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Osteoporosis in patients with chronic kidney disease: Diagnosis, evaluation, and management

Paul D Miller, MD
Section Editor
Clifford J Rosen, MD
Deputy Editor
Jean E Mulder, MD


Changes in mineral metabolism and bone structure develop early in the course of chronic kidney disease (CKD) and worsen with progressive loss of kidney function. CKD-metabolic bone disease (MBD) includes abnormalities of calcium, phosphorus, parathyroid hormone (PTH), or vitamin D; abnormalities in bone turnover, mineralization, volume, linear growth, or strength; and/or vascular or other soft tissue calcification [1]. The more severe forms of CKD-MBD (renal osteodystrophy) occur in patients with advanced CKD. These include hyperparathyroid-mediated high-turnover bone disease or osteitis fibrosa cystica, adynamic bone disease, osteomalacia, and mixed uremic osteodystrophy.

Patients with CKD may have other bone diseases (osteoporosis, vitamin D deficiency) either before or after developing kidney disease. Osteoporosis is a common disease that is characterized by low bone mass with microarchitectural disruption and skeletal fragility, resulting in an increased risk of fracture, particularly at the spine, hip, wrist, humerus, and pelvis [2].

It is difficult to diagnose osteoporosis in the setting of CKD. This is particularly relevant for the aging population, where fragility fractures, reduced glomerular filtration rate (GFR), and low bone mineral density (BMD) are more prevalent. There are multiple reasons why this differentiation is important, not the least of which is that management of osteoporosis versus the spectrum of bone diseases in patients with CKD differ vastly.

This topic card will review the diagnosis, evaluation, and management of osteoporosis in patients with CKD. The pathogenesis, diagnosis, and management of other aspects or MBD in patients with CKD are reviewed elsewhere. (See "Overview of chronic kidney disease-mineral and bone disorder (CKD-MBD)" and "Bone biopsy and the diagnosis of renal osteodystrophy" and "Management of secondary hyperparathyroidism in adult nondialysis patients with chronic kidney disease" and "Management of secondary hyperparathyroidism in dialysis patients".)


Magnitude of the problem — End-stage chronic kidney disease (CKD) is associated with an increased risk of fragility (low trauma) fractures [3,4]. In addition, the risk of fracture-related mortality increases with the severity of CKD [3,5]. In most [6-11], but not all [12], studies, more moderate degrees of renal insufficiency in men and women have also been associated with an increased fracture risk. As an example, in a case-cohort study of women ≥65 years, the risk of hip fracture was increased in women with an estimated glomerular filtration rate (eGFR) of 45 to 59 mL/minute (hazard ratio [HR] 1.57, 95% CI 0.89-2.76) and in those with an eGFR <45 mL/minute (HR 2.32, 95% CI 1.15-4.68) compared with women with an eGFR ≥60 mL/minute [7]. The risk of hip fracture remained, although was attenuated, after controlling for bone density [7,8].

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Literature review current through: Nov 2017. | This topic last updated: Sep 28, 2016.
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