What Is Osteodystrophy?

Table of ContentsView AllTable of ContentsTypesSymptomsCausesDiagnosisTreatment

Table of ContentsView All

View All

Table of Contents

Types

Symptoms

Causes

Diagnosis

Treatment

Osteodystrophy is a medical term used to describe abnormal changes in the growth and formation of bone. It is most commonly the result ofchronic kidney disease. In children, osteodystrophy can cause bone malformation and short stature, while adults may experience brittle bones and fractures.

Because the disease is the result of the malabsorption ofcalcium, osteodystrophy is most commonly treated with calcium supplements.

Types of Osteodystrophy

Osteodystrophy is most often the result ofchronic kidney disease (CKD), a condition in which the gradual loss ofrenal (kidney) functioncauses wastes to accumulate in the body as thekidneys start to fail.

Because osteodystrophy (osteo-meaning “bone” and-dystrophymeaning “the degeneration of”) is most commonly associated with CKD, the termosteodystrophyis often interchangeably withrenal osteodystrophy.

Osteodystrophy doesn’t manifest in the same way in everyone. There are variations based on abnormalities in two biological processes:

How each of these processes occurs with the other can determine if bones are brittle, underdeveloped, or malformed.

Classification

Based on the dynamic of bone turnover and bone mineralization, renal osteodystrophy can be classified into one of the following five types.

Osteodystrophy Symptoms

In early disease, there may be no notable signs or symptoms. It is only when bone turnover and/or mineralization are significantly impaired that the cumulative effect becomes more apparent. When symptoms do appear, they can manifest with:

In adults, symptoms of renal osteodystrophy aren’t usually seen until people have been on dialysis for several years. Over time, the bones can become thin and weak, leading to the classic triad of bone pain, joint pain, and fractures.

Osteodystrophy in children is arguably more profound, since it can lead to short stature and bone deformity. One example is the inward bowing of the legs, referred to as “renal rickets.” Symptoms like these can develop in children well beforedialysisis needed.

Complications

Changes like these can impair blood flow and trigger an array of cardiovascular symptoms, including:

If not treated appropriately, the cardiovascular symptoms of CKD-MBD can lead toheart failureandsudden cardiac death.

Adults with osteodystrophy are also vulnerable toavascular necrosis(a.k.a. osteonecrosis). This occurs when tiny breaks in a bone cause it to collapse and cut off blood circulation. The loss of oxygen and nutrients can cause permanent and irreversible bone death, manifesting with pain, limping, and a reducedrange of motion.

The Link Between Heart and Kidney Disease

The pathogenesis (manner of development) of osteodystrophy is complex. When the kidneys are damaged, they are less able to filter waste from the blood. Among the consequences of this: a mineral known asphosphoruscan start to accumulate in the bloodstream, resulting inhyperphosphatemia(high blood phosphorus).

This can set off a chain reaction of events that can lead to bone damage:

Osteodystrophy is common in people with end-stage renal failure, affecting around 90% of adults and children onhemodialysis.

5 Complications of Hemodialysis

Primary vs. Secondary Causes

When osteodystrophy occurs as a result of CKD, it is said to be the result ofsecondaryhyperparathyroidism leading to hyperphosphatemia and hypocalcemia.

However, if osteodystrophy occurs as a result of the parathyroid glands (with no kidney involvement), it said to be the result ofprimaryhyperparathyroidism.

Risk Factors

Renal osteodystrophy is the result of CKD and the onset of acute kidney failure. In the end, if your kidneys start to fail, you are at risk of osteodystrophy.

With that said, there are certain predisposing factors that can increase your risk of osteodystrophy, including the following.

Menopause can also increase the risk of osteodystrophy in women with CKD due to the increased risk ofosteoporosisin postmenopausal women in general.

What Is Secondary Osteoporosis?

Renal osteodystrophy is most often diagnosed when a person is already being treated forend-stage renal disease, although the condition can develop well before then.

If osteodystrophy is suspected, it can be diagnosed with a combination of a physical examination, blood tests, imaging studies, and a bone biopsy. Even so, osteodystrophy can be difficult to diagnose in the early stages, especially in children, and may require an experiencednephrologistto interpret findings.

Physical Examination

Osteodystrophy is often recognized in adults when a fracture occurs with advancing CKD. A history of bone and joint pain are also common complaints. Upon examination, there may be a significantrestriction in the range of motionof weight-bearing joints, including the hip, knee, or ankle.

The findings can differ significantly in children. Because bone fractures are not a characteristic feature, healthcare providers will look for other common manifestations associated with impaired growth and skeletal deformities, including:

Children with CKD are commonly monitored for growth due to the risk of osteodystrophy. Those that fall below the 30th percentile for their age (meaning that 70% of children will be taller than them) are considered to be ofshort statureand at increased likelihood of osteodystrophy even if no other abnormalities are found.

Blood Tests

As part of an initial work-up, the healthcare provider will order a blood test called acomprehensive metabolic panel, which evaluates your blood chemistry, including calcium levels. If osteodystrophy is suspected, additional blood tests will be ordered to measure phosphorus, PTH, and calcitriol levels.

In early-stage disease, there will typically be an elevation of PTH and FGF-23 levels but otherwise normal calcium and phosphorus levels. With the onset of symptomatic disease, calcium and calcitriol levels will plummet as PTH and phosphorus levels rise.

Imaging Studies

StandardX-raysorcomputed tomography (CT) scansare typically used in the diagnosis of osteodystrophy. They can detect characteristic features of the disease, including calcification, osteomalacia, and areas of abnormal bone resorption.

Some of the common signs of osteodystrophy on X-ray or CT scan include:

Magnetic resonance imaging (MRI), while useful, may not provide any additional information compared to an X-ray or CT scan.Similarly,bone scans(bone scintigraphy) have limited used in early-stage disease and only offer significant insights when osteodystrophy is severe and advanced.

Bone Biopsy

A bone biopsy remains the gold standard tool for the diagnosis of osteodystrophy.By obtaining a sample of bone,medical pathologistscan examine the cells under the microscope to look for characteristic abnormalities in their structure, porosity, or thickness.

Stains are important to the process. People with advanced CKD often have excessive amounts of aluminum and iron in their bodies. With osteodystrophy, these minerals will be found in high concentrations in bone and confirmed with special reactive stains.

A bone biopsy can either be performed with a needle biopsy performed in an office or anopen biopsyperformed in an operating room.

In addition to definitively diagnosing osteodystrophy, a bone biopsy can help determine the appropriate course of treatment and measure a person’s response to treatment.

What You Should Know About Getting a Biopsy

Differential Diagnoses

Because osteodystrophy can be tricky to diagnose, particularly in the early stages, healthcare providers will explore alternate explanations for the symptoms as part of thedifferential diagnosis. The exclusion of these conditions can help support the diagnosis.

The differential diagnosis of renal osteodystrophy varies depending on the sites of involvement. The conditions commonly explored include:

Osteodystrophy is treated with a combination of medications, nutritional supplements, diet, and exercise. Given that renal osteodystrophy most often occurs in people with kidney failure, hemodialysis is typically involved.

How Chronic Kidney Disease Is Treated

Lifestyle

Renal osteodystrophy requires a lifestyle change to prevent further bone loss and damage. This includes the restriction of dietary phosphorus, especially inorganicphosphatesfound in food additives.

Phosphorus-rich foods to limit include:

Routine exercise is also important, since it can improve your bone strength and range of motion. This typically involves low-impactresistance trainingand walking.By exercising outdoors, you are also getting sun exposure, which helps promote vitamin D synthesis in the body.

If you have advanced kidney disease, always consult with a healthcare provider, dietitian, or both before embarking on any diet or exercise program.

Low-Potassium Diet in Chronic Kidney Disease

Over-the-Counter Therapies

Calciumandvitamin D supplementsare also sometimes prescribed in people with hyperparathyroidism. Vitamin D is especially useful in those with primary hyperparathyroidism and is generally prescribed at a daily dose of 2,800 international units (IU).

Prescriptions

Rocaltrol (calcitriol) and One-Alpha (alfacalcidol) are prescription forms of vitamin D that help lower PTH levels when the kidneys are unable to produce ample quantities of calcitriol on their own. The drugs may be taken anywhere from once-daily to thrice-weekly and are not known to cause notable side effects.

There is also an injectable form of calcitriol called Calcijex.

Surgeries

If Sensipar and calcitriol supplementation are unable to slow the progression of osteodystrophy, healthcare providers may recommend a surgical procedure known as parathyroidectomy. The procedure, which removes the parathyroid glands, is generally reserved for people with refractory (treatment-resistant) end-stage renal disease.

Depending on the person’s age and general health, a parathyroidectomy may be performed as eitherinpatient or outpatientsurgery. Parathyroidectomies are minimally invasive, requiring a 2.5-centimeter (roughly 1-inch) incision. Recovery generally takes between one and two weeks.

Akidney transplantis also an option if other treatments fail. Candidates for a transplant are generally those who have not responded to other medical or surgical treatments, are either on dialysis or require dialysis in the near future, and are able to tolerate major surgery.

A Word From Verywell

Osteodystrophy can be a difficult disease to diagnose and a complex one to treat. It requires patience on your part to ensure the correct diagnosis and the appropriate treatment.

Given that osteodystrophy is a relatively strong indicator of CKD progression, it is important to take steps to prevent further loss of kidney function. This includes being adherent to your diet regimen, exercising appropriately, and taking your medications as prescribed.

If you suspect your child has osteodystrophy, ask your healthcare provider to investigate. Given that severe growth impairment in children with CKD is linked to an increased risk of death, it is best to err on the side of caution and seek asecond opinionif needed.

29 SourcesVerywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.Waziri B, Duarte R, Naicker S.Chronic kidney disease-mineral and bone disorder (CKD-MBD): Current perspectives.Int J Nephrol Renovasc Dis. 12:263-76. doi:10.2147/IJNRD.S191156Miller PD.Chronic kidney disease and osteoporosis: evaluation and management.Bonekey Rep. 3:542. doi:10.1038/bonekey.2014.37Bennett J, Suliburk JW, Morón FE.Osseous manifestations of primary hyperparathyroidism: Imaging findings.Int J Endocrinol. 2020:3146535. doi:10.1155/2020/3146535Hruska KA, Sugatani T, Agapova O, Fang Y.The chronic kidney disease - mineral bone disorder (CKD-MBD): Advances in pathophysiology.Bone.100:80-6. doi:10.1016/j.bone.2017.01.023Damasiewicz MJ, Nickolas TL.Rethinking bone disease in kidney disease.JBMR Plus. 2018;2(6):309-22. doi:10.1002/jbm4.10117Kemper MJ, Van Husen M.Renal osteodystrophy in children: Pathogenesis, diagnosis and treatment.Curr Opin Pediatr.26(2):180-6. doi:10.1097/MOP.0000000000000061Fujii H, Joki N.Mineral metabolism and cardiovascular disease in CKD.Clin Exp Nephrol.21(Suppl 1):53-63. doi:10.1007/s10157-016-1363-8Felten R, Perrin P, Caillard S, Moulin B, Javier RM.Avascular osteonecrosis in kidney transplant recipients: Risk factors in a recent cohort study and evaluation of the role of secondary hyperparathyroidism.PLoS ONE.14(2):e0212931. doi:10.1371/journal.pone.0212931Jat JA, Mal P, Kumar D.Renal osteodystrophy in end-stage renal failure on maintenance haemodialysis.J Clin Exp Nephrol.1:25. doi:10.21767/2472-5056.100025Cheung AM, Frame H, Ho M, Mackinnon ES, Brown JP.Bone strength and management of postmenopausal fracture risk with antiresorptive therapies: considerations for women’s health practice.Int J Womens Health. 8:537-47. doi:10.2147/IJWH.S112621Gupta V, Lee M.Growth hormone in chronic renal disease.Indian J Endocrinol Metab.16(2):195-203. doi:10.4103/2230-8210.93736Smith ER.The use of fibroblast growth factor 23 testing in patients with kidney disease.Clin J Am Soc Nephrol. 9(7):1283-303. doi:10.2215/CJN.10941013Kidney Disease: Improving Global Outcomes.KDIGO 2017 clinical practice guideline update for the diagnosis, evaluation, prevention, and treatment of chronic kidney disease–mineral and bone disorder (CKD-MBD). In: Kidney International Supplements.Panwar J, Mathew AJ, Jindal N, Danda D.Utility of plain radiographs in metabolic bone disease - A case-based pictorial review from a tertiary centre.Pol J Radiol. 82:333-44. doi:10.12659/PJR.901601Chang CY, Rosenthal DI, Mitchell DM, Handa A, Kattapuram SV, Huang AJ.Imaging findings of metabolic bone disease.Radiographics.2016;36(6):1871-87. doi:10.1148/rg.2016160004Abdelrazek S, Szumowski P, Rogowski F, Kociura-Sawicka A, Mojsak M.Bone scan in metabolic bone diseases: Review.Nuclear Med Rev.2012;15(2):124-31.Bembem K, Singh T, Singh NP, Saxena A, Jain SL.Bone histo-morphology in chronic kidney disease mineral bone disorder.Indian J Hematol Blood Transfus. 33(4):603-610. doi:10.1007/s12288-016-0754-zCarvalho C, Alves CM, Frazão JM.The role of bone biopsy for the diagnosis of renal osteodystrophy: a short overview and future perspectives.J Nephrol.29,617-26. doi:10.1007/s40620-016-0339-9Shah A, Aeddula NR.Renal osteodystrophy. In: StatPearls.National Kidney Foundation.Phosphorus and your diet. Updated April 2019.Pike M, Taylor J, Kabagambe E, et al.The association of exercise and sedentary behaviours with incident end-stage renal disease: the Southern Community Cohort Study.BMJ Open. 9(8):e030661. doi:10.1136/bmjopen-2019-030661Rolighed L, Rejnmark L, Sikjaer T, et al.Vitamin D treatment in primary hyperparathyroidism: a randomized placebo-controlled trial.J Clin Endocrinol Metab. 2014;99(3):1072-80. doi:10.1210/jc.2013-3978Amgen Inc.Sensipar (cinacalcet) tablets.Moe S, Wazny LD, Martin JE.Oral calcitriol versus oral alfacalcidol for the treatment of secondary hyperparathyroidism in patients receiving hemodialysis: a randomized, crossover trial.Can J Clin Pharmacol.15(1):e36-43.Abbott Pharmaceuticals.Calcijex (calcitriol injection) 1 mcg/mL.Drube J, Wan M, Bonthuis M, et al.Clinical practice recommendations for growth hormone treatment in children with chronic kidney disease.Nat Rev Nephrol.15:577-89. doi:10.1038/s41581-019-0161-4Drüeke TB.Hyperparathyroidism in chronic kidney disease. In: Endotext.National Institute of Diabetes and Digestive and Kidney Diseases.Kidney transplant.Salas P, Pinto V, Rodriguez J, Zambrano MJ, Mericq V.Growth retardation in children with kidney disease.Int J Endocrinol. 2014:453781. doi:10.1155/2013/970946

29 Sources

Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.Waziri B, Duarte R, Naicker S.Chronic kidney disease-mineral and bone disorder (CKD-MBD): Current perspectives.Int J Nephrol Renovasc Dis. 12:263-76. doi:10.2147/IJNRD.S191156Miller PD.Chronic kidney disease and osteoporosis: evaluation and management.Bonekey Rep. 3:542. doi:10.1038/bonekey.2014.37Bennett J, Suliburk JW, Morón FE.Osseous manifestations of primary hyperparathyroidism: Imaging findings.Int J Endocrinol. 2020:3146535. doi:10.1155/2020/3146535Hruska KA, Sugatani T, Agapova O, Fang Y.The chronic kidney disease - mineral bone disorder (CKD-MBD): Advances in pathophysiology.Bone.100:80-6. doi:10.1016/j.bone.2017.01.023Damasiewicz MJ, Nickolas TL.Rethinking bone disease in kidney disease.JBMR Plus. 2018;2(6):309-22. doi:10.1002/jbm4.10117Kemper MJ, Van Husen M.Renal osteodystrophy in children: Pathogenesis, diagnosis and treatment.Curr Opin Pediatr.26(2):180-6. doi:10.1097/MOP.0000000000000061Fujii H, Joki N.Mineral metabolism and cardiovascular disease in CKD.Clin Exp Nephrol.21(Suppl 1):53-63. doi:10.1007/s10157-016-1363-8Felten R, Perrin P, Caillard S, Moulin B, Javier RM.Avascular osteonecrosis in kidney transplant recipients: Risk factors in a recent cohort study and evaluation of the role of secondary hyperparathyroidism.PLoS ONE.14(2):e0212931. doi:10.1371/journal.pone.0212931Jat JA, Mal P, Kumar D.Renal osteodystrophy in end-stage renal failure on maintenance haemodialysis.J Clin Exp Nephrol.1:25. doi:10.21767/2472-5056.100025Cheung AM, Frame H, Ho M, Mackinnon ES, Brown JP.Bone strength and management of postmenopausal fracture risk with antiresorptive therapies: considerations for women’s health practice.Int J Womens Health. 8:537-47. doi:10.2147/IJWH.S112621Gupta V, Lee M.Growth hormone in chronic renal disease.Indian J Endocrinol Metab.16(2):195-203. doi:10.4103/2230-8210.93736Smith ER.The use of fibroblast growth factor 23 testing in patients with kidney disease.Clin J Am Soc Nephrol. 9(7):1283-303. doi:10.2215/CJN.10941013Kidney Disease: Improving Global Outcomes.KDIGO 2017 clinical practice guideline update for the diagnosis, evaluation, prevention, and treatment of chronic kidney disease–mineral and bone disorder (CKD-MBD). In: Kidney International Supplements.Panwar J, Mathew AJ, Jindal N, Danda D.Utility of plain radiographs in metabolic bone disease - A case-based pictorial review from a tertiary centre.Pol J Radiol. 82:333-44. doi:10.12659/PJR.901601Chang CY, Rosenthal DI, Mitchell DM, Handa A, Kattapuram SV, Huang AJ.Imaging findings of metabolic bone disease.Radiographics.2016;36(6):1871-87. doi:10.1148/rg.2016160004Abdelrazek S, Szumowski P, Rogowski F, Kociura-Sawicka A, Mojsak M.Bone scan in metabolic bone diseases: Review.Nuclear Med Rev.2012;15(2):124-31.Bembem K, Singh T, Singh NP, Saxena A, Jain SL.Bone histo-morphology in chronic kidney disease mineral bone disorder.Indian J Hematol Blood Transfus. 33(4):603-610. doi:10.1007/s12288-016-0754-zCarvalho C, Alves CM, Frazão JM.The role of bone biopsy for the diagnosis of renal osteodystrophy: a short overview and future perspectives.J Nephrol.29,617-26. doi:10.1007/s40620-016-0339-9Shah A, Aeddula NR.Renal osteodystrophy. In: StatPearls.National Kidney Foundation.Phosphorus and your diet. Updated April 2019.Pike M, Taylor J, Kabagambe E, et al.The association of exercise and sedentary behaviours with incident end-stage renal disease: the Southern Community Cohort Study.BMJ Open. 9(8):e030661. doi:10.1136/bmjopen-2019-030661Rolighed L, Rejnmark L, Sikjaer T, et al.Vitamin D treatment in primary hyperparathyroidism: a randomized placebo-controlled trial.J Clin Endocrinol Metab. 2014;99(3):1072-80. doi:10.1210/jc.2013-3978Amgen Inc.Sensipar (cinacalcet) tablets.Moe S, Wazny LD, Martin JE.Oral calcitriol versus oral alfacalcidol for the treatment of secondary hyperparathyroidism in patients receiving hemodialysis: a randomized, crossover trial.Can J Clin Pharmacol.15(1):e36-43.Abbott Pharmaceuticals.Calcijex (calcitriol injection) 1 mcg/mL.Drube J, Wan M, Bonthuis M, et al.Clinical practice recommendations for growth hormone treatment in children with chronic kidney disease.Nat Rev Nephrol.15:577-89. doi:10.1038/s41581-019-0161-4Drüeke TB.Hyperparathyroidism in chronic kidney disease. In: Endotext.National Institute of Diabetes and Digestive and Kidney Diseases.Kidney transplant.Salas P, Pinto V, Rodriguez J, Zambrano MJ, Mericq V.Growth retardation in children with kidney disease.Int J Endocrinol. 2014:453781. doi:10.1155/2013/970946

Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.

Waziri B, Duarte R, Naicker S.Chronic kidney disease-mineral and bone disorder (CKD-MBD): Current perspectives.Int J Nephrol Renovasc Dis. 12:263-76. doi:10.2147/IJNRD.S191156Miller PD.Chronic kidney disease and osteoporosis: evaluation and management.Bonekey Rep. 3:542. doi:10.1038/bonekey.2014.37Bennett J, Suliburk JW, Morón FE.Osseous manifestations of primary hyperparathyroidism: Imaging findings.Int J Endocrinol. 2020:3146535. doi:10.1155/2020/3146535Hruska KA, Sugatani T, Agapova O, Fang Y.The chronic kidney disease - mineral bone disorder (CKD-MBD): Advances in pathophysiology.Bone.100:80-6. doi:10.1016/j.bone.2017.01.023Damasiewicz MJ, Nickolas TL.Rethinking bone disease in kidney disease.JBMR Plus. 2018;2(6):309-22. doi:10.1002/jbm4.10117Kemper MJ, Van Husen M.Renal osteodystrophy in children: Pathogenesis, diagnosis and treatment.Curr Opin Pediatr.26(2):180-6. doi:10.1097/MOP.0000000000000061Fujii H, Joki N.Mineral metabolism and cardiovascular disease in CKD.Clin Exp Nephrol.21(Suppl 1):53-63. doi:10.1007/s10157-016-1363-8Felten R, Perrin P, Caillard S, Moulin B, Javier RM.Avascular osteonecrosis in kidney transplant recipients: Risk factors in a recent cohort study and evaluation of the role of secondary hyperparathyroidism.PLoS ONE.14(2):e0212931. doi:10.1371/journal.pone.0212931Jat JA, Mal P, Kumar D.Renal osteodystrophy in end-stage renal failure on maintenance haemodialysis.J Clin Exp Nephrol.1:25. doi:10.21767/2472-5056.100025Cheung AM, Frame H, Ho M, Mackinnon ES, Brown JP.Bone strength and management of postmenopausal fracture risk with antiresorptive therapies: considerations for women’s health practice.Int J Womens Health. 8:537-47. doi:10.2147/IJWH.S112621Gupta V, Lee M.Growth hormone in chronic renal disease.Indian J Endocrinol Metab.16(2):195-203. doi:10.4103/2230-8210.93736Smith ER.The use of fibroblast growth factor 23 testing in patients with kidney disease.Clin J Am Soc Nephrol. 9(7):1283-303. doi:10.2215/CJN.10941013Kidney Disease: Improving Global Outcomes.KDIGO 2017 clinical practice guideline update for the diagnosis, evaluation, prevention, and treatment of chronic kidney disease–mineral and bone disorder (CKD-MBD). In: Kidney International Supplements.Panwar J, Mathew AJ, Jindal N, Danda D.Utility of plain radiographs in metabolic bone disease - A case-based pictorial review from a tertiary centre.Pol J Radiol. 82:333-44. doi:10.12659/PJR.901601Chang CY, Rosenthal DI, Mitchell DM, Handa A, Kattapuram SV, Huang AJ.Imaging findings of metabolic bone disease.Radiographics.2016;36(6):1871-87. doi:10.1148/rg.2016160004Abdelrazek S, Szumowski P, Rogowski F, Kociura-Sawicka A, Mojsak M.Bone scan in metabolic bone diseases: Review.Nuclear Med Rev.2012;15(2):124-31.Bembem K, Singh T, Singh NP, Saxena A, Jain SL.Bone histo-morphology in chronic kidney disease mineral bone disorder.Indian J Hematol Blood Transfus. 33(4):603-610. doi:10.1007/s12288-016-0754-zCarvalho C, Alves CM, Frazão JM.The role of bone biopsy for the diagnosis of renal osteodystrophy: a short overview and future perspectives.J Nephrol.29,617-26. doi:10.1007/s40620-016-0339-9Shah A, Aeddula NR.Renal osteodystrophy. In: StatPearls.National Kidney Foundation.Phosphorus and your diet. Updated April 2019.Pike M, Taylor J, Kabagambe E, et al.The association of exercise and sedentary behaviours with incident end-stage renal disease: the Southern Community Cohort Study.BMJ Open. 9(8):e030661. doi:10.1136/bmjopen-2019-030661Rolighed L, Rejnmark L, Sikjaer T, et al.Vitamin D treatment in primary hyperparathyroidism: a randomized placebo-controlled trial.J Clin Endocrinol Metab. 2014;99(3):1072-80. doi:10.1210/jc.2013-3978Amgen Inc.Sensipar (cinacalcet) tablets.Moe S, Wazny LD, Martin JE.Oral calcitriol versus oral alfacalcidol for the treatment of secondary hyperparathyroidism in patients receiving hemodialysis: a randomized, crossover trial.Can J Clin Pharmacol.15(1):e36-43.Abbott Pharmaceuticals.Calcijex (calcitriol injection) 1 mcg/mL.Drube J, Wan M, Bonthuis M, et al.Clinical practice recommendations for growth hormone treatment in children with chronic kidney disease.Nat Rev Nephrol.15:577-89. doi:10.1038/s41581-019-0161-4Drüeke TB.Hyperparathyroidism in chronic kidney disease. In: Endotext.National Institute of Diabetes and Digestive and Kidney Diseases.Kidney transplant.Salas P, Pinto V, Rodriguez J, Zambrano MJ, Mericq V.Growth retardation in children with kidney disease.Int J Endocrinol. 2014:453781. doi:10.1155/2013/970946

Waziri B, Duarte R, Naicker S.Chronic kidney disease-mineral and bone disorder (CKD-MBD): Current perspectives.Int J Nephrol Renovasc Dis. 12:263-76. doi:10.2147/IJNRD.S191156

Miller PD.Chronic kidney disease and osteoporosis: evaluation and management.Bonekey Rep. 3:542. doi:10.1038/bonekey.2014.37

Bennett J, Suliburk JW, Morón FE.Osseous manifestations of primary hyperparathyroidism: Imaging findings.Int J Endocrinol. 2020:3146535. doi:10.1155/2020/3146535

Hruska KA, Sugatani T, Agapova O, Fang Y.The chronic kidney disease - mineral bone disorder (CKD-MBD): Advances in pathophysiology.Bone.100:80-6. doi:10.1016/j.bone.2017.01.023

Damasiewicz MJ, Nickolas TL.Rethinking bone disease in kidney disease.JBMR Plus. 2018;2(6):309-22. doi:10.1002/jbm4.10117

Kemper MJ, Van Husen M.Renal osteodystrophy in children: Pathogenesis, diagnosis and treatment.Curr Opin Pediatr.26(2):180-6. doi:10.1097/MOP.0000000000000061

Fujii H, Joki N.Mineral metabolism and cardiovascular disease in CKD.Clin Exp Nephrol.21(Suppl 1):53-63. doi:10.1007/s10157-016-1363-8

Felten R, Perrin P, Caillard S, Moulin B, Javier RM.Avascular osteonecrosis in kidney transplant recipients: Risk factors in a recent cohort study and evaluation of the role of secondary hyperparathyroidism.PLoS ONE.14(2):e0212931. doi:10.1371/journal.pone.0212931

Jat JA, Mal P, Kumar D.Renal osteodystrophy in end-stage renal failure on maintenance haemodialysis.J Clin Exp Nephrol.1:25. doi:10.21767/2472-5056.100025

Cheung AM, Frame H, Ho M, Mackinnon ES, Brown JP.Bone strength and management of postmenopausal fracture risk with antiresorptive therapies: considerations for women’s health practice.Int J Womens Health. 8:537-47. doi:10.2147/IJWH.S112621

Gupta V, Lee M.Growth hormone in chronic renal disease.Indian J Endocrinol Metab.16(2):195-203. doi:10.4103/2230-8210.93736

Smith ER.The use of fibroblast growth factor 23 testing in patients with kidney disease.Clin J Am Soc Nephrol. 9(7):1283-303. doi:10.2215/CJN.10941013

Kidney Disease: Improving Global Outcomes.KDIGO 2017 clinical practice guideline update for the diagnosis, evaluation, prevention, and treatment of chronic kidney disease–mineral and bone disorder (CKD-MBD). In: Kidney International Supplements.

Panwar J, Mathew AJ, Jindal N, Danda D.Utility of plain radiographs in metabolic bone disease - A case-based pictorial review from a tertiary centre.Pol J Radiol. 82:333-44. doi:10.12659/PJR.901601

Chang CY, Rosenthal DI, Mitchell DM, Handa A, Kattapuram SV, Huang AJ.Imaging findings of metabolic bone disease.Radiographics.2016;36(6):1871-87. doi:10.1148/rg.2016160004

Abdelrazek S, Szumowski P, Rogowski F, Kociura-Sawicka A, Mojsak M.Bone scan in metabolic bone diseases: Review.Nuclear Med Rev.2012;15(2):124-31.

Bembem K, Singh T, Singh NP, Saxena A, Jain SL.Bone histo-morphology in chronic kidney disease mineral bone disorder.Indian J Hematol Blood Transfus. 33(4):603-610. doi:10.1007/s12288-016-0754-z

Carvalho C, Alves CM, Frazão JM.The role of bone biopsy for the diagnosis of renal osteodystrophy: a short overview and future perspectives.J Nephrol.29,617-26. doi:10.1007/s40620-016-0339-9

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National Kidney Foundation.Phosphorus and your diet. Updated April 2019.

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