Treatment. Treatment of renal osteodystrophy is complex and the recent KDIGO guidelines are the best evidence-based guides for management. The first requirement is appropriate management of the chronic renal disease, which includes procedures such as chronic dialysis and renal transplantation. Additional measures are administration of agents to mitigate hyperphosphatemia, judicious administration of vitamin D analogs to inhibit PTH production, and, if necessary, parathyroidectomy to control the sometimes autonomous (tertiary) hyperparathyroidism. Fractures that occur in CKD may or may not be related to CKD and may be osteoporosis. The differentiation between renal bone disease and osteoporosis is a challenge. Patients with stages 1 to 3 CKD can be diagnosed as other patients with osteoporosis (e.g., by DXA). Patients with stages 4 and 5 CKD often require bone biopsy to exclude the forms of renal osteodystrophy that may also cause low bone mass or fragility fractures.

Orthopedic problems are sometimes severe, and treatment may include internal fixation of slipped capital femoral epiphysis with threaded devices, management of bowleg and knock-knee by bracing or osteotomy, and use of open or closed fixation for the frequent fractures that occur during the course of the disease.

Rickets, osteomalacia, and renal osteodystrophy are distinct entities. They can all be diagnosed by appropriate laboratory testing. Osteomalacia and renal osteodystrophy often require quantitative bone histomorphometry to make a correct diagnosis. Once a diagnosis is made, each entity can be managed by specific interventions.