President, URREA, Ann Arbor, MI, Professor
Emeritus of Medicine and Epidemiology
Christopher O. Simon, MSW, LCSW-C
Social Work Coordinator, Independent
Dialysis Foundation
Donna L. Mapes, DNSc, MS
Adjunct Senior Researcher, URREA
Adjunct Assistant Clinical Professor, UCSF
Descriptions of best practices in this newsletter
are intended to highlight and communicate
successful approaches to advancing the goals of
K/DOQI. They do not necessarily represent an
endorsement by NKF.
Best Practice is published bimonthly by the National
Kidney Foundation. The material is covered by
copyright. All rights reserved. Express written
permission is required to reproduce, in any manner,
the contents of this issue. For more information
write to National Kidney Foundation,
30 E. 33rd Street, New York, NY 10016.
© 2004 National Kidney Foundation
Additional guidelines are currently being developed and are due to be published within the next year. One K/DOQI work group is examining
issues related to cardiovascular disease among dialysis patients, while another group is developing guidelines on diagnosis and staging
of diabetic kidney disease. Each of these new guidelines will be accompanied by an implementation guide in an effort to translate the
recommendations into clinical practice.
AN INDIVIDUALIZED APPROACH
While extensive effort has gone into the guideline development process and attention has been paid to detail and scientific rigor, it is
essential to emphasize that these documents are guidelines, not standards or mandates. Each recommendation in the guidelines is accompanied
by a rationale, enabling caregivers to make informed decisions about the proper care plan for each individual patient. Variations in practice
are expected and appropriate. (Copies of K/DOQI guidelines may be ordered from the National Kidney Foundation or accessed online at
www.kdoqi.org)
K/DOQI: MAKING LIVES BETTER FOR PATIENTS WITH CHRONIC KIDNEY DISEASE
Continued from p.1
DOPPS Findings Help Define Best Practices in Dialysis
by Friedrich K. Port, MD, President of URREA
These were the first comprehensive efforts to provide evidence-based guidance to clinical care teams.
The guidelines, supported by an educational grant from Amgen, the Founding and Principal Sponsor of Despite the success of dialysis therapy in
K/DOQI, have been widely adopted in the United States and abroad. They have served as the basis for improving and lengthening the lives of
clinical performance measures developed by the Centers for Medicare and Medicaid Services (CMS). patients with kidney failure, hemodialysis
These guidelines are evolving documents; they were updated in 2000 and new updates are expected patients continue to have higher death and
for three of them in 2005 and for the fourth, on anemia management, in 2006. hospitalization rates and poorer quality of
life than the general population. To address
FROM DOQI TO K/DOQI this situation, the Dialysis Outcomes and
In the course of developing the DOQI guidelines, it became evident that, while it was necessary to Practice Patterns Study (DOPPS) was initiated
improve the health status of individuals who require maintenance dialysis, an even greater opportu- in 1996 with the aim of improving our
nity existed. This was to improve outcomes for all patients with CKD, beginning at the earliest stages understanding of which dialysis practices
of kidney injury through the entire course of progressive loss of kidney function, well before kidney achieve the best patient outcomes.
failure sets in and replacement therapy becomes necessary to sustain life.
Before the DOPPS, it was difficult to
There is growing evidence that it is possible to delay the progression of kidney disease to kidney determine the degree to which differences
failure and prevent complications such as cardiovascular disease. Yet, the application of these in patient outcomes were related to patient
characteristics (such as heart disease) or to
medical advances remains inconsistent, resulting in variation in clinical practice and, sadly, avoidable
poor outcomes. Therefore, a new and more ambitious program was initiated to encompass the entire variations in the care given to patients. It
spectrum of kidney disease. To reflect this expansion, reference to “dialysis” in the acronym was was also hard to discern which methods of
changed to “disease” and the new initiative was termed Kidney Disease Outcomes Quality Initiative performing dialysis treatment were most
(K/DOQI), launched in January 2000. helpful and which were potentially harmful.
CKD GUIDELINES The primary points of study for the DOPPS,
The centerpiece of K/DOQI is the CKD guidelines on evaluation, classification, and stratification. which is coordinated by the University Renal
The publication of these guidelines in February 2002 marked a milestone in the evolution of clinical Research and Education Association (URREA)
practice guidelines and the delivery of care in nephrology. Specifically, these guidelines defined CKD in Ann Arbor, Michigan, include risks of
and classified its stages, irrespective of underlying cause; determined laboratory measurements for hospitalization and death, vascular access
the clinical assessment of kidney function; associated the level of kidney function with systemic complications, quality of life, diseases
complications that develop during progressive kidney disease; and stratified the risk of loss of kidney that accompany kidney failure, patient
function and development of cardiovascular disease in CKD. characteristics, medication use, nutrition
and dialysis prescriptions.
INTERVENTIONAL GUIDELINES
The classification proposed in the CKD guidelines constitutes
DOPPS currently collects data on dialysis
the basis of K/DOQI interventional guidelines. The first of these
patients and facilities in 12 countries—
guidelines—the management of dyslipidemias in CKD—is
Australia, New Zealand, Belgium, Canada,
intended to guide practitioners as they manage their patients’
France, Germany, Italy, Japan, Spain, Sweden,
lipid levels to appropriate targets. It was published as a
the United Kingdom and the United States.
supplement to the American Journal of Kidney Diseases (AJKD)
The international scope of the DOPPS
in April 2003. maximizes the diversity of practices and
The second set of interventional guidelines, on the management patient characteristics that can be explored.
Dialysis units enrolled in the DOPPS collect a
of mineral and bone disorders in CKD (published as a supple-
ment to the AJKD in October 2003), addresses the significant wealth of data about their patients, such as
roles of serum phosphorus and calcium, parathyroid hormone, the cause of kidney disease, other medical
and vitamin D in the high incidence of bone disease and cardiac conditions, laboratory
disorders in patients with CKD. Another set of interventional values and medications.
(All information that
guidelines, published in May 2004, addresses the evaluation
dialysis units collect
and management of blood pressure in CKD.
about their patients is
kept strictly confidential.)
Characteristics of
participating facilities,
such as staffing
ratios for nurses and
technicians; preventive
care policies; and the
frequency of visits by
physicians, dietitians,
and social workers, are
also studied. Dots represent dialysis facilities collecting data for the DOPPS.
Because the DOPPS studies patients and
treatment over time, it can track trends
in dialysis practices. The DOPPS allows for
important observations of the impact of
dialysis practice guidelines and provides
support for their refinement and the
development of new guidelines.
In the U.S., for instance,
DOPPS data, along with
other medical evidence,
have been used by the
National Kidney
Foundation to
periodically update the
Kidney Disease
Outcomes Quality
Initiative (K/DOQI)
Clinical Practice
Guidelines. The K/DOQI
guidelines cover a wide
range of practices for
FIGURE 1: Vascular Access Use Among First-Time Hemodialysis Patients in
treating chronic kidney Europe, Japan, and the United States
disease.
Examples of K/DOQI guidelines that have
been confirmed by the DOPPS include (but
are not limited to) optimum hemodialysis
dose; control of anemia, phosphorus
(phosphate), calcium, and parathyroid
hormone (PTH); and choice of vascular
access. The DOPPS has shown that there
were improvements in dialysis dose and
control of anemia from 1999/2000 to
2002/2003. However, control of phosphorus
did not improve during this time.
TWO RECENT FINDINGS FROM THE DOPPS
VASCULAR ACCESS: The DOPPS revealed differ-
ent patterns of vascular access use in Europe,
Japan and the U.S., particularly the type of
access used by patients newly starting
chronic hemodialysis treatments. As Figure 1
shows, 65% to 75% of such patients in
Japan and Europe began their hemodialysis
treatment with an AV fistula, compared to
only 15% in the U.S. In the U.S., synthetic
grafts accounted for 24% of vascular
accesses in patients beginning hemodialysis.
In Europe and Japan, the percentage was
far lower (3% to 8%).
The DOPPS analysis also showed that
synthetic grafts were associated with nearly
twice the rate of having an intervention or
failure as compared with AV fistulae. About
half of the synthetic grafts required some
intervention during one year, compared to
32% for AV fistulae. Furthermore, use of a
catheter for vascular access was associated
with a 1.6-fold higher failure rate of a
subsequently used AV fistula.
This example highlights how the findings
of DOPPS researchers support the K/DOQI
guidelines. Those guidelines recommended
AV fistulae as the preferred access for
hemodialysis patients, and minimizing the
use of catheters.
QUALITY OF LIFE: Using the Kidney
Disease Quality of Life Short Form, a patient
questionnaire, the DOPPS analyzed a variety
of quality of life scores that reflected each
patient’s state of mental health and general
physical health. The quality of life summary
scores were compared with each patient’s
level of albumin as related to patient
outcomes. Low albumin levels have been
used to predict the likelihood of patient
hospitalization and/or death.
Continued p.4
 DOPPS FINDINGS
Continued from p.3
Patients with lower mental and physical summary scores had
worse outcomes than patients with higher mental and physical
scores. In fact, patients’ physical scores were better predictors
of patient hospitalization and/or death than albumin levels. As
a result, this study suggests that asking patients directly about
their physical and mental issues can be very useful in managing
patients and avoiding serious problems.
The DOPPS offers numerous additional findings on modifiable
practices that are associated with greater longevity, fewer
hospital admissions and better quality of life (see future issues
of this newsletter for additional examples). The team at URREA
thanks all dialysis units and patients who have contributed
to this important data collection. Their participation—plus
funding from Amgen and Kirin—made these and other DOPPS
investigations possible.
REFERENCES
Goodkin DA, Bragg-Gresham JL, Koenig KG, et al. Association of comorbid
conditions and mortality in hemodialysis patients in Europe, Japan, and
the United States: The Dialysis Outcomes and Practice Patterns Study
(DOPPS). J Am Soc Nephrol. 2003;14:3270-3277.
Mapes DL, Lopes AA, Satayathum S, et al. Health-related quality of life as
a predictor of mortality and hospitalization: The Dialysis Outcomes and
Practice Patterns Study (DOPPS). Kidney Int. 2003;64:339-349.
Pisoni RL, Young EW, Mapes DL, Keen ML, Port FK. Vascular access use and
outcomes in the U.S., Europe, and Japan: Results from the Dialysis
Outcomes and Practice Patterns Study (DOPPS). Nephrol News Issues.
May 2003:39-45.
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30 East 33rd Street
New York, NY 10016 PAID
New York, NY
Permit No. 5327
Update: What’s New in Managing Bone
Disease in CKD
by George R. Bailie, PharmD, PhD,
Professor of Pharmacy Practice, Albany College of Pharmacy
MEDICATIONS
Clinicians treating patients with chronic
kidney disease who are on dialysis and
who develop secondary hyperparathy-
roidism now have a new class of
agents, the calcimimetics, at their
disposal. The first oral drug of this
class, cinacalcet, recently received FDA
approval. Calcimimetics have a novel
mechanism of action that is distinct
from both vitamin D analogs and
phosphate binders. They increase the
sensitivity of the calcium-sensing
receptor on parathyroid cells to serum
calcium concentrations. Thus, lower serum calcium concentrations
are needed to stimulate the receptors. Stimulation of the calcium-
sensing receptors directly results in lowered PTH secretion. As a
result, there is less bone turnover and less calcium released into the
systemic circulation. Serum calcium phosphorus product values also
decrease. Vitamin D analogs act on vitamin D receptors (VDR) on
parathyroid cells to reduce PTH secretion, but VDR stimulation in
the gastrointestinal tract causes enhanced calcium absorption. The
exact place of calcimimetics in treatment remains to be clarified.
The FDA has also recently approved a new indication for the
pro-hormone vitamin D2 analog, doxercalciferol. This drug, which
had previously been approved for the treatment of secondary
hyperparathyroidism in dialysis patients, is now approved for the
treatment of secondary hyperparathyroidism that develops in the
earlier stages (3 and 4) of chronic kidney disease prior to dialysis.
EDUCATIONAL RESOURCES
In October 2003, the National Kidney Foundation published the
K/DOQI Clinical Practice Guidelines for Bone Metabolism and
Disease in CKD. Copies of the Guidelines are available from the
NKF. The Guidelines may also be accessed online at www.kdoqi.org.
A wide variety of educational tools have also been developed to
help implement the Guidelines. These include clinical handbooks,
patient education booklets, wall charts and pocket tools. For
more information and to obtain materials, contact the NKF at
800-622-9010 ext.175, or e-mail: crystalt@kidney.org
02-91-4506
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