Chronic kidney disease and bisphosphonate treatment: are prescribing guidelines unnecessarily restrictive?

The prevalence of both osteoporosis and chronic kidney disease (CKD) increases with advancing age. Bisphosphonates are effective in the prevention and treatment of osteoporosis but current recommendations limit their use in patients with renal impairment because of concern regarding the safety profile of these agents in the setting of reduced renal function. The appropriateness of bisphosphonate treatment for patients with CKD is also in question since CKD is independently associated with a variety of skeletal abnormalities, collectively termed renal osteodystrophy, including pre-existing low bone turnover. The evidence to support the current prescribing restrictions is not robust and there are some data to suggest both that bisphosphonate treatment reduces fracture risk without an increase in adverse events in patients with CKD, and that in clinical practice there is underutilisation of this treatment in early CKD. Appropriate prospective trial data with clinically important end points in CKD patients is awaited.