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

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.

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 bisphosphonate...

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...