CKD-associated osteoporosis in patients with CKD G4-5D: a pragmatic treatment approach.

Fracture risk increases along the progression of chronic kidney disease (CKD) to become several-fold higher in patients with CKD G4-5D as compared to the kidney-healthy background population matched for age and sex. In 2023, Kidney Disease Improving Global Outcomes (KDIGO) introduced the term CKD-associated osteoporosis to acknowledge and emphasize the overlap in diagnostic workup and therapeutic choices when treating bone fragility in CKD versus other conditions of osteoporosis, while maintaining the need to individualise the treatment plan with knowledge of CKD. Although evidence-based practice guidelines promote management strategies that are widely accepted in postmenopausal women and elderly men, there is a clear need to perform randomized controlled trials to confirm or disprove the benefits of therapy in the setting of advanced CKD. Lifestyle modification, as a 'low risk/potentially high return' intervention, should be considered in all patients. Current evidence furthermore supports a sequential approach to treatment, where mineral metabolism should be optimised, including parathyroid hormone targeting therapy, before initiating bone targeting drugs. We review the current standards of treatment and discuss novel developments in the pathophysiology, diagnosis, outcome prediction and management of CKD-associated osteoporosis and propose a pragmatic treatment algorithm, pending more definite evidence from appropriately designed and powered clinical trials.