Diagnosis and therapeutic decisions of osteoporosis in chronic kidney disease

10 (maximum of 10) Illustrations: 2 (usually 2, exceptionally maximum 3) Key points: 5/5 Vignette A 63 year old woman with end-stage chronic kidney disease (CKD) secondary to glomerulonephritis, on hemodialysis therapy, presented with scoliosis, back pain and progressive loss of physical function for which corrective surgery was planned.Optimization of bone health was requested by the surgeon as a dual energy x-ray absorptiometry (DXA) scan had revealed osteoporosis at spine, hip and forearm.Due to previous subtotal parathyroidectomy and normal parathyroid hormone and bone-specific alkaline phosphatase levels a low bone turnover state was suspected.An iliac bone biopsy was performed and revealed low bone turnover, a mineralization defect, and severe osteoporosis.The patient was treated with calcium and intensified vitamin D supplementation, followed by a 2-year course of teriparatide.Monitoring of bone turnover markers indicated a bone anabolic response to therapy, and a repeat DXA showed increases in BMD at spine and hip.A repeat biopsy at end of treatment showed normal bone turnover and mineralization.This case demonstrates the complicated bone health of patients with advanced CKD.As there are no randomized trials for fracture pretention in patients with CKD,care must be individualized and is often based on expert opinion.The use of bone biopsy is safe and informative in guiding therapy. Case descriptionA 63-year-old Black woman with end-stage kidney disease (ESKD), presented with scoliosis, back pain and progressive loss of physical function for which corrective surgery was planned.Optimization of bone health was requested by the surgeon as a dual energy x-ray absorptiometry (DXA) scan had revealed osteoporosis at spine, hip and forearm.The patient had a lifelong history of CKD due to glomerulonephritis and was currently on hemodialysis for the last 25 years.She had received glucocorticoid injections as a child, but no glucocorticoid therapy since.She began hemodialysis at age 33 and at 43 underwent a subtotal parathyroidectomy due to tertiary hyperparathyroidism.She stopped having menses at age 33 and shortly after starting hemodialysis and at age 57 she underwent bilateral oophorectomy due to virilization.She was never prescribed hormone replacement therapy.She had poor physical function, was walking with a cane, with no history of falls or fractures.She was on a phosphate-restricted diet with consequently low calcium intake.Current medical therapy included cholecalciferol (400 IU/day) and phosphate binders (as needed) with no active vitamin D, calcimimetics or bone-targeting