The Challenge of Fractures in Patients with Chronic Kidney Disease.

Abstract

People with chronic kidney disease (CKD) are at increased risk of fractures in comparison to the non-CKD population and fractures are associated with high mortality and worsening quality of life. The higher risk observed in the CKD population is related to the complex interplay of CKD-mineral bone disorder (MBD) abnormalities causing changes in bone turnover (T), mineralization (M), and volume (V), along with other risk factors accumulated as glomerular filtration rate declines. The approach for evaluation of bone disease and fracture risk in CKD is different from the approach in the general population. First, diagnosis of the type of renal osteodystrophy is not based only on assessment of bone density and traditional risk factors for osteoporosis. Second, there may be limitations of currently available fracture risk tools in the CKD population. Third, treatment choice should take into consideration the three components of the TMV classification along with the stage of kidney disease and comorbidities, but the assessment of these components has not been well established. Lastly, current data are limited on efficacy and safety of treatments for fracture prevention in CKD. As new medications for the treatment of osteoporosis become available, there is an urgency to establish more clear guidelines for the diagnosis, fracture risk stratification, and treatment of bone disease in CKD. In this review, we discuss the complexity and controversies regarding management of bone disease in the CKD population highlighting points where future research is needed, while offering clinical considerations for the current care of this population.