Predialysis management of divalent ion metabolism.

Disordered divalent ion metabolism has its origins in the earliest stages of renal impairment. Early intervention is essential to minimize its effects, especially in the light of recent reports demonstrating an association between serum phosphate and relative risk of mortality in dialysis patients. As the age and comorbidity of patients accepted for renal replacement therapy increases, the complexity of their management also increases. A dedicated "predialysis" enables a multidisciplinary team to intervene in an orderly and appropriate fashion to delay progression, modify comorbidity, prevent uraemic complications and prepare the patient mentally and physically for dialysis and renal transplantation. Part of this process involves the identification of patients at high risk of the skeletal and biochemical complications of renal osteodystrophy. Correction of hypocalcemia, acidosis, hyperphosphatemia and rising PTH levels should be achieved quickly. Oral calcitriol therapy is frequently necessary, and requires careful monitoring and supervision.