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KDIGO 2016 CLINICAL PRACTICE GUIDELINE …

KDIGO 2016 CLINICAL PRACTICE GUIDELINE UPDATE ON DIAGNOSIS, EVALUATION, PREVENTION AND TREATMENT OF CKD-MBD PUBLIC REVIEW DRAFT AUGUST 2016 ii TABLE OF CONTENTS iii Work Group iv KDIGO Executive vi Reference vii CKD viii Conversion ix Abbreviations and x 1 Summary and Comparison of 2016 Updated and 2009 KDIGO CKD-MBD 2 Chapter : Diagnosis of CKD MBD: 7 Chapter : Treatment of CKD MBD Targeted at Lowering High Serum Phosphorus and Maintaining Serum 12 Chapter : Treatment of Abnormal PTH levels in CKD 24 Chapter : Treatment of Bone with Bisphosphonates, Other Osteoporosis Medications, and Growth 31 Chapter 5: Evaluation and Treatment of Kidney Transplant Bone 32 Appendix: Methodologic Approach to the 2016 KDIGO CKD-MBD 34 45 iii DISCLAIMER SECTION I: USE OF THE CLINICAL PRACTICE GUIDELINE This CLINICAL PRACTICE GUIDELINE U

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Transcription of KDIGO 2016 CLINICAL PRACTICE GUIDELINE …

1 KDIGO 2016 CLINICAL PRACTICE GUIDELINE UPDATE ON DIAGNOSIS, EVALUATION, PREVENTION AND TREATMENT OF CKD-MBD PUBLIC REVIEW DRAFT AUGUST 2016 ii TABLE OF CONTENTS iii Work Group iv KDIGO Executive vi Reference vii CKD viii Conversion ix Abbreviations and x 1 Summary and Comparison of 2016 Updated and 2009 KDIGO CKD-MBD 2 Chapter : Diagnosis of CKD MBD: 7 Chapter : Treatment of CKD MBD Targeted at Lowering High Serum Phosphorus and Maintaining Serum 12 Chapter : Treatment of Abnormal PTH levels in CKD 24 Chapter : Treatment of Bone with Bisphosphonates, Other Osteoporosis Medications, and Growth 31 Chapter 5: Evaluation and Treatment of Kidney Transplant Bone 32 Appendix: Methodologic Approach to the 2016 KDIGO CKD-MBD 34 45 iii DISCLAIMER SECTION I: USE OF THE CLINICAL PRACTICE GUIDELINE This CLINICAL PRACTICE GUIDELINE Update document is based upon the best information available as of August 2016.

2 It is designed to provide information and assist decision making. It is not intended to define a standard of care, and should not be construed as one, nor should it be interpreted as prescribing an exclusive course of management. Variations in PRACTICE will inevitably and appropriately occur when clinicians take into account the needs of individual patients, available resources, and limitations unique to an institution or type of PRACTICE . Every health-care professional making use of these recommendations is responsible for evaluating the appropriateness of applying them in any particular CLINICAL situation. The recommendations for research contained within this document are general and do not imply a specific protocol.

3 SECTION II: DISCLOSURE Kidney Disease: Improving Global Outcomes ( KDIGO ) makes every effort to avoid any actual or reasonably perceived conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the Work Group. All members of the Work Group are required to complete, sign, and submit a disclosure and attestation form showing all such relationships that might be perceived as or are actual conflicts of interest. This document is updated annually and information is adjusted accordingly. All reported information will be published in its entirety in the final publication and is kept on file at KDIGO .

4 Note: This draft version of the KDIGO 2016 CLINICAL PRACTICE GUIDELINE Update on Diagnosis, Evaluation, Prevention and Treatment of CKD-MBD is not final. Please do not quote or reproduce any part of this document. iv WORK GROUP MEMBERSHIP Work Group Co-Chairs Markus Ketteler, MD Klinikum Coburg Coburg, Germany Mary B. Leonard, MD, MSCE Stanford University School of Medicine Stanford, USA Work Group Geoffrey A. Block, MD Denver Nephrology Denver, USA Pieter Evenepoel, MD, PhD University Hospitals Leuven Leuven, Belgium Masafumi Fukagawa, MD, PhD Tokai University School of Medicine Isehara, Japan Charles A. Herzog, MD Hennepin County Medical Center Minneapolis, USA Linda McCann, RN, CSR, LD Eagle, USA Sharon M.

5 Moe, MD Indiana University School of Medicine Roudebush Veterans Affairs Medical Center Indianapolis, USA Rukshana Shroff, MD, PhD Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK Marcello A. Tonelli, MD, SM, FRCPC University of Calgary Calgary, Canada Nigel D. Toussaint MBBS, FRACP, PhD Royal Melbourne Hospital University of Melbourne Melbourne, Australia Marc G. Vervloet, MD, PhD, FERA VU University Medical Center Amsterdam Amsterdam, The Netherlands v Evidence Review Team Johns Hopkins University Evidence-based PRACTICE Center Baltimore, USA Karen A. Robinson, PhD, Associate Professor of Medicine and Project Director Casey M.

6 Rebholz, PhD, MPH, MS, Co-Investigator Lisa M. Wilson, ScM, Project Manager Ermias Jirru, MD, MPH, Research Assistant Marisa Chi Liu, MD, MPH, Research Assistant Jessica Gayleard, BS, Research Assistant Allen Zhang, BS, Research Assistant vi KDIGO EXECUTIVE COMMITTEE Garabed Eknoyan, MD Norbert Lameire, MD, PhD Founding KDIGO Co-Chairs Bertram L. Kasiske, MD Immediate Past Co-Chair Wolfgang C. Winkelmayer, MD, ScD KDIGO Co-Chair David C. Wheeler, MD, FRCP KDIGO Co-Chair Ali K. Abu-Alfa, MD Olivier Devuyst, MD, PhD J rgen Floege, MD Bertram L. Kasiske, MD Andrew S. Levey, MD Zhi-Hong Liu, MD Ziad A. Massy, MD, PhD Roberto Pecoits-Filho, MD, PhD Brian Pereira, MBBS, MD, MBA Yusuke Tsukamoto, MD Angela Yee-Moon Wang, MD, PhD, FRCP Christoph Wanner, MD KDIGO Staff John Davis, Chief Executive Officer Danielle Green, Managing Director Michael Cheung, Chief Scientific Officer Tanya Green, Communications Director Melissa McMahan, Programs Director vii REFERENCE KEYS NOMENCLATURE AND DESCRIPTION FOR RATING GUIDELINE RECOMMENDATIONS Within each recommendation, the strength of recommendation is indicated as Level 1, Level 2, or Not Graded, and the quality of the supporting evidence is shown as A, B, C, or D.

7 Grade* Implications Patients Clinicians Policy Level 1 We recommend Most people in your situation would want the recommended course of action and only a small proportion would not. Most patients should receive the recommended course of action. The recommendation can be evaluated as a candidate for developing a policy or a performance measure. Level 2 We suggest The majority of people in your situation would want the recommended course of action, but many would not. Different choices will be appropriate for different patients.

8 Each patient needs help to arrive at a management decision consistent with her or his values and preferences. The recommendation is likely to require substantial debate and involvement of stakeholders before policy can be determined. * The additional category Not Graded was used, typically, to provide guidance based on common sense or where the topic does not allow adequate application of evidence. The most common examples include recommendations regarding monitoring intervals, counseling, and referral to other CLINICAL specialists. The ungraded recommendations are generally written as simple declarative statements, but are not meant to be interpreted as being stronger recommendations than Level 1 or 2 recommendations.

9 Grade Quality of Evidence Meaning A High We are confident that the true effect lies close to that of the estimate of the effect. B Moderate The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. C Low The true effect may be substantially different from the estimate of the effect. D Very low The estimate of effect is very uncertain, and often will be far from the truth. viii CURRENT CHRONIC KIDNEY DISEASE (CKD) NOMENCLATURE USED BY KDIGO CKD is defined as abnormalities of kidney structure or function, present for > 3 months, with implications for health.

10 CKD is classified based on Cause, GFR category (G1-G5), and Albuminuria category (A1-A3), abbreviated as CGA. Prognosis of CKD by GFR and albuminuria category Prognosis of CKD by GFR and Albuminuria Categories: KDIGO 2012 Persistent albuminuria categories Description and range A1 A2 A3 Normal to mildly increased Moderately increased Severely increased <30 mg/g <3 mg/mmol 30-300 mg/g 3-30 mg/mmol >300 mg/g >30 mg/mmol GFR categories (ml/min/ m2) Description and range G1 Normal or high 90 G2 Mildly decreased 60-89 G3a Mildly to moderately decreased 45-59 G3b Moderately to severely decreased 30-44 G4 Severely decreased 15-29 G5 Kidney failure <15 Green: low risk (if no other markers of kidney disease, no CKD).


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