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

Adynamic bone disease associated with chronic kidney disease

Wajeh Y Qunibi, MD
William L Henrich, MD, MACP
Section Editor
Jeffrey S Berns, MD
Deputy Editor
Alice M Sheridan, MD


Disorders of mineral and bone metabolism are common sequelae of chronic kidney disease (CKD). Such disorders have traditionally been collectively termed renal osteodystrophy. However, disorders of bone and mineral metabolism in progressive CKD are frequently associated with abnormalities in cardiovascular structures and function, and bone is now recognized as an endocrine organ that plays an active role in the various metabolic abnormalities and in the cardiovascular complications commonly encountered in CKD patients [1]. Consequently, an international work group convened in 2006 by Kidney Disease: Improving Global Outcomes (KDIGO) recommended that the term, renal osteodystrophy, be exclusively used to define bone pathology associated with CKD. KDIGO recommended the term chronic kidney disease-mineral and bone disorder (CKD-MBD) be used to describe the much broader systemic disorder that occurs as a result of CKD [2,3].

CKD-MBD is a systemic disorder that develops in the course of CKD and may manifest by one or more of the following:

Abnormalities of calcium, phosphorus, parathyroid hormone (PTH), or vitamin D metabolism

Abnormalities in bone turnover, mineralization, volume linear growth, or strength

Vascular or other soft-tissue calcification

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: Mar 10, 2016.
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. Vervloet MG, Massy ZA, Brandenburg VM, et al. Bone: a new endocrine organ at the heart of chronic kidney disease and mineral and bone disorders. Lancet Diabetes Endocrinol 2014; 2:427.
  2. 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.
  3. Chapter 1: Introduction and definition of CKD-MBD and the development of the guideline statements. Kidney Int 2009; 76113:S3.
  4. National Kidney Foundation. K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease. Am J Kidney Dis 2003; 42:S1.
  5. 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.
  6. Changsirikulchai S, Domrongkitchaiporn S, Sirikulchayanonta V, et al. Renal osteodystrophy in Ramathibodi Hospital: histomorphometry and clinical correlation. J Med Assoc Thai 2000; 83:1223.
  7. Spasovski GB, Bervoets AR, Behets GJ, et al. Spectrum of renal bone disease in end-stage renal failure patients not yet on dialysis. Nephrol Dial Transplant 2003; 18:1159.
  8. Moe SM, Drüeke TB. A bridge to improving healthcare outcomes and quality of life. Am J Kidney Dis 2004; 43:552.
  9. Cunningham J, Sprague SM, Cannata-Andia J, et al. Osteoporosis in chronic kidney disease. Am J Kidney Dis 2004; 43:566.
  10. Rocha LA, Higa A, Barreto FC, et al. Variant of adynamic bone disease in hemodialysis patients: fact or fiction? Am J Kidney Dis 2006; 48:430.
  11. Brandenburg VM, Floege J. Adynamic bone disease-bone and beyond. NDT Plus 2008; 1:135.
  12. Morrow B, Qunibi W. Specific bone and mineral disorders in patients with chronic kidney disease. Clin Rev Bone Miner Metab 2012; 10:184.
  13. Hercz G, Pei Y, Greenwood C, et al. Aplastic osteodystrophy without aluminum: the role of "suppressed" parathyroid function. Kidney Int 1993; 44:860.
  14. Ferreira A, Frazão JM, Monier-Faugere MC, et al. Effects of sevelamer hydrochloride and calcium carbonate on renal osteodystrophy in hemodialysis patients. J Am Soc Nephrol 2008; 19:405.
  15. D'Haese PC, Spasovski GB, Sikole A, et al. A multicenter study on the effects of lanthanum carbonate (Fosrenol) and calcium carbonate on renal bone disease in dialysis patients. Kidney Int Suppl 2003; :S73.
  16. 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.
  17. Barreto FC, Barreto DV, Canziani ME, et al. Association between indoxyl sulfate and bone histomorphometry in pre-dialysis chronic kidney disease patients. J Bras Nefrol 2014; 36:289.
  18. Coen G, Mazzaferro S, Ballanti P, et al. Renal bone disease in 76 patients with varying degrees of predialysis chronic renal failure: a cross-sectional study. Nephrol Dial Transplant 1996; 11:813.
  19. de Oliveira RA, Barreto FC, Mendes M, et al. Peritoneal dialysis per se is a risk factor for sclerostin-associated adynamic bone disease. Kidney Int 2015; 87:1039.
  20. Coen G, Ballanti P, Bonucci E, et al. Renal osteodystrophy in predialysis and hemodialysis patients: comparison of histologic patterns and diagnostic predictivity of intact PTH. Nephron 2002; 91:103.
  21. Haris A, Sherrard DJ, Hercz G. Reversal of adynamic bone disease by lowering of dialysate calcium. Kidney Int 2006; 70:931.
  22. Goodman WG, Ramirez JA, Belin TR, et al. Development of adynamic bone in patients with secondary hyperparathyroidism after intermittent calcitriol therapy. Kidney Int 1994; 46:1160.
  23. Kuizon BD, Goodman WG, Jüppner H, et al. Diminished linear growth during intermittent calcitriol therapy in children undergoing CCPD. Kidney Int 1998; 53:205.
  24. National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis 2002; 39:S1.
  25. 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.
  26. Malluche HH, Monier-Faugere MC. Risk of adynamic bone disease in dialyzed patients. Kidney Int Suppl 1992; 38:S62.
  27. Cannata-Andía JB. Hypokinetic azotemic osteodystrophy. Kidney Int 1998; 54:1000.
  28. 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.
  29. Hernandez D, Concepcion MT, Lorenzo V, et al. Adynamic bone disease with negative aluminium staining in predialysis patients: prevalence and evolution after maintenance dialysis. Nephrol Dial Transplant 1994; 9:517.
  30. McClelland RJ, Sayers BM. Evaluation of the cross-correlation method for the objective determination of auditory threshold in normal hearing subjects. Rev Laryngol Otol Rhinol (Bord) 1982; 103:387.
  31. Fang Y, Ginsberg C, Seifert M, et al. CKD-induced wingless/integration1 inhibitors and phosphorus cause the CKD-mineral and bone disorder. J Am Soc Nephrol 2014; 25:1760.
  32. Evenepoel P, D'Haese P, Brandenburg V. Sclerostin and DKK1: new players in renal bone and vascular disease. Kidney Int 2015; 88:235.
  33. Drüeke TB, Massy ZA. Changing bone patterns with progression of chronic kidney disease. Kidney Int 2016; 89:289.
  34. Drüeke TB. The pathogenesis of parathyroid gland hyperplasia in chronic renal failure. Kidney Int 1995; 48:259.
  35. Piraino B, Chen T, Cooperstein L, et al. Fractures and vertebral bone mineral density in patients with renal osteodystrophy. Clin Nephrol 1988; 30:57.
  36. Coco M, Rush H. Increased incidence of hip fractures in dialysis patients with low serum parathyroid hormone. Am J Kidney Dis 2000; 36:1115.
  37. Danese MD, Kim J, Doan QV, et al. PTH and the risks for hip, vertebral, and pelvic fractures among patients on dialysis. Am J Kidney Dis 2006; 47:149.
  38. Kurz P, Monier-Faugere MC, Bognar B, et al. Evidence for abnormal calcium homeostasis in patients with adynamic bone disease. Kidney Int 1994; 46:855.
  39. London GM, Marty C, Marchais SJ, et al. Arterial calcifications and bone histomorphometry in end-stage renal disease. J Am Soc Nephrol 2004; 15:1943.
  40. London GM, Marchais SJ, Guérin AP, et al. Association of bone activity, calcium load, aortic stiffness, and calcifications in ESRD. J Am Soc Nephrol 2008; 19:1827.
  41. Barreto FC, Barreto DV, Moysés RM, et al. K/DOQI-recommended intact PTH levels do not prevent low-turnover bone disease in hemodialysis patients. Kidney Int 2008; 73:771.
  42. Ureña P, De Vernejoul MC. Circulating biochemical markers of bone remodeling in uremic patients. Kidney Int 1999; 55:2141.
  43. Couttenye MM, D'Haese PC, Van Hoof VO, et al. Low serum levels of alkaline phosphatase of bone origin: a good marker of adynamic bone disease in haemodialysis patients. Nephrol Dial Transplant 1996; 11:1065.
  44. Frazão JM, Martins P. Adynamic bone disease: clinical and therapeutic implications. Curr Opin Nephrol Hypertens 2009; 18:303.
  45. West SL, Lok CE, Langsetmo L, et al. Bone mineral density predicts fractures in chronic kidney disease. J Bone Miner Res 2015; 30:913.
  46. Malluche HH, Davenport DL, Cantor T, Monier-Faugere MC. Bone mineral density and serum biochemical predictors of bone loss in patients with CKD on dialysis. Clin J Am Soc Nephrol 2014; 9:1254.
  47. Mathew S, Lund RJ, Strebeck F, et al. Reversal of the adynamic bone disorder and decreased vascular calcification in chronic kidney disease by sevelamer carbonate therapy. J Am Soc Nephrol 2007; 18:122.
  48. Ok E, Asci G, Duman S, et al. Reduction of calcium exposure slows down progression of vascular calcification and improves adynamic bone disease. Late-Breaking Clinical Trials at Renal Week 2008. CJASN 2008; 3:RB01.
  49. Teng M, Wolf M, Ofsthun MN, et al. Activated injectable vitamin D and hemodialysis survival: a historical cohort study. J Am Soc Nephrol 2005; 16:1115.
  50. Kalantar-Zadeh K, Kuwae N, Regidor DL, et al. Survival predictability of time-varying indicators of bone disease in maintenance hemodialysis patients. Kidney Int 2006; 70:771.
  51. Cejka D, Kodras K, Bader T, Haas M. Treatment of Hemodialysis-Associated Adynamic Bone Disease with Teriparatide (PTH1-34): A Pilot Study. Kidney Blood Press Res 2010; 33:221.
  52. Palcu P, Dion N, Ste-Marie LG, et al. Teriparatide and bone turnover and formation in a hemodialysis patient with low-turnover bone disease: a case report. Am J Kidney Dis 2015; 65:933.