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Discussion
The focus of this article is to briefly review the pathophysiology of CKD-MBDs and to call for increased awareness of the NKF KDIGO guidelines and the early features of CKD-MBDs that can be evaluated and treated. In addition, this review discusses differentiating CKD-MBDs from traditional clinical criteria for assessment and treatment of osteoporosis. Early (stage 1 to 3) CKD comprises the majority (96%) of patients with CKD in the U.S. Treatment of CKD-MBDs is complicated by progressive changes in serum FGF-23, calcium, phosphate, PTH, and 1,25-dihydroxyvitamin D levels, with changes in bone mass and histology as kidney function declines. Management of bone loss associated with stage 2 to 4 CKD-MBDs is possible with judicious selection of calcium, vitamin D and VDRa analogs, antiresorptive agents (bisphosphonates or denosumab), or teriparatide anabolic therapy. In situations where the type of bone disease is not clinically evident and treatment choice is unclear, a tetracycline-labeled iliac crest bone biopsy can be used to help determine the presence of high or low BTO or osteomalacia. The limitation of all of the above-noted studies with bisphosphonates, denosumab, teriparatide, and cinacalcet is that effects of treatment on vascular calcification, bone histomorphometry findings, and other clinical outcomes were not all included in the various study designs.
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