What is your approach to bisphosphonate use in patients with advanced chronic kidney disease and osteoporosis?

I have used serum markers of bone turnover in decision-making for patients with chronic renal disease, both to initiate treatment and to monitor response. This seems to have a basis in the literature (Smout et al., PMID 35703216).

This approach has also helped to minimize doses of oral bisphosphonates as well. I believe the most important intervention that can be made is to ensure iPTH is being managed appropriately. This is a delicate balancing act with the Nephrologist.

At this point I would use them. I think the most recent data indicates that they are safe and effective in treating osteoporosis in patients with advanced CKD.

Safety of Oral Bisphosphonates in Moderate-to-Severe Chronic Kidney Disease: A Binational Cohort Analysis

I misstated before. I meant to say there is more and more evidence that DEXA scans can be informative even in advanced CKD, which, a few decades ago, was not believed to be the case. However, the data on bisphosphonate use in CKD is more problematic. Above is an example of one that suggests there may be a slightly higher rate of progression of CKD with bisphosphonate use, but that is not the only measure that one should look at. It is hard to see why bisphosphonates would increase the risk of CKD progression, but assuming that is the case, still osteoporosis and fractures also have high morbidity and mortality. I strongly believe one sho...