Can oral bisphosphonates be given to people with renal impairment to treat osteoporosis?

In the main, bisphosphonates are not metabolized and are excreted unchanged in urine.  There are concerns about using them in chronic kidney disease, end-stage renal disease and older people because of their potential nephrotoxicity and hypocalcaemic effects.

  • Oral bisphosphonates are licensed for use in people with creatinine clearance (CrCl) as low as 30-35mL/min.  There are data confirming that the effectiveness and safety of bisphosphonates, in women with osteoporosis, are not affected by impaired renal function (CKD 1-3); but this finding has not been confirmed in people with CKD stages 4 and 5 including those with ESRD or on dialysis.
  • Cases of adynamic bone disease associated with bisphosphonate use have been reported in people with CKD stages 2-4.  Until there are better data in these groups, oral bisphosphonates should be used with care to treat osteoporosis in people with CKD.  A renal specialist should be consulted about using these agents in people with CKD stages 4 and 5 and, if used, their use should be reviewed if renal function deteriorates.
  • Care is also needed in estimating GFR, by cross-checking MDRD or CKD-EPI estimates with the Cockcroft and Gault formula; particularly in people with CKD stage 3-5, so that renal function is not-overestimated.  It is also important to recognise that people with CKD may also have elements of renal bone disease which will complicate management.