Parathyroid Hormone-Related Bone Loss in End-Stage Renal Disease: Where to Measure?

Renal osteodystrophy is almost universally found in patients with end-stage renal disease (ESRD). Although bone biopsy is the gold standard for assessment of bone status it is infrequently used.
Guidelines (KDIGO, 2009) recommend the use of dual-energy X-ray absorptiometry (DXA), as a method for measuring bone quantity, in all dialysis patients who either have had fractures or have risk factors for osteoporosis but state against routine use of DXA for bone mineral density (BMD) measurement. This is because low BMD measured by DXA was consistently associated with an increased risk of low trauma fractures in general population but in patients with ESRD studies produced conflicting results (Inaba et al., 2005
Jamal et al., 2002
Kaji et al., 2002
Urena et al., 2003
Yamaguchi et al., 1996). There are many causes of this heterogeneity including secondary hyperparathyroidism, presence of low bone turnover disease, osteomalacia, site of BMD measurement or fracture assessment (clinical vs. radiological).