Bone Abstracts

Background: Osteoporosis management in advanced chronic kidney disease stage 45 (eGFR 30 mL/min/1.73m²) remains a major clinical challenge due to altered bone-mineral metabolism and limited therapeutic options. In the UK, there is currently no established national guideline addressing osteoporosis treatment in this population.

Clinical Presentation: A 62-year-old female with hypopituitarism secondary to pituitary apoplexy following childbirth, on long-term hydrocortisone replacement, presented with severe osteoporosis in 2024. She experienced early menopause at age 30, having opted against hormone replacement therapy, and had additional risk factors including type 2 diabetes mellitus and chronic kidney disease. DEXA demonstrated severe osteoporosis (lumbar spine T-score -3.5, left hip -3.6, femoral neck -3.8), with FRAX indicating high fracture risk (major osteoporotic fracture 29%, hip fracture 16%). Biochemistry showed elevated PTH (25 pmol/L), vitamin D 121 nmol/L, corrected calcium 2.41 mmol/L, and phosphate 1.33 mmol/L. CKD had progressed from stage 3b (eGFR 40 mL/min/1.73m²) to stage 4 (eGFR 16 mL/min/1.73m²) over last two years, attributed to recurrent acute kidney injury, diabetes, and cardiorenal syndrome in the context of heart failure. She had been considered for peritoneal dialysis and was treated with alfacalcidol 250 ng daily. Pharmacological options were limited. Bisphosphonates were contraindicated due to renal impairment. Denosumab was considered but deemed high risk due to potential severe hypocalcaemia and the need for intensive monitoring, which was not feasible. Specialist input confirmed no suitable anti-osteoporotic therapy was available. Management was therefore conservative, including vitamin D supplementation, dietary calcium optimisation (8001000 mg/day), exercise, and fall prevention strategies.

Conclusion: This case highlights a therapeutic gap in osteoporosis management in advanced CKD. Despite very high fracture risk, treatment options remain extremely limited due to safety concerns and lack of approved therapies. While KDIGO guidelines emphasise optimisation of CKDmineral bone parameters without a clear pharmacological pathway, European consensus statements support a pragmatic, individualised approach in selected high-risk patients. This highlights the lack of robust evidence and national guidance. Further research and multidisciplinary consensus are needed to establish safe and effective treatment pathways for osteoporosis in CKD stage 45.