Unlabelled: Chronic kidney disease (CKD)-associated osteoporosis increases fracture risk, yet clinical guidance remains unclear. A survey of 89 Italian nephrologists revealed heterogeneous biomarker availability and varied treatment approaches. Denosumab was the preferred antiresorptive agent, while anabolic drugs were rarely used. Findings highlight progress in CKD-related bone health management despite existing uncertainties. CKD-associated osteoporosis comprises the skeletal effects of a complex mineral and bone disorder causing increased risks of fragility fractures (FF), cardiovascular events, and mortality. Existing clinical guidance about CKD-associated osteoporosis is vague, leading us to hypothesize that a treatment gap exists and that clinical practice is dependent on local availability of diagnostic tools.

Purpose and methods: The aim of the current survey was to determine current attitudes and practices among Italian nephrologists regarding the evaluation and management of CKD-associated osteoporosis. An online survey was designed, consisting of 9 thematic groups with a set of 16 closed questions regarding the availability of biomarkers and BTMs at reference laboratories and their use for the diagnosis and treatment of CKD-associated osteoporosis in patients with different stages of CKD, including CKD stages G4-5 and dialysis patients. Results were compared to a previous survey on the use of BTMs from 2022.

Results: Eighty-nine Italian nephrologists participated in the survey, reporting that parathyroid hormone (PTH), alkaline phosphatase, and 25-hydroxy-vitamin D measurements were available in 92-100% of their reference laboratories. Measurements for fibroblast growth factor-23, Klotho, Matrix Gla protein, procollagen type 1 N-terminal propeptide, and tartrate-resistant acid phosphatase 5b were available in 64-74% of cases. Regarding PTH cut-off values, 47.2% followed KDOQI and 43.8% followed KDIGO recommendations. Vitamin D was widely used across CKD stages (cholecalciferol 27-37.1%, calcifediol 9-12.4%, calcitriol 47.2-53.9%, and paricalcitol 21.3-30.3). Denosumab was the preferred antiresorptive agent in all CKD stages (22.5%-28.1%), while the use of bisphosphonates was uncommon in advanced CKD. Anabolic drugs were rarely prescribed.

Conclusions: The availability of bone biomarkers is heterogeneous, and an uncertainty still exists regarding the clinical use of biomarkers in CKD-associated osteoporosis. Nonetheless, our findings indicate that Italian nephrologists are increasingly taking proactive steps to prevent and treat bone fragility in CKD patients.