How to manage a 70-year-old patient with Chronic Kidney Disease (CKD), osteopenia diagnosed by Dual-Energy X-ray Absorptiometry (DEXA) scan, and a previous history of fracture?

From the Guidelines

For a 70-year-old patient with chronic kidney disease (CKD), osteopenia on DEXA scan, and previous fracture history, I recommend a comprehensive approach focusing on both bone health and kidney function, starting with calcium supplementation of 1000-1200 mg daily and vitamin D supplementation with calcifediol 25 μg daily or calcitriol 0.25-0.5 μg daily, depending on CKD stage and PTH levels, as suggested by the Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline update 1.

Key Considerations

• The patient's CKD stage and PTH levels should guide the choice of vitamin D supplementation, with calcifediol or calcitriol used based on the specific needs of the patient.
• Bisphosphonate therapy may be considered with dose adjustments for kidney function, using alendronate 35-70 mg weekly or risedronate 35 mg weekly for mild-moderate CKD, but avoiding these medications if eGFR is below 30-35 ml/min due to the risk of adverse effects 1.
• For severe CKD, denosumab 60 mg subcutaneously every 6 months may be a safer option as it does not require renal clearance, but its use should be weighed against the potential risks, including hypocalcemia 1.
• Fall prevention strategies, including home safety assessment, balance training, and appropriate assistive devices, are crucial to reduce the risk of fractures in this patient population.

Monitoring and Follow-Up

• Regular monitoring should include serum calcium, phosphate, PTH, and vitamin D levels every 3-6 months to adjust treatment as necessary and prevent complications such as hypercalcemia or hypocalcemia.
• Annual DEXA scans should be performed to track bone mineral density and assess the effectiveness of the treatment plan.

Treatment Approach

• The treatment approach should be individualized based on the patient's specific needs, taking into account the presence of CKD-MBD, as indicated by abnormal levels of calcium, phosphate, PTH, alkaline phosphatases, and 25(OH)D 1.
• A bone biopsy may be considered to guide treatment, especially before the use of bisphosphonates, due to the high incidence of adynamic bone disease in patients with CKD 1.

From the FDA Drug Label

The efficacy and safety of Prolia in the treatment of patients with glucocorticoid-induced osteoporosis was assessed in the 12-month primary analysis of a 2-year, randomized, multicenter, double-blind, parallel-group, active-controlled study Enrolled patients ≥ 50 years of age who were in the glucocorticoid-continuing subpopulation were required to have a baseline BMD T-score of ≤ -2.0 at the lumbar spine, total hip, or femoral neck; or a BMD T-score ≤ -1. 0 at the lumbar spine, total hip, or femoral neck and a history of osteoporotic fracture. Patients were randomized (1:1) to receive either an oral daily bisphosphonate (active-control, risedronate 5 mg once daily) (n = 397) or Prolia 60 mg subcutaneously once every 6 months (n = 398) for one year. In the glucocorticoid-initiating subpopulation, Prolia significantly increased lumbar spine BMD compared to the active-control at one year (Active-control 0.8%, Prolia 3.8%) with a treatment difference of 2.9% (p < 0. 001).

The patient has osteopenia and a history of fracture, and is 70 years old with CKD.

• The patient's age and history of fracture suggest an increased risk of further fractures.
• Denosumab (Prolia) may be considered as a treatment option to increase bone mineral density (BMD) and reduce the risk of further fractures.
• However, the patient's CKD should be taken into account when considering treatment options, as it may affect the patient's ability to tolerate certain medications.
• The patient should receive at least 1000 mg calcium and 800 IU vitamin D supplementation daily to support bone health 2.
• It is essential to weigh the potential benefits and risks of treatment with denosumab (Prolia) in this patient, considering their individual clinical circumstances.

From the Research

Management of a 70-year-old with CKD, Osteopenia, and Previous Fracture

To manage a 70-year-old patient with chronic kidney disease (CKD), osteopenia, and a previous history of fracture, several factors need to be considered:

• CKD-Mineral and Bone Disorder (CKD-MBD): CKD is associated with the development of CKD-MBD, which includes abnormalities in calcium, phosphorus, parathyroid hormone (PTH), and vitamin D metabolism, leading to increased fracture risk 3, 4.
• Osteoporosis Treatment: Traditional osteoporosis treatments such as bisphosphonates, denosumab, and teriparatide have been adapted for CKD patients, but recent innovations have introduced agents aimed at enhancing bone mass and reducing fracture incidence 5.
• Lifestyle Modifications: Lifestyle modifications, such as exercise, calcium, and vitamin D supplementation, smoking cessation, and avoidance of excessive alcohol intake, are important before initiating antiresorptive or anabolic agents to treat osteoporosis in CKD patients 3.
• Hyperphosphatemia and Secondary Hyperparathyroidism (SHPT) Management: Managing hyperphosphatemia and SHPT are crucial in CKD patients with osteoporosis 3, 4.
• Diagnostic Methods: Using either DXA or FRAX to screen fracture risk should be considered in patients with CKD-MBD, and biomarkers such as bALP and iPTH may assist in assessing bone turnover 3.
• Personalized Approach: Osteoporosis management in CKD patients necessitates a personalized approach guided by the disease's stage and individual profile 5.
• Osteosarcopenia: CKD exacerbates osteosarcopenia, a condition combining osteoporosis and sarcopenia, through disruptions in mineral metabolism, hormonal imbalances, and inflammation, further compromising musculoskeletal health 6.
• Targeted Therapeutic Strategies: Targeted therapeutic strategies, including mineral metabolism correction, resistance exercise, and anabolic interventions, are essential to mitigate osteosarcopenia's progression and improve patient outcomes in CKD 6.