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Denosumab Hypocalcaemia Monitoring CKD — ESENeph MCQ

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ModerateChronic Kidney DiseaseDenosumab Hypocalcaemia Monitoring CKDESENeph

A 40-year-old woman with CKD G3a from lupus nephritis develops osteoporosis (T-score -2.8 at hip). She is on Prednisolone 7.5 mg daily for maintenance immunosuppression. NICE recommends bone protection for glucocorticoid-induced osteoporosis. Which agent requires special monitoring in CKD?

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Correct answer: E — Denosumab requires close calcium monitoring in CKD as it can cause severe symptomatic hypocalcaemia – lower GFR impairs the compensatory PTH-vitamin D response; calcium and vitamin D supplementation and post-injection calcium checks are essential

Denosumab (anti-RANKL monoclonal antibody) potently inhibits osteoclast-mediated bone resorption. The resulting decrease in calcium release from bone normally triggers compensatory PTH rise and 1,25-dihydroxyvitamin D production. In CKD, this compensation is impaired (reduced 1-alpha-hydroxylase activity). Severe symptomatic hypocalcaemia can occur, sometimes requiring hospitalisation. MHRA issued a Drug Safety Update about Denosumab-associated hypocalcaemia in CKD. Monitoring includes: pre-treatment calcium and vitamin D repletion, calcium check 2 weeks post-injection, and ongoing supplementation. Bisphosphonates are renally cleared and should be used cautiously in CKD G4-5.

Reference: MHRA 2014 – Denosumab Safety; NICE CG146 – Osteoporosis; KDIGO 2017 CKD-MBD