Current concepts and management strategies in chronic kidney disease-mineral and bone disorder.

The term renal osteodystrophy describes the pathological changes in bone structure in chronic kidney disease (CKD); however, this term fails to describe adequately the adverse changes in mineral and hormonal metabolism in CKD that have grave consequences for patient survival. CKD-mineral and bone disorder (CKD-MBD) is a broader, newly defined term that should be used instead of renal osteodystrophy to define the mineral, bone, hormonal, and calcific cardiovascular abnormalities that are seen in CKD. The new paradigm in the management of renal bone disease is to "think beyond the bones" and strive to improve cardiovascular outcomes and survival. This means treating other aspects of the disease process that go beyond merely controlling parathyroid hormone levels. Primary physicians need to take a proactive approach to the management of CKD-MBD because the disorder begins early in the course of CKD, well before a patient is referred to a nephrologist. This review outlines the evidence behind the understanding of CKD-MBD, its implications for overall mortality, and the latest recommendations for management of CKD-MBD in patients with predialysis CKD.

Metabolic, renal, and nutritional consequences of bariatric surgery: implications for the clinician.

Management of obesity-associated comorbidities costs about $60 billion/year, about 5% of total US healthcare expenditure. Bariatric surgery is the only proven effective weight loss therapy for severely obese patients with a BMI > or =35 kg/m2. Bariatric surgery produces long-term weight loss, improves quality of life, and reduces the number of sick days and medication costs. Surgery has a profound effect on the metabolic milieu and nutritional status from the first few days after surgery, even before significant weight loss has been achieved. Metabolic effects of bariatric surgery reduce obesity-related comorbidities like type 2 diabetes, hypertension, metabolic syndrome, and cardiovascular disease risk. Improvement in renal function is seen, but adverse effects like oxalate nephropathy can lead to chronic kidney disease or end-stage renal disease (CKD/ESRD). Surgery can also lead to micronutrient deficiencies, making dietary supplementation necessary. Reduction in insulin resistance and hypertension after surgery makes medication adjustment imperative. Improvement in comorbidities and nutritional deficiencies after bariatric surgery has important clinical implications.

Bone disease in organ transplant patients: pathogenesis and management.

Bone disease is common in recipients of kidney, heart, lung, liver, and bone marrow transplants, and causes debilitating complications, such as osteoporosis, osteonecrosis, bone pain, and fractures. The frequency of fractures ranges from 6% to 45% for kidney transplant recipients to 22% to 42% for heart, lung, and liver transplant recipients. Bone disease in transplant patients is the sum of complex mechanisms that involve both preexisting bone disease before transplant and post-transplant bone loss due to the effects of immunosuppressive medications. Evaluation of bone disease should preferably start before the transplant or in the early post-transplant period and include assessment of bone mineral density and other metabolic factors that influence bone health. This requires close coordination between the primary care physician and transplant team. Patients should be stratified based on their fracture risk. Prevention and treatment include risk factor reduction, antiresorptive medications, such as bisphosphonates and calcitonin, calcitriol, and/or gonadal hormone replacement. A steroid-avoidance protocol may be considered.

Dyslipidemia in chronic kidney disease: managing a high-risk combination.

Cardiovascular disease (CVD) is the single largest cause of mortality in patients with chronic kidney disease (CKD), with those patients having a 10-year CVD-related morbidity and mortality of > 20%. This has led to the inclusion of CKD as a CVD equivalent, and justifies the aggressive treatment of modifiable risk factors such as dyslipidemia. Primary care physicians (PCP) often manage patients with CKD in the early stages of the disease and have a pivotal role in affecting long-term outcomes in CKD patients related to cardiovascular and all-cause mortality. Therefore, treatment of dyslipidemia often becomes the responsibility of the PCP and comes with its own set of challenges because of CKD-related issues (eg, the dose adjustments required). Exacerbating this problem is the fact that current guidelines are lengthy and complex. This article discusses the current guidelines for treating dyslipidemia in patients with CKD. Few studies have examined the safety and efficacy of pharmacotherapy for treatment of dyslipidemia in the CKD population, and ongoing studies such as the Study of Heart and Renal Protection (SHARP) should help clarify the current treatment guidelines.