the target range for serum phosphorus was set at 3.56.0  mg / dl in the new japanese guideline . a number of reports have been published concerning the validation of target ranges for serum phosphorus and calcium concentrations . these studies , mainly from the western world , have largely used mortality as a primary end point . however , in the 2012 jsdt guideline , we have defined target serum phosphorus / calcium ranges according to the results of an analysis of data from the jsdt patient registry , where patients were treated in accordance with the previous jsdt guideline . following the first release of the guideline in 2006 and increased awareness about ckd - mbd in japan , new drugs such as cinacalcet hydrochloride and lanthanum carbonate have been available in clinical practice . accordingly , data from 128,125 dialysis patients , who were monitored from the end of 2006 to the end of 2009 , were analyzed . in addition to analytic model used for the previous baseline model ( b ) ( with a 3-year life expectancy ) , time - dependent ( td ) and time averaged ( ta ) models were used to set target levels for serum phosphorus / calcium and pth , using mortality as an end point . accordingly , we have set the target range for serum phosphorus in dialysis patients at 3.56.0  mg / dl . in the kdoqi guidelines , the range was set at 3.55.5  mg / dl while the more recent kdigo guideline on ckd - mbd of 2009 recommended that the serum phosphorus level should be lowered towards normal if higher than the reference level . we derived the target level by stratifying serum phosphorus levels in our data set , and this analysis produced a j - shaped curve , in that mortality was found to be increased with both hyperphosphatemia and hypophosphatemia . when p<0.01 was used to indicate statistical significance , the recommended target range was 3.65.0  mg / dl for model b , 4.16.0  mg / dl for model td , and 4.15.5  mg / dl for model ta . when a hazard ratio ( hr ) of > 1.2 was considered statistically significant , the recommended range was 3.16.0  mg / dl for model b , 3.66.5  mg / dl for model td , and 4.16.0  mg / dl for model ta . model td characteristically reflects a relatively short - term prognosis , whereas model ta reflects a relatively long - term prognosis . therefore , we continue to recommend a serum phosphorus target range between 3.5 and 6.0  mg / dl , in accordance with our previous guidelines . we recommend that the target range for serum calcium be between 8.4 and 10.0  mg / dl . the kdoqi guidelines state that serum calcium levels be 8.49.5  mg / dl , while kdigo recommends a target within the normal range . serum calcium levels were validated in the same way as phosphorus levels . when the significance level was set at p<0.01 , the recommended range was determined to be 9.0  mg / dl for model b , 9.0  mg / dl for model td , and 8.69.5  mg / dl for model ta . when a hr of > 1.2 was considered statistically significant , the recommended range was 10.0  mg / dl for model b , 9.0  mg / dl for model td , and 8.110.0  mg / dl for model ta . unlike with serum phosphorus concentrations , the risk of mortality increased in a linear pattern for both models b and td . there is still scope for discussion concerning the elimination of the lower limit , and based on the j - shaped curve from modeled ta results and the reference level for healthy people , we consider that 8.410.0  mg / dl should be used as the target level , in accordance with previous guidelines . nevertheless , this statistical validation using data from the jsdt patient database indicates that serum calcium concentrations in patients on dialysis should be maintained at the lowest possible level . from the previous guidelines , a nine - section chart has been adopted as the treatment tool for keeping serum levels of serum phosphorus and calcium at optimal levels . in each of the nine categories , methods for adjusting the dose of pharmacological medications to keep serum phosphorus and corrected calcium levels within the target range . are provided . to validate the recommendations published in our previous guideline , we used the same jsdt patient registry data set to project the 3-year prognosis for patients in each of the nine categories . in addition , target concentrations for serum calcium and phosphorus from the previous guideline were used in the revised version . the results showed that the risk of mortality decreased in the group with normal serum calcium / phosphorus levels and in the group with normal serum phosphorus plus low calcium levels . these findings indicate that the prognosis improves when both serum phosphorus and calcium are kept within the target range . when we examined the relationship between the frequency of attaining target serum phosphorus / calcium levels and prognosis from 2006 to the end of 2008 , we found that the more frequently the target level was attained the lower was the mortality risk . this suggests that constant maintenance of serum phosphorus / calcium levels within the target ranges leads to improvement in life expectancy . based on these findings , we recommend prompt treatment change when the serum phosphorus or corrected calcium levels are constantly high . figure 2 shows treatment / control methods for each part of the nine - section chart . the general objective is that when serum phosphorus levels are high we suggest that a sufficient dialysis dose be ensured and that patients are instructed to reduce their dietary phosphorus intake . also , it is important to assess the nutritional state , including the amount of food eaten , when serum phosphorus levels are low . once these precautions are taken , we suggest that pharmacological therapy should be started to control the mineral parameters in the following order of priority : serum phosphorus , calcium , and pth . in cases with high serum phosphorus levels , the start / increase of a phosphorus binder should be considered , and treatment with active vitamin d sterols should be reduced / suspended depending upon each patient 's condition . when a phosphate binder is prescribed , furthermore , it is important to bear in mind that certain drugs are more effective when taken at specific times . for instance , sevelamer hydrochloride should be taken before a meal , and caco3 and lanthanum carbonate should be taken immediately after a meal . as the efficacy of caco3 is influenced by gastric ph , co - administration of a gastric secretion inhibitor may weaken the drug 's efficacy . lanthanum carbonate , a chewable tablet , should always be chewed , and if an elderly person can not chew the tablet , it should be crushed and administered orally . if the serum phosphorus level is low , reduction / suspension of phosphorus binder should be considered , and starting / increasing active vitamin d could be considered in some cases . when serum calcium is high , dose reduction / discontinuation of active vitamin d sterols and/or caco3 should be considered . when a concurrently high measured pth level is observed , starting cinacalcet hydrochloride treatment or increasing the dose if hypercalcemia persists , the reason for the lack of improvement should be sought , and a change in dialysate calcium concentration should be considered . when the serum calcium level is low , starting treatment with / increasing the dose of active vitamin d derivatives and/or caco3 should be contemplated , and if cinacalcet hydrochloride is being administered , the dose may need to be reduced / discontinued . administration of caco3 between meals is also effective , because it increases the serum calcium level . the addition of cinacalcet hydrochloride to this nine - section chart is a change from the previous guideline . although cinacalcet hydrochloride is mainly used to suppress pth , it is included in the cases in which the pth level is high ( or low ) , because cinacalcet hydrochloride simultaneously lowers serum phosphorus / calcium levels , and pth control and serum phosphorus / calcium control are closely linked . in other words , administering cinacalcet hydrochloride as a method to control the serum calcium or phosphorus level is advisable for patients with high serum pth levels . first , when cinacalcet hydrochloride is going to be administered , it is reasonable to maintain the corrected serum calcium at levels 9.0  mg / dl in order to avoid excessive hypocalcemia . moreover , any assessment should take into account that serum pth is lowest 48  h after cinacalcet administration and the calcium level is lowest after 812  h ( table 1 ) . in this new japanese guideline , intact pth ( ipth ) target level was set at 60240  pg / ml . although the normal range of ipth is 1065  mg / ml with the chemiluminescence enzyme immunoassay method , the levels in patients with ckd stage 5 generally exceed it . however , as the end - organ action of pth is reduced in ckd , a pth level within the normal range would actually reflect the presence of a hypoparathyroid state . the previous jsdt guideline set the recommended range of ipth between 60 and 180  pg / ml , in order to drive parathyroid function towards a more suppressed state . our re - analysis revealed that pth levels slightly higher than those previously thought to be optimal should be recommended , as supported by several clinical studies . based on these findings , we recommend that the upper limit of the target range should be raised above that of the previous guideline . the kdigo guideline set the target range for parathyroid function in dialysis patients to circulating pth levels between two and nine times greater than the upper limit of the normal reference range in the general population . however , as all clinical studies mentioned above only analyzed a relatively short - term survival , it is uncertain whether guidelines based on these results would be beneficial in terms of long - term survival . the long - term treatment policy that advocates parathyroid function should be controlled to avoid the development of hyperparathyroidism ' has been adopted in japan , and the studies mentioned above support its validity . increasing the upper limit of the pth target range could give clinicians the unintended message that it is acceptable for parathyroid function to appear hyperactive as compared with the physiological condition . furthermore , high pth levels have been reported to make the control of serum phosphorus / calcium more difficult , which indirectly disturbs the achievement of therapeutic goals recommended by this guideline . taking all the above into account , the jsdt committee decided to conserve in principle the policy proposed by the previous guideline but to widen the target range slightly towards a higher value . thus , in this revised jsdt clinical practice guideline , the new standard target range for ipth levels is between 60 and 240  pg / ml . severe secondary hyperparathyroidism is defined as ipth levels > 500  pg / ml or whole ,  bio - intact ' pth levels > . it also appears reasonable to consider surgical ptx even at lower pth levels if hyperphosphatemia or hypercalcemia is difficult to manage with medical treatment . one of the major changes since the release of the previous jsdt guideline is the introduction of cinacalcet hydrochloride to the japanese market . several studies have shown the efficacy of cinacalcet for dialysis patients with secondary hyperparathyroidism refractory to treatment with active vitamin d derivatives and those with marked parathyroid hyperplasia , in whom surgical ptx may be the treatment of choice . indeed , a post - hoc analysis of randomized clinical trials reported significant reductions in ptx in patients treated with cinacalcet compared with the placebo plus standard of care group . given the absence of evidence comparing these two treatment modalities , we suggest that the therapeutic decision be made on a case - by - case basis , considering the patient 's preference and general condition . patients who are refractory to cinacalcet treatment and those who discontinue treatment due to adverse effects should be considered for ptx . therefore , the mineral and bone disorder outcomes study for japanese ckd stage 5d patients ( mbd-5d ) was conducted . mbd-5d is a 3-year case - cohort study involving hemodialysis patients with severe secondary hyperparathyroidism . the whole cohort was comprised of 8229 patients enrolled in the study , with a sub - cohort of randomly selected patients ( 3276 ) from the whole cohort . future studies will investigate the effect of various prescription patterns on clinical outcomes of this patient cohort . we have outlined the management strategies for maintaining serum phosphate , calcium , and pth of japanese dialysis patients within predefined target ranges , as stated in the new jsdt guideline for ckd - mbd . at present , it is important to assess and take into account the nutrition status of these patients . malnutrition in elderly dialysis subjects greatly limits the possibility to prescribe phosphorus - restricted diets as they may contribute to increase mortality . in japan , we also hesitate to indicate surgical parathyroidectomy in elderly patients with severe secondary hyperparathyroidism . however , because in japanese dialysis patients ' crude mortality rate / year is only 10.1% , it is important to start long - term management of ckd - mbd in elderly patients as early as possible . although japanese dialysis patients differ in several aspects from those of other countries , we have included in the new jsdt guideline for ckd - mbd evidence based on reports stemming from countries all over the world and published in english during the past 5 years . in addition , we have also analyzed the jsdt registry database for this purpose and incorporated the results , as appropriate . we hope that the revised japanese guideline will improve the control of secondary hyperparathyroidism and clinical outcomes in the dialysis patient population of our country .
disturbances in mineral and bone metabolism have a critical role in the pathogenesis of cardiovascular complications in patients with chronic kidney disease ( ckd ) . 
 the term  renal osteodystrophy ' has recently been replaced by  ckd - mineral and bone disorder ( ckd - mbd ) ' , which includes abnormalities in bone and mineral metabolism and vascular calcification . the japanese society for dialysis therapy clinical practice guideline for the management of secondary hyperparathyroidism in chronic dialysis patients 
 was originally published in japanese in 2006 , then in english in 2008 . during the past 5 years , this first guideline has contributed to a considerably better understanding and control of secondary hyperparathyroidism in ckd patients by physicians , other medical professionals , and the patients themselves . however , since its publication several new therapeutic modalities have become available for japanese dialysis patients , which added more evidence to this area . 
 thus , we revised the guideline to include several new policies , and the new guideline was published in japanese in 2012 . 
 this article contains the new guideline text , and clinical significance of ckd - mbd in japan .