CKD-associated osteoporosis in patients with CKD G4-5D: a pragmatic treatment approach

Area of Science:

• Nephrology
• Endocrinology
• Bone Metabolism

Background:

• Fracture risk is substantially elevated in advanced chronic kidney disease (CKD G4-5D) compared to the general population.
• The 2023 Kidney Disease Improving Global Outcomes (KDIGO) guidelines introduced 'CKD-associated osteoporosis' to highlight treatment overlaps and the need for CKD-specific considerations.
• Existing guidelines for osteoporosis management are primarily based on postmenopausal women and elderly men, necessitating tailored approaches for CKD patients.

Purpose of the Study:

• To review current standards in the pathophysiology, diagnosis, and management of CKD-associated osteoporosis.
• To discuss novel developments and emerging therapeutic strategies for bone fragility in CKD.
• To propose a pragmatic treatment algorithm for CKD-associated osteoporosis, acknowledging the need for further clinical trial evidence.

Main Methods:

• Comprehensive review of current literature on CKD-associated osteoporosis.
• Analysis of diagnostic workup and therapeutic choices in CKD bone fragility.
• Discussion of evidence-based practice guidelines and their applicability to advanced CKD.

Main Results:

• Fracture risk escalates significantly with CKD progression, particularly in stages G4-5D.
• CKD-associated osteoporosis requires individualized treatment plans, integrating CKD knowledge with general osteoporosis management.
• Lifestyle modifications are recommended as a low-risk, high-return intervention for all patients.

Conclusions:

• Optimizing mineral metabolism, including parathyroid hormone targeting, should precede bone-targeting drug initiation.
• There is a critical need for randomized controlled trials to validate therapeutic benefits in advanced CKD.
• A sequential treatment approach and pragmatic algorithms are proposed pending further evidence.