As glomerular filtration rate (GFR) declines from
age-related bone loss or disease that specifically induces a decline in GFR, there are a number of metabolic bone conditions that may accompany the decline in GFR. These metabolic bone conditions span a spectrum from mild-to-severe
secondary hyperparathyroidism in early stages of
chronic kidney disease (CKD) to the development of additional heterogeneous forms of
bone diseases each with distinctly quantitative bone histomorphometric characteristics.
Osteoporosis can also develop in patients with CKD and
end-stage renal disease (
ESRD) for many reasons beyond
age-related bone loss and postmenopausal (PMO) bone loss. Diagnosing
osteoporosis in patients with severe CKD or
ESRD is not as easy to do as it is in patients with PMO. The diagnosis of
osteoporosis in patients with CKD/
ESRD must be done by first excluding other forms of
renal osteodystrophy, through biochemical profiling or by double
tetracycline-labeled bone biopsy and the finding of low trabecular bone volume. In such patients oral
bisphosphonates seem to be safe and effective down to GFR levels of 15 mL/min. In patients with stage 5 CKD, who are fracturing because of
osteoporosis or who are on chronic
glucocorticoids, reducing the oral
bisphosphonate dosage to half of its usual prescribed dosing for PMO seems reasonable from known
bisphosphonate pharmacokinetics. However, we need better scientific data to fully understand
bisphosphonate usage in this population. This paper deals with the evidence available to understand management of patients with CKD and opinions on what might be a reasonable clinical approach where evidence is currently lacking.