Treatment of Osteoporosis in Patients with Chronic Kidney Disease

To discuss current evidence on the diagnosis and management of osteoporosis in patients with chronic kidney disease (CKD).

Osteoporosis and fractures are prevalent in older CKD patients and associated with poor process indicators and outcomes. While osteoporosis treatment is generally similar in patients without or with CKD up to stage 3, there is still a lack of evidence to guide many areas of osteoporosis management in CKD stages 4-5. There is an urgent need to establish local multidisciplinary care pathways for CKD and dialysis patients with osteoporosis, involving nephrologists, bone specialists and fracture liaison services. Optimization of calcium and vitamin D metabolism and non-pharmacological measures including exercise and falls prevention should be considered in all patients. Withholding bone drugs solely based on glomerular filtration rates may constitute renalism (discrimination based on kidney function), which would further widen the already large treatment gap in osteoporosis. On the other hand, more evidence is needed to inform almost every aspect of anti-osteoporotic pharmacotherapy in CKD stages 4-5. The concept of choosing between antiresorptive or anabolic bone drugs based on a pre-treatment assessment of bone turnover (using biomarkers or bone biopsies), is a dogma in urgent need of critical re-evaluation. This narrative review aims to summarize our current understanding of the management of CKD-associated osteoporosis and fracture prevention in stage 4-5 CKD patients.