The Janus face of parathyroid hormone in renal osteodystrophy.

This editorial comment discusses novel insights into renal osteodystrophy from a parallel publication, highlighting that uremia per se independently impairs bone cell viability and induces skeletal parathyroid hormone resistance. Using multimodal bone analyses, Wagner et al. show that parathyroid hormone exerts compartment-specific effects: protective for trabecular osteocytes yet detrimental to cortical integrity via increased porosity and by bone fibrosis and increased resorption. These findings redefine optimal parathyroid hormone targets and emphasize addressing uremic toxicity to reduce fracture risk in chronic kidney disease.