Fragility fractures in dialysis and transplant patients. Is it osteoporosis, and how should it be treated?

The term "osteoporosis" must be applied with caution to the uremic population, which has a complex range of metabolic bone disease. Trials of therapeutic interventions to prevent fractures in non uremic populations with osteoporosis cannot be generalized to uremic patients. It is unclear what, if any, role systematic bone densitometry measurement can play in the management of uremic patients who suffer "fragility" fractures--either for diagnostic purposes or to determine the effectiveness of therapy. Estrogen therapy--and perhaps SERMs (raloxifene)--appear to be a reasonable addition to conventional management of secondary HPT with calcium salts and vitamin D analogs. Using bisphosphonates to manage patients who have pre-existing fractures should be considered experimental at best. In certain circumstances, such treatment may be harmful. While the evidence is better that early therapy with intravenous pamidronate in the peri-transplant interval may mitigate the steroid-induced bone loss seen in those patients during the first 12 postoperative months, even that indication needs to be subjected to systematic clinical studies to develop appropriate clinical practice guidelines.