Introduction 1 2 3 4 5 6 Recommendations Recommendation 1 Clinical, biochemical and radiological markers of renal bone disease should be monitored regularly. 1  Table 1  Frequency of measurements for biochemical and radiological markers of renal osteodystrophy 1 Frequency of measurement (every x month) Target  GFR GFR GFR <15, dialysis  59–30 29–15 (Evidence) Calcium or 6 3 1 2 Ionized calcium 2 Phosphate 6 3 1 Normal range for age band Calcium phosphorus product 6 3 1 2 2 2 2, 3 Alkaline phosphatase 6 3 1 Normal range for age band Serum bicarbonate/base excess 6 3 1 Normal range, at least: bicarbonate >22 mmol/l Base excess >−5 mmol/l Intact PTH/whole PTH 6 3 1 2 Up to 2–3 times upper limit of normal in advanced CRF or on dialysis 3 4 4 4 >20 ng/l Left hand and wrist X-ray   6–12 No radiological signs of hyperparathyroidism No Looser zones or osteopenia 2 2 2 2 2 3 4 Plasma calcium must be adjusted for albumin levels (= corrected calcium) or by measuring ionized (free) calcium, in patients with hypoalbuminemia or acid-base disorders. Ionized calcium values are often available on blood gas analysis systems with calcium-sensitive electrodes, but correct values are only obtained in validated conditions. Alkaline phosphatase as a marker for osteoblast activity has particular importance in both low and high-turnover bone disease with elevated or low alkaline phosphatase serum levels, respectively. 2 7 8 9 10 11 12 Radiological signs of renal bone disease, which alone are not sensitive enough to indicate therapy-adaptations, include signs of hyperparathyroidism and growth zone lesions. Periosteal resorption zones and metaphyseal changes are the most obvious signs. In late adolescent and young adult patients, Looser zones as specific signs of osteomalacia may be found. The sites and expression of bone lesions are age-dependent according to the age-dependent growth and remodeling at different sites of the skeleton. In pre-school children, the metaphysis of the distal radius and ulna may present only minor abnormalities, whereas more severe lesions may be seen at the upper and lower femoral epiphysis. Adynamic bone disease shows no specific radiological changes. However, extraosseous calcifications, fractures or osteopenia may indicate adynamic bone disease. 12 Recommendation 2 Metabolic acidosis should be corrected (evidence). 13 14 14 15 4 15 3 16 17 18 19 Recommendation 3 The plasma-phosphate level should be kept within the normal age-specific range (evidence). 2 20 21 22 23 1 2 24 21 25 2 3 26 27 23 1 2 28 29 1 30 31 32 33 34 Recommendation 4 If plasma phosphate is elevated, phosphate intake should be limited to the recommended levels. 35 Recommendation 5 In case of hyperphosphatemia, the dialysis efficacy should be optimized (evidence). 36 2 5 37 38 39 40 41 42 38 42 43 44 Recommendation 6 For control of hyperphosphatemia, aluminium-free phosphate binders should be administered (evidence). 3 19 2 24 3 45 3 46 47 2 2 5 29 48 3 49 50 Recommendation 7 Vitamin D deficiency should be avoided (evidence). 3 51 2 3 2 3 52 3 3 53 3 2 3 54 Recommendation 8 Marked hyperparathyroidism should be prevented in children with CRF prior to dialysis (evidence). 55 2 10 56 Recommendation 9 PTH levels should be kept at two to three times the upper limit of the normal range in end-stage renal disease (evidence). 56 57 2 3 57 58 59 56 56 58 60 57 59 61 61 5 Recommendation 10 If PTH is elevated in children with CRF or if PTH is elevated more than two to three times normal in the presence of Pi <2 mmol/l in dialyzed children, active vitamin D metabolites should be administered orally (evidence). 2 3 3 63 64 59 2 3 57 61 65 66 65 66 67 68 63 69 70 63 71 72 Recommendation 11 Treatment with growth hormone should not be started in the presence of severe hyperparathyroid bone disease. 73 74 75 76 77 78 79 80 Recommendation 12 In case of hypercalcemia, active vitamin D metabolites and calcium-containing phosphate binders should be stopped and dialysate changed to low calcium solutions (evidence). 2 2 1 1 29  Fig. 1  Ca-cont  Ca-free  phos-binder  vit D  ADBD  Recommendation 13 2 2 2 2 2 2 ++ Recommendation 14 2 3 3 81 82 83 84 85