Is there a practical role for a virtual bone biopsy using high‐resolution imaging of bone in patients with chronic kidney disease?

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Renal osteodystrophy (ROD) is a complex disorder of bone resulting from the metabolic and hormonal abnormalities that arise in chronic kidney disease (CKD). ROD is manifested as disruption of bone architecture and abnormal remodeling and affects all levels of bone structure hierarchy, leading to impaired bone quality and compromised bone strength with an increased susceptibility to fracture. Studies in patients across the spectrum of CKD, ranging from CKD stage 3 to end‐stage kidney disease including dialysis and especially renal transplantation, have overwhelmingly highlighted the greater risk of fracture in the CKD population when compared with age‐matched and gender‐matched populations.1 Higher rates of hospitalization and mortality occur in patients with advanced CKD who develop fractures.4 Early and accurate diagnosis of ROD is therefore crucial, but current diagnostic methods are inadequate for the need. Lack of robust screening tools for ROD has also limited our ability to develop therapeutic options and conduct appropriate interventional trials. Routinely used validated therapeutics, such as bisphosphonates and other anti‐resorptive agents, remain underused in advanced CKD due to the paucity of evidence and the dynamic nature of ROD.
The complex pathophysiology of ROD, combined with the limited efficacy of dual‐energy X‐ray absorptiometry (DXA) and the unreliability of currently used serum and urinary biomarkers to act as stand‐alone screening tools for fracture risk in patients with CKD, puts the onus of a definitive diagnosis on bone biopsy. However, this procedure is invasive, requires specialist expertise to perform and interpret the results and is rarely performed in current clinical practice. Moreover, bone histomorphometry only depicts microstructure at a single point in time and bone biopsies performed at one site may not reflect concurrent changes at another. The non‐invasive assessment of bone microstructure, by high‐resolution imaging techniques such as high‐resolution peripheral quantitative computed tomography (HR‐pQCT) and high‐resolution magnetic resonance imaging (HR‐MRI or micro‐MRI), has therefore attracted increased attention. To date, most research in high‐resolution imaging of bone has focused on populations without CKD; however, a few imaging studies have targeted the added complexities of bone pathology unique to the CKD population. We discuss the importance of these to the future diagnosis and management of ROD.
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