Thematic Area: CKD-MBD

Haemodiafiltration versus high-flux haemodialysis—a Consensus Statement from the EuDial Working Group of the ERA

Reference: Battaglia Y, Shroff R, Meijers B, et al. Haemodiafiltration versus high-flux haemodialysis - a Consensus Statement from the EuDial Working Group of the ERA. Nephrol Dial Transplant. Published online February 6, 2025. doi:10.1093/ndt/gfaf024

The Consensus Statement was reviewed and evaluated by ERKNet experts using the AGREE-II methodology. Following this assessment, the ERKNet Network Board officially endorsed the guideline and committed to implementing its recommendations in clinical practice.

Diagnosis and management of mineral and bone disorders in infants with CKD: clinical practice points from the ESPN CKD‑MBD and Dialysis working groups and the Pediatric Renal Nutrition Taskforce

Reference: Bacchetta J, Schmitt CP, Bakkaloglu SA, et al. Diagnosis and management of mineral and bone disorders in infants with CKD: clinical practice points from the ESPN CKD-MBD and Dialysis working groups and the Pediatric Renal Nutrition Taskforce. Pediatr Nephrol. 2023;38(9):3163-3181. doi:10.1007/s00467-022-05825-6

The guidance dicument was reviewed and evaluated by ERKNet experts using the AGREE-II methodology. Following this assessment, the ERKNet Network Board officially endorsed the guideline and committed to implementing its recommendations in clinical practice.

Clinical Practice Recommendations for Native Vitamin D Therapy in Children with CKD Stages 2-5 and on Dialysis

Reference: Shroff R, Wan M, Nagler EV, et al. Nephrol Dial Transplant. (2017). doi: 10.1093/ndt/gfx065

Core Recommendations:

1. Measure serum 25(OH)D concentration for assessing the vitamin D status of children with CKD 2-5D. Measurement is recommended 6 – 12 monthly, depending on the CKD stage  
2. Maintain serum 25(OH)D levels above 75nMol/L  (>30ng/ml)  
3. A treatment regimen, guided by age and vitamin D concentration, for the prevention and treatment of vitamin D deficiency is suggested. An intensive replacement phase followed by a maintenance phase of treatment is recommended  
4. Mega-dose vitamin D therapy is not recommended 
5. Vitamin D supplementation must be stopped at serum 25(OH)D concentrations above 120nMol/L (48ng/ml). Symptomatic toxicity from Vitamin D is defined as serum 25(OH)D above 250nMol/L with hypercalcaemia, hypercalciuria and suppressed PTH

Comments by evaluators:

• Very helpful guideline in a field where evidence and evidence-based guidelines are missing

Clinical Practice Recommodations for Treatment with Active Vitamin D Analogues in Children with CKD Stage 2-5 and on Dialysis

Reference: Shroff R, Wan M, Nagler EV, et al. Nephrol Dial Transplant. (2017). doi: 10.1093/ndt/gfx080

Core Recommendations:

1. Suggest vitamin D analogues in children with CKD 2-5D who have persistently increased serum PTH concentrations above the CKD specific target range
2. Any vitamin D analogue can be used to reduce PTH levels.
3. Start vitamin D analogues in the lowest dose to achieve target PTH concentrations and maintain normocalcemia. Subsequent titration of vitamin D therapy may be performed based on trends in serum calcium, phosphate and PTH level. 

Comments by evaluators:

• no comments

KDIGO Clinical Practice Guideline for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD) (including 2017 update)

Reference: Kidney Disease: Improving Global Outcomes (KDIGO) CKD-MBD Work Group. Kidney Int Suppl. (2009). doi: 10.1038/ki.2009.188

Core Recommendations:

1. In children with CKD 3-5D maintain serum calcium in the age-appropriate normal range. 
2. It is reasonable to base the choice of phosphate-lowering treatment on serum calcium levels 
3. Calcitriol and vitamin D analogs may be considered to maintain serum calcium levels in the age-appropriate normal range  

Comments by evaluators:

• In some guidelines the distinction between adults and children is not always clear.
• The described rationale is solid and based on systematically gathered information.

Prevention and Treatment of Renal Osteodystrophy in Children on Chronic Renal Failure: European Guidelines

Reference: Klaus G, Watson A, Edefonti A, et al. Pediatr Nephrol. (2006). doi: 10.1007/s00467-005-2082-7

Core Recommendations:

1. Clinical, biochemical and radiological markers of renal bone disease should be monitored regularly  
2. Metabolic acidosis should be corrected  
3. For control of hyperphosphataemia aluminium free phosphate binders should be administered 
4. Vitamin D deficiency should be avoided 
5. Marked hyperparathyroidism should be avoided and PTH levels should be kept at two to three times the upper limit of the normal range in end-stage renal disease
6. Treatment with growth hormone should not be started in the presence of severe hyperparathyroid bone disease
7. In case of hypercalcemia, active vitamin D metabolites and calcium-containing phosphate binders should be stopped and dialysate changed to low-calcium solutions.
8. Parathyroidectomy has to be considered in case of severe, therapy-refractory hyperparathyroidism with radiological signs in combination with hypercalcemia and/or elevated calcium phosphorus product

Comments by evaluators:

• This guideline was published in 2006 before rigorous guideline development methodology was defined and systems such as GRADE were available. The guideline is widely quoted and used in many paediatric nephrology centres around Europe. Currently, there is no better evidence to challenge or change these recommendations.
• The recommendation on parathyroidectomy may be outdated, as cinacalcet use should be considered before considering surgery.
• The discipline/content expertise and the description of the members’ role in the guideline is not always clear.