Diagnosis, Evaluation and Management of Osteoporosis in Chronic Kidney Disease: Navigating Treatment Approaches -Indian Consensus Statement

Vijay Kher^1*Rajkumar Sharma²Georgi Abraham³Bharat Shah⁴Sishir Gang⁵Sanjeev Gulati⁶Manisha Sahay⁷Jatin Kothari⁸Anil Kumar Bt⁹Raja Ramachandran¹⁰Sanjay Kalra¹¹Rakesh Kumar Sahay⁷Om Lakhani¹²Jay Kumar Sharma¹³Deepak Bunger¹³Thomas L Nickolas¹⁴

• ¹Epitome Kidney Urology Institute & Lions Hospital, New Delhi, India
• ²Medanta Hospital, Amar Shaheed Path, Golf City, Lucknow, Uttar Pradesh, Lucknow, India
• ³MGM Healthcare and Hospital, Nelson Manickam Rd, Collectorate Colony, Aminjikarai, Chennai, Tamil Nadu, Chennai, India
• ⁴Institute of Renal Sciences, Gleneagles Hospital,, Mumbai, India
• ⁵Muljibhai Patel Urological Hospital, Nadiād, Gujarat, India
• ⁶Fortis Escorts Hospital, Delhi, India
• ⁷Osmania Medical College and Hospital, Hyderabad, Telangana, India
• ⁸Nanavati Max Super Speciality Hospital, Mumbai, India
• ⁹Gleneagles BGS Hospital, Bengaluru, India
• ¹⁰Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, Haryana, India
• ¹¹Bharti Hospital, Karnal, Haryana, India
• ¹²Zydus Hospitals, Ahmedabad, Gujarat, India
• ¹³Intas Pharmaceuticals Limited, Ahmedabad, India
• ¹⁴Columbia University Irving Medical Center, Columbia University, New York, New York, United States

Managing osteoporosis (OP) in chronic kidney disease (CKD) presents significant challenges due to altered bone metabolism. Given the lack of robust clinical trial data and a notable knowledge gap exists among nephrologists regarding an optimal management in this population, an expert consensus is crucial for developing tailored management strategies. This study aimed to gather an expert opinion to bridge this gap and establish consensus recommendations on the diagnosis and management of osteoporosis in CKD patients.Methods: A panel of 13 Indian and 1 international experts, including nephrologists and endocrinologists, participated in a structured survey and discussion process. Thirteen Indian experts provided their opinion on key clinical issues, including screening, diagnosis, and treatment strategies for osteoporosis in CKD. Consensus was achieved in a single round of voting, and recommendations were formulated based on the level of agreement among the panelists.The expert panel reached a strong consensus (80-100% agreement) on several critical recommendations. It was agreed that osteoporosis in CKD is often asymptomatic, with fragility fractures being less common, and thus, early screening using dual-energy X-ray absorptiometry (DXA) is essential. The panel emphasized the importance of evaluating bone turnover status using serum biomarkers such as bone-specific alkaline phosphatase (BSAP) and intact parathyroid hormone (iPTH) to guide treatment decisions. Tailored treatment strategies were recommended, with a judicious use of bisphosphonates and denosumab, depending on the patient's estimated glomerular filtration rate (eGFR) and bone turnover state. The management of renal osteodystrophy (ROD) was deemed necessary before addressing CKD-induced osteoporosis.This expert consensus provides critical insights and guidance for the management of osteoporosis in CKD. The recommendations emphasize individualized treatment approaches, the importance of early screening, and the integration of multidisciplinary care.These findings aim to fill existing knowledge gaps and improve clinical outcomes for CKD patients with osteoporosis.