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Diagnosis and management of osteoporosis in chronic kidney disease stages 4 to 5D: a call for a shift from nihilism to pragmatism


The European Renal Association–European Dialysis and Transplant Association (ERA-EDTA) CKD-MBD working group, in collaboration with the Committee of Scientific Advisors of the International Osteoporosis Foundation, published a position paper for the diagnosis and management of osteoporosis in patients with CKD stages 4–5D (eGFR < 30 ml/min 1.73 m2). The present article reports and summarizes the main recommendations included in this 2021 document. The following areas are reviewed: diagnosis of osteoporosis; risk factors for fragility fractures; fracture risk assessment; intervention thresholds for pharmacological intervention; general and pharmacological management of osteoporosis; monitoring of treatment, and systems of care, all in patients with CKD stages 4–5D. Guidance is provided for clinicians caring for CKD stages 4–5D patients with osteoporosis, allowing for a pragmatic individualized diagnostic and therapeutic approach as an alternative to current variations in care and treatment nihilism.

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EUROD is supported by an unrestricted grant from Amgen.

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Correspondence to P. Evenepoel.

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Conflict of interest

PE has received lecture and consultancy fees from Amgen, Vifor FMC, and Medice, unrelated to this work.

JC has received lecture and consultancy fees from Amgen, Vifor FMC, and Opko, unrelated to this work.

MKJ has received advisory and lecture fees from Amgen, Lilly UK, Internis, Consilient Health, Zebra Medical Vision, Kyowa Kirin Hakin, UCB, and Abbvie.

MHLP has received lecture fees from AMGEN.

DPA’s institution has received research grants from UCB Biopharma, Amgen, and Les Laboratories Servier; speaker fees from Amgen, and consultancy fees from UCB Biopharma.

Janssen, on behalf of IMI-funded EHDEN and EMIF consortium, and synapse Management partners have supported training programs organized by DPA’s department and open for external participants.

PUT declares advisory and/or lecture fees from Amgen, Astellas, GSK, Hémotech, Medici, Sanofi, and Vifor-Pharma FMC.

SF has received research grants from AMGEN, UCB, Alexion, and Agnovos and has received advisory and/or lecture fees from Amgen, UCB, E Lilly, and Agnovos.

JCA declares has received lecture and advisory fees from Vifor, Amgen, Kyowa-Kirin, and ASOFARMA.

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Reprinted from: Evenepoel P, Cunningham J, Ferrari S, et al, European Renal Osteodystrophy (EUROD) workgroup, an initiative of the CKD-MBD working group of the ERA-EDTA, and the committee of Scientific Advisors and National Societies of the IOF, European Consensus Statement on the diagnosis and management of osteoporosis in chronic kidney disease stages G4–G5D, Nephrology Dialysis Transplantation 2021; 36 (1): 42–59. By permission of Oxford University Press on behalf of the ERA-EDTA from the full-text Consensus Statement published in Nephrology Dialysis Transplantation at

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Evenepoel, P., Cunningham, J., Ferrari, S. et al. Diagnosis and management of osteoporosis in chronic kidney disease stages 4 to 5D: a call for a shift from nihilism to pragmatism. Osteoporos Int 32, 2397–2405 (2021).

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  • Chronic kidney disease
  • Osteoporosis