Bone Turnover-Guided Treatment of Low Bone Density in Haemodialysis Patients Using Bone Biopsy and Fluoride Positron Emission Tomography Imaging.

AIM: Chronic kidney disease-mineral and bone disorder (CKD-MBD) contributes to skeletal fragility through abnormalities in bone turnover. This study evaluated turnover-guided therapy using bone histomorphometry and 18F-NaF PET/CT in haemodialysis patients with low bone mineral density (BMD).

METHODS

Adult haemodialysis patients at a single centre (2018-2024) underwent turnover assessment by bone biopsy (n = 31) or PET/CT (n = 27). Patients were grouped according to whether treatment followed an institutional turnover-guided protocol introduced in 2020. Outcomes included changes in BMD, bone turnover markers (BTMs), and PET-derived Ki values. For the biopsy cohort, multiple linear regression assessed treatment effects.

RESULTS

In the biopsy cohort, protocol-consistent treatment preserved distal radius BMD compared with historical controls. The annualised difference was +2.06% (95% CI 0.74-3.38; p = 0.005) unadjusted and +2.38% (95% CI 0.24-4.51; p = 0.033) adjusted. No significant effects were seen at spine, hip, or femoral neck. BTMs decreased in protocol-treated patients (B-ALP -32.2%, TRACP5b -48.1%), while controls showed no significant change. In the PET/CT cohort, high-turnover patients (n = 13) showed reductions in Ki at the iliac crest (-17.1%) and lumbar spine (-14.4%), alongside decreases in BTMs (B-ALP -22.6%, TRACP5b -40.0%). Distal radius BMD improved at 1 year in patients whose turnover normalised (+2.1% vs. -2.4%; p = 0.04).

CONCLUSION

Turnover-guided treatment was associated with improvements in BMD, BTMs, and PET-derived metabolic activity. These findings suggest the potential utility of turnover-informed therapy in CKD-MBD and support 18F-NaF PET/CT as a non-invasive alternative to biopsy.