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  • Review Article
  • Published:

Therapy for patients with CKD and low bone mineral density

Nature Reviews Nephrology volume 9, pages 681–692 (2013)Cite this article

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Abstract

Patients with chronic kidney disease (CKD) have a high risk of bone fracture owing to their low bone mineral density, which resembles that of postmenopausal osteoporosis. However, the mineral and bone disorder associated with CKD (CKD–MBD) is more complex than osteoporosis and the same treatments might not be appropriate. In particular, vascular calcifications are strongly associated with CKD–MBD, and must be taken into consideration. Post hoc analyses of data from pivotal osteoporosis studies suggest that in patients with mild stage 3 CKD and normal parathyroid hormone (PTH), calcium and phosphate measurements, conventional medications for osteoporosis (such as raloxifene, bisphosphonates, teriparatide and denosumab) are effective at reducing fracture rates. However, for patients with stage 4–5 CKD, or those with abnormal PTH and mineral values, the available data are insufficient to determine whether these commonly used medications are effective against fractures. Moreover, all medications used to treat osteoporosis have known or potential adverse effects in patients with CKD. Medicines that increase bone formation by upregulating Wnt signalling have shown promise in patients with osteoporosis and might be used to treat CKD–MBD in the future, but off-target effects could limit their use in in this setting.

Key Points

  • Low bone density or fractures in patients with chronic kidney disease (CKD) differ from those with CKD and mineral bone disorder (MBD)

  • Long-term bisphosphonate therapy dramatically reduces bone formation, which could lead to adynamic bone disease

  • Raloxifene might offer some benefit in patients on haemodialysis, but this agent is only effective against vertebral fractures in patients with osteoporosis

  • Teriparatide has only been studied in a small number of patients with low parathyroid hormone levels

  • Fall prevention and exercise programmes should be incorporated into treatment strategies for patients with CKD–MBD

  • Further research on the safety and efficacy of bone strengthening drugs in patients with CKD is required—existing studies are small and do not provide adequate guidance for clinicians

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Figure 1: Factors that contribute to abnormal bone homeostasis in patients with chronic kidney disease.
Figure 2: Mineralizing surface (as measured by surface deposition of tetracycline in bone biopsy samples) in normal individuals, patients with osteoporosis, and changes in the mineralizing surface in patients receiving osteoporosis treatment.
Figure 3: Factors that affect vascular calcification.
Figure 4: Low bone turnover could result in a vicious cycle of bone disease in patients with CKD–MBD.
Figure 5: Factors that regulate FGF-23 in osteocytes.

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  1. Department of Medicine, University of Washington, Box 356426, 1959 NE Pacific Street, Seattle, 98195-6426, WA, USA

    Susan M. Ott

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S. M. Ott has acted as a consultant for the Group Health Research Institute.

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Ott, S. Therapy for patients with CKD and low bone mineral density. Nat Rev Nephrol 9, 681–692 (2013). https://doi.org/10.1038/nrneph.2013.182

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