Dr. R. Daelemans ZNA Nierkliniek
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CKD-MBD Chronic Kidney Disease – Mineral Bone Disorder Dr. R. Daelemans ZNA Nierkliniek
Transcript of Dr. R. Daelemans ZNA Nierkliniek
CKD-MBD
Chronic Kidney Disease – Mineral Bone Disorder
Dr. R. Daelemans ZNA Nierkliniek
CKD-MBD
1. Definitie en diagnose
2. Fysiopathologie
3. Gevolgen
4. Behandeling
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Chronic Kidney Disease: risk of death and CV events Go, NEJM 2004
Go, NEJM 2004
Foley, Am J Kidney Dis 1998
The definition, classification and prognosis of CKD: a KDIGO report
Levey A. Kidney Int 2011
‘systeemaandoening’ door interactie tussen
nier, bijschildklier, bot, GI tractus, CV systeem
• calcium, fosfaat, PTH, vit D
• botmetabolisme:
- FGF-23
- osteïtis fibrosa
- osteomalacie / adynamisch bot
• vasculaire en klep calcificaties
Moe, Kidney Int 2006
CKD – MBD: DIAGNOSE
• Labo: P, Ca, 25OH vitD,
PTH (FGF-23)
• Calcificaties:
• RX abdomen
• CT, MRI
• Echocardio
• Botbiopsie
CKD – MBD: FYSIOPATHOLOGIE
P vit D
PTH
Secundaire hyperpara
NIERFUNCTIE
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CKD Nier: P excretie P Bot: Ca, P vrijstelling
Nier: vit D Klotho Bot: FGF-23 Bijschildklier:PTH
Darm: Ca absorptie Darm: P absorptie Nier: P excretie
Phosphorus, PTH and FGF-23 in CKD Isakova, Kidney Int 2011
Time profile of changes in P, PTH, vit D, FGF-23 and Klotho
John, Am J Kidney Dis 2012
Serum Phosphorus and the incidence of CV disease in the community
Dhingra, Arch Intern Med 2007
25 OH vitamin D and cardiovascular disease risk
Wang, Circ Cardiovasc Outcomes 2012
Vitamine D: update 2013 Gröber, Dermato-Endocrinol 2013
PTH levels and cardiovascular disease risk Thompson, Nat Rev Endocrinol 2013
FGF-23 and mortality in hemodialysis patients
FGF-23 FGF-23
PTH
1,25 OH vit D
RAAS
KLOTHO
inflammatie
LVH
Guttierez, NEJM 2008
FGF-23 and CV mortality in the community
Arnlov, Kidney Int 2013
Arterial calcification: role of the bone vascular axis
Thompson, Nat Rev Endocrinol 2013
Arterial calcification: role of the bone-vascular axis
Thompson, Nat Rev Endocrinol 2013 PROMOTOREN
• P, Ca, FGF-23
• vit D
INHIBITOREN
MGP
FetuinA
Magnesium
VSMC
OSTEOBLAST
23
24
CKD-MBD: BEHANDELING
DOEL
CKD: normaliseren P, Ca, 25OH vit D, PTH
Dialyse: normaliseren P, Ca, 25OH vit D
PTH: 150-300 pg/mL
CKD-MBD in Europe: cosmos study Fernandez-Martin, NDT 2013
CKD-MBD: BEHANDELING
1. Fosfaatbeperkend dieet
2. Fosfaatbinders
3. Behandelen hyperparathyroïdie - vitamine D
- calcimimetica
- parathyroïdectomie
CKD-MBD: BEHANDELING
CALCIUMZOUTEN NIET CALCIUMHOUDENDE P BINDERS
• Ca carbonaat, Ca acetaat
• Ca acetaat (Phoslo®)
• Ca acetaat + Mg carbonaat (Renepho®)
• Sevelamer (Renagel®, Renvela®)
• Lanthanum (Fosrenol® )
FOSFAATBINDERS
Phosphate-binding agents lower risk of mortality
Cannata-Andia, Kidney Int 2013
Effects of calcium-based versus non-calcium based phosphate binders on mortality: a meta-analysis
Jamal S, Lancet 2013
Sevelamer: effects in CKD Rastogi, Ther Adv Cardiovasc Dis 2013
Renagel, Renvela
Magnesium and outcomes in patients with CKD
Massy, Clin Kidney J 2012
• HypoMg and coronary artery
calcifications (Framingham
Heart Study)
Hruby JACC 2014
• HypoMg, risk of death and
GFR decline
Van Laecke S Am J Med 2013
Mg belet mineralisatie van VSMC door expressie MGP
CKD - MBD: BEHANDELING
VITAMINE D
VOEDING
Huid: UV cholecalciferol (D3) ergocalciferol (D2)
LEVER
25-OH Vit D
NIER
1,25 (OH) 2 vit D
CKD - MBD: BEHANDELING
VITAMINE D
Cholecalciferol D3 (D-Cure®) Actief vit D
Alfacalcidol (1 Alpha Leo®)
Calcitriol (Rocaltrol®)
Vitamin D treatment in CKD: a meta-analysis
Duranton, Am J Nephrol 2013
CKD – MBD: BEHANDELING
CALCIMIMETICA: Cinacalcet (Mimpara®)
PTH en FGF-23
(Echo study)
calcificaties
(Advance study) mortaliteit
(Evolve study)
CKD – MBD: BEHANDELING
PARATHYROIDECTOMY
Naranda J Int Med Res 2011 Goldenstein Plosone 2013
Ca supplements and risk of myocardial events
Bolland, BMJ 2010
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CKD - MBD: VITAMINE K
• CKD vit. K deficiëntie
MGP
• Vit K antag: coumarines vit K depletie inhibitor calcificaties
calcificaties
• Substitutie vit K: minder klep calcificaties
Shurgers L Kidney Int 2013
Krüger Semin Dial 2014
Zhang J Cardiovasc Pharmacol 2014
BESLUIT
1. CKD – MBD CV mortaliteit
2. Diagnose (vroegtijdig): Ca, P, 25OH vit D, PTH, (FGF-23), calcificaties
3. Behandeling: dieet, fosfaatbinders, vitamine D, calcimimetica, PTx
INDIVIDUEEL hyperCa, calcificaties, hoog PTH
