Osteoporosis in chronic kidney disease: diagnostic dilemmas and therapeutic controversies

INTRODUCTION: Fracture risk is substantially increased in chronic kidney disease (CKD) and rises with declining kidney function. Skeletal fragility in CKD results from reduced bone mass, altered bone microarchitecture, and disturbances in mineral and endocrine regulation of bone turnover, leading to high morbidity and mortality. AREAS COVERED: This review summarizes recent data on fracture incidence across CKD stages and discusses current diagnostic challenges, including the role and limitations of fracture risk prediction tools, dual-energy X-ray absorptiometry, and biochemical markers of mineral metabolism and bone turnover. The contribution of advanced imaging techniques to microarchitectural assessment is also addressed. Current guideline-based approaches are reviewed, alongside therapeutic considerations and the limited evidence supporting osteoporosis treatments in advanced CKD. A literature search was performed in Pubmed restricted to clinical studies published from 2015 through 2025 for a contemporary update on the topic. Osteoporosis after kidney transplantation was not included. EXPERT OPINION: In the absence of evidence-based treatment protocols for CKD-associated osteoporosis, fracture prevention should rely on pragmatic individualized risk assessment. Optimization of mineral metabolism and cautious use of bone-targeting therapies in high-risk patients are key components of management strategy. Future studies should prioritize CKD-specific fracture outcomes and validated diagnostic strategies to guide treatment decisions.