First global consensus on managing vertebral fractures in advanced chronic kidney disease

A coalition of leading international experts in nephrology, bone health, and musculoskeletal disease has released the first comprehensive Consensus Statement on the Management of Vertebral Fractures in Chronic Kidney Disease (CKD) Stages G4–G5D. The statement highlights a neglected yet devastating complication of advanced kidney disease: skeletal fragility and vertebral fractures.

Published in Nephrology Dialysis Transplantation, the Consensus is a joint initiative of the International Osteoporosis Foundation (IOF) Skeletal Fragility–Chronic Kidney Disease (SKY-CKD) Working Group, the European Society for Clinical and Economic Aspects of Osteoporosis (ESCEO), the European Renal Association (ERA) CKD-MBD Working Group, and the European Renal Osteodystrophy (EUROD) group.

A Silent Epidemic in Kidney Disease

Patients with advanced CKD experience a higher (four times greater) risk of hip fractures than that in the general population, with 50% or more sustaining vertebral fractures (VFs, evaluated by the quantitative vertebral morphometry method). Yet VFs remain vastly underdiagnosed — particularly because most are relatively asymptomatic—  but they are still associated with increased risk of further fractures at vertebral and non-vertebral sites. The statement underscores that vertebral fractures are not only disabling but are also strongly linked to cardiovascular events — including myocardial infarction — and increased mortality across CKD stages. 

"Skeletal fragility in chronic kidney disease has been overlooked for far too long," said Professor Maria Fusaro, MD, senior author and Chair of the IOF SKY-CKD Working Group. 

"We aimed to provide the first practical, evidence-based (when available) guidance to help clinicians identify and manage vertebral fractures in CKD, with a particular focus on stages G4–G5D. We have emphasized the importance of carefully evaluating the benefit–risk profile of osteoporosis treatments in these patients before prescribing. In contrast, patients with CKD stages G1–G3 can generally be managed similarly to other osteoporotic patients. By highlighting this issue, we aim to better equip healthcare professionals to enhance both the quality of life and survival for these patients by enhanced identification and prevention of future fractures."

The Consensus provides a detailed summary of recommendations for clinical care specific to CKD Stages G4-G5D, including:
•    Recognize vertebral fractures (VFs) as a major clinical problem in CKD
•    Actively screen for both symptomatic and ‘silent’ vertebral fractures
•    Use fracture risk assessment tools cautiously in advanced CKD
•    Optimize non-pharmacological measures to reduce fracture risk
•    Correct CKD-related mineral and metabolic abnormalities before osteoporosis treatment
•    Consider vertebral fractures an indication for bone-targeted treatment
•    Tailor osteoporosis pharmacotherapy to CKD stage;  careful evaluation of the risk/benefit ratio is required for patients in CKD G4-5D
•    Implement regular monitoring for fracture risk and treatment effects
•    Promote multidisciplinary models of care such as Fracture Liaison Services to ensure coordinated, comprehensive management of skeletal fragility in patients with CKD.

A Call to Action

Professor Eugene McCloskey, MD, Chair of the IOF Committee of Scientific Advisors and co-author, stated:  

"IOF congratulates the authors of this important new consensus statement, made possible through the invaluable collaborative efforts of many international experts under the leadership of the IOF SKY-CKD Working Group. The publication is essential reading for nephrologists, endocrinologists, and all clinicians involved in the care of patients with advanced CKD."

"Vertebral fractures are associated with functional impairment and increased mortality in CKD G4–5D, underscoring their major clinical and prognostic impact. By translating complex research into practical recommendations, the authors are making a direct contribution to better patient care and improved long-term outcomes."

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Reference:
Fusaro M, Chandran M, Nickolas T, Ferrari S, Cossettini A, Ebeling PR, Mc Closkey E, Harvey N, Pierroz DD, Cannata-Andia J, Cheung A, Guglielmi G, Glüer C, Foldes J, Lems W, Trombetti A, Mithal A, Napoli N, Haarhaus M, Ferraro PM, Ketteler M, Bellasi A, Moyses R, Evenepoel P, Jørgensen HS, Reginster J-Y, Halbout P, Bover J, Gallieni M, Salam S, Eastell R, Hansen D, Cavalier E, Brandi ML; SKY-CKD IOF Working Group, on behalf of ESCEO, in collaboration with CKD-MBD Working Group of the ERA, and EUROD. A Consensus Statement on the Management of Vertebral Fractures in CKD Stages G4-G5D. Nephrol Dial Transplant. 2025;gfaf256. https://doi.org/10.1093/ndt/gfaf256

About IOF
The International Osteoporosis Foundation (IOF) is the world’s largest nongovernmental organization dedicated to the prevention, diagnosis, and treatment of osteoporosis and related musculoskeletal diseases. IOF’s membership committees include leading scientific experts, 340 patient organizations and medical societies in more than 150 countries, as well as universities worldwide. The IOF Capture the Fracture® initiative counts over 1,250 Fracture Liaison Services across all regions of the world. Together, this global network works to prioritize bone health and fracture prevention, sharing a vision of a world free from fragility fractures, where healthy mobility is a reality for all. @iofbonehealth www.osteoporosis.foundation