Adherence to K/DOQI guidelines for calcium-based phosphate binders in clinical practice.

OBJECTIVE: The Kidney Disease Outcomes Quality Initiative (K/DOQI) clinical practice guidelines for bone metabolism in chronic kidney disease recommend that calcium-based phosphate binders (CBPBs) be used in limited doses and be reduced or withheld when albumin-adjusted serum calcium exceeds target values, or when parathyroid hormone is below the target range. We sought to assess the pattern of CBPB use in a clinical practice setting. DESIGN: This was a retrospective review. PATIENTS: We reviewed 283 patients at three hemodialysis units in New York and New Jersey in which 39 physicians practice. METHODS: Data collected included intact parathyroid hormone levels (from February and May, 2006), blood chemistries (from April and May, 2006), and the use of CBPBs, vitamin D, and cinacalcet. The use of CBPBs was classified as "consistent" or "inconsistent" with the guidelines 1 month after the blood tests of May 2006 (to allow time for dosing adjustments). Because cinacalcet was not available when the K/DOQI guidelines were published, a failure to reduce or stop CBPBs in the presence of elevated calcium levels was still considered to be "consistent" use if cinacalcet was initiated in the appropriate time frame (5 patients). RESULTS: CBPBs were used in 172 of 283 patients (61%). In 10% (17 patients), doses exceeded the 1500-mg limit for calcium. Adjusted serum calcium levels exceeded 2.5 mmol/L (10.2 mg/dL) in 8 cases; CBPBs were not reduced or stopped in any of these. Similarly, CBPBs were reduced in only 2 of 27 patients on vitamin D, with an adjusted serum calcium level of 2.38 to 255 mmol/L (9.5 to 10.2 mg/dL). In all 10 patients with consecutive intact parathyroid hormone values of less than 150 ng/L (150 pg/mL), CBPBs were not discontinued or reduced. CONCLUSIONS: Overall, 50 of 172 patients (29%) receiving CBPBs did so in a manner inconsistent with K/DOQI guidelines. The reasons for this inconsistency are speculative, and may include disagreement with the opinion-based recommendations, insufficient knowledge of the guidelines, or individual patient considerations (including cost, tolerance, and effectiveness).

Medical treatment of renal artery stenosis: is it effective and appropriate?

Recent advances in endovascular technology have radically changed the options available for the clinical management of the patient with renovascular disease. These treatment options have fueled an ongoing debate concerning the appropriateness of interventional endovascular therapy for the stenotic renal artery versus conservative medical management. This review examines a typical clinical case scenario and analyzes relevant published literature and the recent guidelines from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) highlighting the significant shortcomings of evidence-based data when it comes to the management of this complex patient population. Early diagnosis provides the best opportunity for appropriate utilization of therapeutic options and rational timing of deployment of interventional techniques. Recommendations for conservative medical management are made based on the review of the medical management arms of the published interventional series. In addition, suggestions are made for practical modifications to the JNC 7 hypertension management protocol to better address the challenging diagnostic and management issues raised by the renovascular patient.