Severe hypocalcemia following denosumab injection in a hemodialysis patient

Denosumab is a human monoclonal antibody directed against RANKL (receptor activator of NF-κB ligand) and is a novel treatment for postmenopausal osteoporosis, although its safety and efficacy in end-stage renal disease is unclear. We report the case of a 61-year-old female hemodialysis patient who developed severe hypocalcemia (total serum calcium, 5.37 mg/dL [1.34 mmol/L]) after receiving a single subcutaneous injection of denosumab. We review this medication's mechanism of action and the very limited data regarding its use in stage 5 chronic kidney disease. We advise against the use of denosumab in those treated with hemodialysis due to the risk of severe hypocalcemia and lack of evidence supporting its efficacy in treating osteoporosis in this population.