What is the management of Bone Mineral Density (BMD) suggestive of osteoporosis in End-Stage Renal Disease (ESRD) patients on dialysis?

From the Guidelines

Management of bone mineral density (BMD) suggestive of osteoporosis in end-stage renal disease (ESRD) patients on dialysis requires careful consideration of renal osteodystrophy and adynamic bone disease. For these patients, I recommend first optimizing mineral metabolism by maintaining serum calcium between 8.4-10.2 mg/dL, phosphorus between 3.5-5.5 mg/dL, and intact PTH between 150-300 pg/mL, as suggested by the Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline update 1.

Key Considerations

• Vitamin D supplementation is essential, with calcidiol (25-OH vitamin D) maintained above 30 ng/mL using ergocalciferol 50,000 IU weekly or cholecalciferol 1,000-2,000 IU daily.
• For active treatment, consider calcitriol 0.25-1.0 mcg daily or selective vitamin D receptor activators like paricalcitol 1-5 mcg three times weekly with dialysis.
• Bisphosphonates should generally be avoided due to accumulation in renal failure and risk of adynamic bone disease, though denosumab 60 mg subcutaneously every 6 months may be used with close monitoring of calcium levels, as noted in the guideline update 1.
• Teriparatide 20 mcg subcutaneously daily for up to 24 months can be considered in severe cases with low PTH.

Monitoring and Assessment

• Regular monitoring of calcium, phosphorus, PTH, and alkaline phosphatase is crucial, along with BMD assessment every 1-2 years.
• The Canadian Society of Nephrology guidelines for the management of patients with ESRD treated with intensive hemodialysis also suggest using a dialysate calcium of 1.50 mmol/L or higher to maintain a neutral or positive calcium balance, while avoiding predialysis hypercalcemia and oversuppression of PTH 1. This approach addresses the complex bone metabolism in ESRD patients where traditional osteoporosis treatments may be contraindicated or require significant dose adjustments.

From the FDA Drug Label

In patients with advanced chronic kidney disease [i.e., estimated glomerular filtration rate (eGFR) < 30 mL/min/1.73 m2], including dialysis-dependent patients, evaluate for the presence of chronic kidney disease mineral and bone disorder (CKD-MBD) with intact parathyroid hormone (iPTH), serum calcium, 25(OH) vitamin D, and 1,25(OH)2 vitamin D prior to decisions regarding Prolia treatment. Consider also assessing bone turnover status (serum markers of bone turnover or bone biopsy) to evaluate the underlying bone disease that may be present. Monitor serum calcium weekly for the first month after Prolia administration and monthly thereafter. Instruct all patients with advanced chronic kidney disease, including those who are dialysis-dependent, about the symptoms of hypocalcemia and the importance of maintaining serum calcium levels with adequate calcium and activated vitamin D supplementation. Treatment with Prolia in these patients should be supervised by a healthcare provider who is experienced in diagnosis and management of CKD-MBD.

The management of Bone Mineral Density (BMD) suggestive of osteoporosis in patients with End-Stage Renal Disease (ESRD) on dialysis with denosumab involves:

• Evaluating the presence of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD) before initiating treatment
• Assessing bone turnover status to evaluate the underlying bone disease
• Monitoring serum calcium levels weekly for the first month and monthly thereafter
• Instructing patients on the importance of maintaining serum calcium levels with adequate calcium and vitamin D supplementation
• Supervision by a healthcare provider experienced in CKD-MBD diagnosis and management 2, 2, 2.

From the Research

Management of BMD Suggestive for Osteoporosis in ESRD on Dialysis

• The management of osteoporosis in patients with end-stage renal disease (ESRD) on dialysis is complex and requires careful consideration of various factors, including the patient's bone mineral density (BMD), renal function, and overall health status 3, 4.
• Bisphosphonates are a class of medications that are commonly used to treat osteoporosis, but their use in patients with ESRD on dialysis is limited due to concerns about renal toxicity and the potential for adverse effects on bone turnover 3, 5.
• However, some studies suggest that oral bisphosphonates may be safe and effective in patients with ESRD on dialysis, particularly those with a glomerular filtration rate (GFR) of 15 mL/min or higher 4.
• The dosage of bisphosphonates in patients with ESRD on dialysis may need to be adjusted to minimize the risk of adverse effects, and the use of intravenous bisphosphonates may be preferred in some cases 4, 5.
• Other medications, such as selective estrogen receptor modulators (SERMs) and parathyroid hormone analogs, may also be used to treat osteoporosis in patients with ESRD on dialysis, but more research is needed to determine their safety and efficacy in this population 6, 7.
• The diagnosis of osteoporosis in patients with ESRD on dialysis can be challenging, and may require the use of imaging studies, such as dual-energy X-ray absorptiometry (DXA), and blood biomarkers, such as parathyroid hormone and bone-specific alkaline phosphatase concentrations 7.
• Bone biopsy may also be necessary to determine the underlying bone disease and to guide treatment decisions in patients with ESRD on dialysis 4, 7.