Table 6.

Summary of the 34 consensus statements with their respective grading

PICO question	Consensus statement
1 How to assess CKD-MBD in infants under 2 years of age?	1.1 Clinical evaluation 1.1.1 We suggest physical examination for clinical signs of CKD-MBD in infants with the frequency of assessment based on the infant’s corrected gestational age, stage of CKD, comorbidities, and severity of MBD (level X, moderate recommendation) 1.1.2 We suggest regular monitoring of growth (weight, length, and head circumference), and plotted serially on centile growth charts (level C, weak recommendation) 1.1.3 In children with inherited disorders that affect bone health, we suggest specific follow-up tailored to their underlying kidney disease (level C, weak recommendation) 1.2 Biochemical evaluation 1.2.1 We suggest measuring biomarkers of CKD-MBD (Ca, P, ALP, PTH, 25(OH)D, HCO3) with frequency of assessment based on the infant’s (corrected) age, stage of CKD, underlying disease, and the presence and severity of MBD (level C, moderate recommendation) 1.2.2 We suggest to measure ionized Ca levels where available (level C, weak recommendation) 1.3 Radiological evaluation 1.3.1 Do not perform routine X-rays in infants with CKD (level D, weak recommendation) 1.3.2 We suggest plain X-rays in infants with clinical suspicion of rickets or other bone involvement (level D, weak recommendation) 1.3.3 We suggest an individualized approach to radiological monitoring in infants with genetic diseases with specific bone involvement (level C, moderate recommendation)
2 What are the biochemical targets so as to optimize management of CKD-MBD?	2.1 We suggest maintaining serum Ca, P, ALP, and HCO3 within the age-related normal ranges (level D, weak recommendation) 2.2 We suggest maintaining PTH levels within the CKD-stage dependent target ranges (level D, weak recommendation) 2.3 We suggest maintaining 25(OH)D within the target range defined in older children (level C, weak recommendation) 2.4 We recommend that therapeutic decisions are based on trends rather than on a single laboratory value, taking into account all available CKD-MBD assessments (level X, strong recommendation)
3 What are the targets of dietary control of CKD-MBD in this age group?	3.1 We suggest that the dietary Ca and P intake in infants with CKD should be assessed regularly (level C, weak recommendation) 3.2 We suggest that the total Ca intake from feed, food, and medications is within the suggested dietary intake (SDI) in infants with CKD. The Ca requirement may need to exceed twice the SDI in infants with rapid growth or those with mineral depleted bone, with careful monitoring (level C, weak recommendation) 3.3 We suggest that the dietary P intake from feed and food is within the SDI for age (level C, weak recommendation) 3.4 A phosphate restricted diet must not compromise protein or calcium intake, with addition of phosphate binders as required (level X, strong recommendation) 3.5 We recommend using preterm infant nutritional requirements as a guide for preterm infants with CKD, adjusting their intake according to growth and biochemistry (level D, weak recommendation)
4 What are the specificities of therapeutic management in this age group?	4.1 Native vitamin D 4.1.1 We suggest that all newborns, including preterm infants, with CKD receive vitamin D supplements from birth (level C, moderate recommendation) 4.1.2 We suggest that serum 25(OH)D concentrations are kept within a target range of 75–120 nmol/L (level D, weak recommendation) 4.2 Calcium supplementation and calcium in the dialysate 4.2.1 We recommend Ca supplementation in case of hypocalcemia (level X, strong recommendation) 4.2.2 We suggest oral Ca supplementation in case of persistently high PTH levels, provided P levels are controlled (level D, weak recommendation) 4.2.3 Use intravenous Ca to correct serum Ca levels in acute hypocalcemic emergencies (level X, strong recommendation) 4.2.4 We suggest increasing dialysate Ca concentrations in order to keep serum Ca (ionized Ca where available) levels in the normal range in infants undergoing dialysis (level D, weak recommendation) 4.2.5 We recommend avoiding vitamin A supplementation in infants with CKD (level X, strong recommendation) 4.3 Phosphate binders and phosphate supplementation 4.3.1 Maintain P levels within the normal range for age, by adapting nutrition first but without compromising protein intake (level C, moderate recommendation) 4.3.2 Introduce P binders if serum P is not controlled with optimized nutritional management (level C, moderate recommendation) 4.3.3 We suggest using Ca-based P binders as first-line therapy (level D, weak recommendation) 4.3.4 We suggest considering sevelamer carbonate in infants with hypercalcemia (level D, weak recommendation) 4.3.5 We suggest providing P supplementation after optimization of nutritional phosphate intake in case of persistent hypophosphatemia (level D, weak recommendation) 4.4 Management of secondary hyperparathyroidism 4.4.1 We suggest starting active vitamin D in the lowest dose to achieve target PTH and normal calcium levels (level C, moderate recommendation) 4.4.2 We recommend giving native vitamin D and active vitamin D analogs directly by mouth, and avoiding nasogastric or gastrostomy tubes (level X, strong) 4.4.3 We recommend considering initiation or optimization of dialysis in infants with persistently uncontrolled SHPT and/or hyperphosphatemia despite an optimized nutritional and medical management (level C, moderate recommendation) 4.4.4 Cinacalcet may be considered with extreme caution in infants on dialysis who have persistent and severe hyperparathyroidism in the presence of high or high-normal calcium levels, despite optimized conventional management, including active vitamin D (level D, weak recommendation) 4.4.5 Parathyroidectomy may be considered as a last resort treatment when all medical management fails to control SHPT (level D, weak recommendation)