Managing Osteoporosis in Patients with Chronic Kidney Disease

Q: Managing Osteoporosis in Patients with Chronic Kidney Disease

1. <br>Regarding renal function： When the creatinine (Cr) level is 1, the estimated clearance rate indicates that the renal function score should be greater than 60. <br>Changes in urine output are not reliable indicators of renal function changes due to numerous confounding fact

Treatment of Osteoporosis in Kidney Disease

Dear Dr.
Huang,
In March, I inquired about joint pain, and further examinations revealed severe osteoporosis with a T-score of approximately -3.5.
My kidney function tests show creatinine at 1 and BUN at 11, which are within normal limits.
I have been monitoring my kidney health for many years due to a congenital smaller left kidney.
My urine output has decreased from 2800-3500 mL to around 1200 mL, with daytime output of about 500 mL and nighttime output of 700 mL.
I often experience symptoms such as arrhythmias, bone pain, physical weakness, and disrupted sleep with nocturia for the past 5 years.
My blood pressure is 105/70 in the summer and 150/100 in the winter.

I have adjusted my diet, but my albumin level is 4.7, indicating adequate nutrition.
Is it possible that my osteoporosis is related to the chronic nature of my kidney disease, particularly the so-called stage 2 or 3 changes? The orthopedic specialist has suggested using bisphosphonates, either orally or via injection.
Will these medications affect my kidney function, considering that they need to be taken long-term? Given the irreversible nature of chronic kidney disease, is osteoporosis treatment effective, or is calcium supplementation sufficient?
I would greatly appreciate your insights on this matter.
Thank you very much.

Nanping, 50~59 year old female. Ask Date: 2011/07/15

Dr. Huang Yaoxuan reply Internal Medicine

1.
Regarding renal function: When the creatinine (Cr) level is 1, the estimated clearance rate indicates that the renal function score should be greater than 60.
Changes in urine output are not reliable indicators of renal function changes due to numerous confounding factors; therefore, regular blood tests are necessary for monitoring.
Additionally, regular blood pressure measurements are more important (we generally recommend controlling blood pressure, managing diet, and engaging in moderate exercise).
The shape of the kidneys (notably, your left kidney is congenitally smaller) does not affect the treatment approach for kidney health and is not a factor in assessing renal function.
2.
Osteoporosis: As mentioned earlier, if your Cr level is 1, your renal function is likely classified as stage 2 chronic kidney disease.
The balance of calcium, phosphorus, and parathyroid hormone in your body should not significantly change.
It is advisable to discuss your osteoporosis condition and subsequent treatment plans with an orthopedic or metabolic specialist.
Regarding medications used for treatment, all may have potential side effects (even calcium supplementation can have side effects; be cautious as even commercially available calcium-containing health products may pose risks).
You should discuss this with your physician.
Lastly, you mentioned bisphosphonates; there is an article you may refer to (the URL is "http://www.tsim.org.tw/journal/jour20-6/06.PDF"), which discusses the relationship between bisphosphonates and nephrotoxicity in the paragraph on the right side of page 519.

Reply Date: 2011/07/15

More Info

Managing osteoporosis in patients with chronic kidney disease (CKD) is a complex issue that requires a comprehensive understanding of both conditions. Osteoporosis, characterized by decreased bone density and increased fracture risk, can be exacerbated by CKD due to various factors, including alterations in mineral metabolism, hormonal changes, and the effects of medications.

In your case, with a T-score of -3.5 indicating severe osteoporosis, it is crucial to address both the bone health and the underlying kidney function. Your creatinine level of 1 mg/dL and BUN of 11 mg/dL suggest that your kidney function is relatively stable, but the reduction in urine output and the history of hypertension are concerning. The fact that you have been tracking your kidney health for years is commendable, as regular monitoring is essential for managing CKD.

The relationship between CKD and osteoporosis is multifaceted. Patients with CKD often experience disturbances in calcium, phosphorus, and vitamin D metabolism, which can lead to secondary hyperparathyroidism and further bone loss. Additionally, the use of certain medications, such as bisphosphonates, which are commonly prescribed for osteoporosis, raises concerns regarding their impact on kidney function. While bisphosphonates are generally safe for patients with mild to moderate CKD, their use should be approached with caution, especially in those with more advanced kidney disease.

In your situation, the recommendation from your orthopedic specialist to consider bisphosphonates is reasonable, but it is essential to weigh the benefits against potential risks. Bisphosphonates can help improve bone density and reduce fracture risk, but they may also lead to complications such as osteonecrosis of the jaw or atypical femoral fractures, particularly in long-term use. Therefore, a thorough discussion with your nephrologist and orthopedic specialist is crucial to determine the best course of action.

Calcium and vitamin D supplementation are also vital components of osteoporosis management, especially in CKD patients. Ensuring adequate levels of these nutrients can help mitigate bone loss. However, it is essential to monitor serum calcium and phosphorus levels closely, as CKD can lead to hyperphosphatemia, which can further complicate bone health.

In terms of dietary adjustments, a balanced diet rich in calcium and vitamin D, along with regular weight-bearing exercises, can significantly benefit bone health. However, given your history of hypertension and kidney issues, it is advisable to consult with a dietitian who specializes in renal nutrition to create a tailored dietary plan that meets your specific needs.

Moreover, addressing other risk factors for osteoporosis, such as smoking cessation, limiting alcohol intake, and managing any underlying conditions like hypertension, is crucial. Your fluctuating blood pressure readings indicate that blood pressure management is also a priority, as uncontrolled hypertension can further complicate both kidney and bone health.

In summary, managing osteoporosis in the context of CKD requires a multidisciplinary approach. Collaboration between your nephrologist, orthopedic specialist, and dietitian will help ensure that you receive comprehensive care tailored to your unique health needs. Regular monitoring of kidney function, bone density, and overall health will be essential in optimizing your treatment plan and improving your quality of life.

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