Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Bone biopsy and the diagnosis of renal osteodystrophy

L Darryl Quarles, MD
Section Editor
Jeffrey S Berns, MD
Deputy Editor
Alice M Sheridan, MD


Bone biopsy and histologic evaluation of tetracycline-labeled bone is required for accurate stratification of bone diseases in chronic kidney disease (CKD). The indications for when to perform a bone biopsy and whether bone imaging and biomarkers can supplant histologic assessment of bone are not clear.

There are five major types of bone disease that occur in patients with advanced chronic renal failure [1-4]:

Predominant hyperparathyroid-mediated high-turnover bone disease (osteitis fibrosa [OF])

Low-turnover osteomalacia (defective mineralization in association with low osteoclast and osteoblast activities)

Mixed uremic osteodystrophy (MUO; hyperparathyroid bone disease with a superimposed mineralization defect)

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Jan 12, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Malluche H, Faugere MC. Renal bone disease 1990: an unmet challenge for the nephrologist. Kidney Int 1990; 38:193.
  2. Sherrard DJ, Hercz G, Pei Y, et al. The spectrum of bone disease in end-stage renal failure--an evolving disorder. Kidney Int 1993; 43:436.
  3. Martin KJ, Olgaard K, Coburn JW, et al. Diagnosis, assessment, and treatment of bone turnover abnormalities in renal osteodystrophy. Am J Kidney Dis 2004; 43:558.
  4. Gal-Moscovici A, Popovtzer MM. New worldwide trends in presentation of renal osteodystrophy and its relationship to parathyroid hormone levels. Clin Nephrol 2005; 63:284.
  5. Moe S, Drüeke T, Cunningham J, et al. Definition, evaluation, and classification of renal osteodystrophy: a position statement from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int 2006; 69:1945.
  6. Atsumi K, Kushida K, Yamazaki K, et al. Risk factors for vertebral fractures in renal osteodystrophy. Am J Kidney Dis 1999; 33:287.
  7. Coco M, Rush H. Increased incidence of hip fractures in dialysis patients with low serum parathyroid hormone. Am J Kidney Dis 2000; 36:1115.
  8. Sanchez CP, Salusky IB, Kuizon BD, et al. Bone disease in children and adolescents undergoing successful renal transplantation. Kidney Int 1998; 53:1358.
  9. Quarles LD, Lobaugh B, Murphy G. Intact parathyroid hormone overestimates the presence and severity of parathyroid-mediated osseous abnormalities in uremia. J Clin Endocrinol Metab 1992; 75:145.
  10. Hercz G, Pei Y, Greenwood C, et al. Aplastic osteodystrophy without aluminum: the role of "suppressed" parathyroid function. Kidney Int 1993; 44:860.
  11. Carmen Sánchez M, Auxiliadora Bajo M, Selgas R, et al. Parathormone secretion in peritoneal dialysis patients with adynamic bone disease. Am J Kidney Dis 2000; 36:953.
  12. Moe SM. Management of renal osteodystrophy in peritoneal dialysis patients. Perit Dial Int 2004; 24:209.
  13. Sprague SM. The role of the bone biopsy in the diagnosis of renal osteodystrophy. Semin Dial 2000; 13:152.
  14. Ureña P, De Vernejoul MC. Circulating biochemical markers of bone remodeling in uremic patients. Kidney Int 1999; 55:2141.
  15. Ureña P, Hruby M, Ferreira A, et al. Plasma total versus bone alkaline phosphatase as markers of bone turnover in hemodialysis patients. J Am Soc Nephrol 1996; 7:506.
  16. Civitelli R, Armamento-Villareal R, Napoli N. Bone turnover markers: understanding their value in clinical trials and clinical practice. Osteoporos Int 2009; 20:843.
  17. Nickolas TL, Cremers S, Zhang A, et al. Discriminants of prevalent fractures in chronic kidney disease. J Am Soc Nephrol 2011; 22:1560.
  18. Bauer D, Krege J, Lane N, et al. National Bone Health Alliance Bone Turnover Marker Project: current practices and the need for US harmonization, standardization, and common reference ranges. Osteoporos Int 2012; 23:2425.
  19. Vasikaran S, Eastell R, Bruyère O, et al. Markers of bone turnover for the prediction of fracture risk and monitoring of osteoporosis treatment: a need for international reference standards. Osteoporos Int 2011; 22:391.
  20. Nickolas TL, Stein E, Cohen A, et al. Bone mass and microarchitecture in CKD patients with fracture. J Am Soc Nephrol 2010; 21:1371.
  21. Yamaguchi T, Kanno E, Tsubota J, et al. Retrospective study on the usefulness of radius and lumbar bone density in the separation of hemodialysis patients with fractures from those without fractures. Bone 1996; 19:549.
  22. Ureña P, Bernard-Poenaru O, Ostertag A, et al. Bone mineral density, biochemical markers and skeletal fractures in haemodialysis patients. Nephrol Dial Transplant 2003; 18:2325.
  23. Jamal SA, Hayden JA, Beyene J. Low bone mineral density and fractures in long-term hemodialysis patients: a meta-analysis. Am J Kidney Dis 2007; 49:674.
  24. Nickolas TL, Leonard MB, Shane E. Chronic kidney disease and bone fracture: a growing concern. Kidney Int 2008; 74:721.
  25. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int Suppl 2013; 3:5.
  26. National Kidney Foundation. K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease. Am J Kidney Dis 2003; 42:S1.
  27. Mazzaferro S, Coen G, Ballanti P, et al. Deferoxamine test and PTH serum levels are useful not to recognize but to exclude aluminum-related bone disease. Nephron 1992; 61:151.
  28. Slatopolsky E. The interaction of parathyroid hormone and aluminum in renal osteodystrophy. Kidney Int 1987; 31:842.
  29. Andress DL, Ott SM, Maloney NA, Sherrard DJ. Effect of parathyroidectomy on bone aluminum accumulation in chronic renal failure. N Engl J Med 1985; 312:468.
  30. Kidney Disease: Improving Global Outcomes (KDIGO) CKD-MBD Work Group. KDIGO clinical practice guideline for the diagnosis, evaluation, prevention, and treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD). Kidney Int Suppl 2009; :S1.
  31. Hodgson SF. Skeletal remodeling and renal osteodystrophy. Semin Nephrol 1986; 6:42.