Management of mineral and bone disorder in chronic kidney disease: quo vadis?

Mineral and bone disorder in chronic kidney disease (CKD-MBD) is a serious complication because of its profound impact on morbidity and mortality. Recent introduction of calcimimetic cinacalcet hydrochloride has led to a major breakthrough in the management of CKD-MBD. Numerous clinical studies have shown that in dialysis patients with secondary hyperparathyroidism, cinacalcet effectively reduces serum parathyroid hormone levels without increasing serum calcium and phosphorus levels. This is in contrast to vitamin D analogs that inhibit parathyroid hormone secretion at the price of enhanced intestinal absorption of calcium and phosphorus. More recent studies have focused on the efficacy of combination therapy with calcimimetics and low-dose vitamin D analogs. One of the most important issues in this context is whether treatment with cinacalcet results in improved clinical outcomes. This is currently under investigation by prospective clinical trials. However, many important questions remain unresolved, including issues with whether and how calcimimetics and vitamin D analogs should be combined and whether calcimimetics or vitamin D analogs should be preferred as primary therapy. With a view to improving patient-level outcomes, further work should establish more precisely the role of calcimimetics and vitamin D analogs in combination with other therapeutic approaches for CKD-MBD management.