Renal Osteodystrophy

Definition of Renal Osteodystrophy

Renal osteodystrophy is an alteration of bone morphology in
patients with CKD (Chronic Kidney Disease). It is one measure of
the skeletal component of the systemic disorder of CKD-MBD
(Mineral and Bone Disorder) that is quantifiable by
histomorphometry of bone biopsy. This is the new KDIGO
definition as described in the paper by Moe.

The following diagram shows the complex causes of renal bone disease. The dotted blue
lines show the "frustrated" feed-back loops that do not function because of the kidney
disease itself. Click on the colored areas to see more.

As the above diagram shows, some factors lead to increased bone formation and
resorption, whereas others lead to decreased bone formation and resorption. Thus there is
a spectrum of possible manifestations, from low to high turnover, from low to high volume,
and with or without mineralization abnormalities. Patients tend to fall into groups as shown
on the next diagram. Individuals within a give group could have high or low bone volume.
Bone strength can be impaired in all of the forms.

Bone density in CKD stage 5

Click on graph for larger view. Here is an Excel file with a list of the studies.

This graph is a summary of 64 studies arranged in chronological order; each point is the

mean value for a study. When more than one skeletal site or gender was measured in a
study, the points are connected by a vertical line. If data from men and women were
reported separately, the points for the women are in a lighter shade. Size of points is
larger in studies with greater numbers of subjects. Data from studies that reported g/cm2
were converted to Z-scores using the average age of the group of subjects and published
normal reference ranges. Overall, the average cortical bone density for patients with CKD
stage 5D was about 0.5 to 1 standard deviation below expected for age and gender, but at
the spine the bone density measurements were closer to the average in persons without
CKD.
Unfortunately, there is no one-to-one correspondance between bone density and type of
renal osteodystrophy. In those with osteitis fibrosis the bone density Z-score ranges from
-3 to +2.5, and in patients with adynamic bone the range is similar, from -2.5 to +1.8.
Furthermore, the bone density is not as consistently related to fracture as it is in
osteoporosis. Overall patients with CKD have an increased risk of fractures.

Fractures in CKD

Basic treatment strategies

Keep phosphate below 5.5 mg/dL
Dietary phosphate restriction
Calcium acetate with meals to "bind" phosphate
Newer phosphate binders such as sevelamer are helpful
Longer hours on dialysis
Aluminum hydroxide as last resort
Keep serum calcium less than 9.5 mg/dL
Calcium carbonate
Calcitriol if necessary
Adjust dialysate calcium
Control PTH
Calcium supplements
Calcitriol
Vitamin-D metabolites that are less likely to produce hypercalcemia (paricalcitol)
Calcimimetics (cinecalcet)
Partial parathyroidectomy may become necessary
Avoid vascular calcifications
Treatment of low bone density
Patients with CKD stages 1-3 (estimated GFR above 30 ml/min) can be treated with the
usual osteoporosis medications as long as they do not have secondary
hyperparathryoidism. However, in more severe CKD treatment is uncertain.
No evidence that bisphosphonates help prevent fractures

Bisphosphonates do increase PTH and lower bone formation

Raloxifene may be useful in postmenopausal women
No studies of calcitonin
Estrogen probably beneficial in younger women, but be careful about coagulation
Estrogen dose should be half that used in normal women
Bone disease and fractures are common after renal transplantation.
Guidelines for treating the phosphate-calcium-PTH axis, along with an extensive reference
list, have been published by the National Kidney Foundation.
Here is a summary of a meeting of an international panel of investigators: Cunningham
(2004). Osteoporosis in chronic kidney disease. Am J Kidney Dis 43: 566-71.
Updated 12/14/07