What are the treatment options for Adynamic Bone Disease (ABD) in patients with Chronic Kidney Disease (CKD), specifically for a nearly 100-year-old comfort care patient with osteopenia and compression fractures?

From the Guidelines

For a comfort care patient with adynamic bone disease (ABD) in the setting of chronic kidney disease (CKD) who is nearly 100 years old with osteopenia and compression fractures, treatment should focus on symptom management and quality of life rather than aggressive interventions. The primary goal should be pain control using appropriate analgesics such as acetaminophen (500-1000mg every 6-8 hours as needed, not exceeding 3000mg daily in elderly patients with renal impairment) or low-dose opioids if necessary for fracture-related pain, as there is no strong evidence to support the use of specific treatments for ABD in CKD patients, especially in the context of comfort care 1.

Key Considerations

• Calcium levels should be maintained in the low-normal range (8.5-9.5 mg/dL) while avoiding excessive calcium supplementation that could worsen vascular calcification, as suggested by the need to balance mineral metabolism in CKD patients 1.
• Vitamin D supplementation should be modest, using native vitamin D (cholecalciferol 800-1000 IU daily) rather than active vitamin D analogs which might suppress parathyroid hormone (PTH) further, considering the potential risks associated with vitamin D analogues in patients not receiving dialysis 1.
• Phosphate binders may be used if hyperphosphatemia is present, preferring non-calcium based options like sevelamer (800mg with meals) when possible, to minimize the risk of arterial calcification.
• Avoid bisphosphonates as they can further reduce bone turnover in ABD, which is a critical consideration in managing patients with adynamic bone disease.

Symptom Management and Quality of Life

• Physical therapy for gentle mobilization and proper positioning can help prevent further fractures and manage pain.
• Bracing may provide comfort for vertebral compression fractures.
• The treatment approach should prioritize the patient's comfort and quality of life, given the limited life expectancy and focus on comfort care, and should be guided by the principles of minimizing harm and maximizing benefit in the context of the patient's overall health status and goals of care.

From the FDA Drug Label

INDICATIONS AND USAGE Predialysis Patients Calcitriol is indicated in the management of secondary hyperparathyroidism and resultant metabolic bone disease in patients with moderate to severe chronic renal failure (Ccr 15 to 55 mL/min) not yet on dialysis. Dialysis Patients Calcitriol is indicated in the management of hypocalcemia and the resultant metabolic bone disease in patients undergoing chronic renal dialysis In these patients, calcitriol administration enhances calcium absorption, reduces serum alkaline phosphatase levels, and may reduce elevated parathyroid hormone levels and the histological manifestations of osteitis fibrosa cystica and defective mineralization

The FDA drug label does not answer the question.

From the Research

Treatment Options for Adynamic Bone Disease (ABD) in Patients with Chronic Kidney Disease (CKD)

• The treatment of ABD in patients with CKD, particularly those with stages 4-5/5D CKD, is challenging and requires careful consideration of the underlying bone disease and the patient's overall health status 2.
• Before starting pharmacological therapy, it is essential to discriminate between osteoporosis and CKD-Mineral and Bone Disorder (CKD-MBD) using quantitative bone histomorphometry 2.
• In patients with stage 4 CKD, bisphosphonates and denosumab may be effective in reducing fracture incidence, although evidence for safety and efficacy is limited in advanced CKD 2.
• Alendronate, risedronate, and denosumab have been shown to be effective and well-tolerated in stage 4 CKD, but their use in stage 5/5D CKD is limited by the lack of large clinical trials and concerns about adverse events such as adynamic bone disease or hypocalcaemia 2.
• Anabolic treatment has been suggested to improve bone turnover and mass in patients with advanced CKD and low bone turnover, but uncertainty about safety exceeds that of antiresorptive agents 3.

Considerations for a Nearly 100-Year-Old Comfort Care Patient with Osteopenia and Compression Fractures

• In patients with advanced CKD, the goal is to prevent fractures and alleviate CKD-induced MBD and subsequent osteoporosis 4.
• Lifestyle modifications, such as exercise, calcium, and vitamin D supplementation, smoking cessation, and avoidance of excessive alcohol intake, are essential before initiating pharmacological therapy 4.
• Managing hyperphosphatemia and secondary hyperparathyroidism (SHPT) is also crucial in patients with CKD-MBD 4.
• The treatment strategy for CKD-associated osteoporosis should be patient-centered, taking into account the type of renal osteodystrophy and the patient's overall health status 4.
• The relationship between low parathyroid hormone (PTH) level, ABD, increased risk of fracture, and vascular calcifications may partially explain the association of ABD with increased mortality rates, highlighting the need for careful management of ABD in patients with CKD 5.