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Fragility fracture in chronic kidney disease stage 4 — MSRA MCQ

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Hardall topics relevant for this examFragility fracture in chronic kidney disease stage 4MSRA

A 74-year-old woman is reviewed after a lateral thoracic spine radiograph, requested for persistent pain after lifting a light shopping bag, shows a new T12 wedge compression fracture. She has no neurological symptoms, weight loss or features suggesting malignancy. She had a low-trauma distal radius fracture 3 years ago. She has CKD G4 due to diabetic kidney disease. Her eGFR has been stable at 27 mL/min/1.73 m². Corrected calcium is 2.31 mmol/L and 25-hydroxyvitamin D is 68 nmol/L. Phosphate and parathyroid hormone concentrations have not been measured. She can sit upright and has no dysphagia, dental infection or planned dental extraction. What is the most appropriate management now to reduce her future fracture risk?

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Correct answer: E — Measure phosphate and parathyroid hormone concentrations and seek specialist renal advice before selecting anti-fracture pharmacotherapy

This patient has established high fracture risk: a vertebral fracture after minimal trauma, with a previous fragility fracture. In most people this would justify prompt anti-fracture treatment. However, her eGFR of 27 mL/min/1.73 m² places her in CKD G4, where CKD-mineral and bone disorder must be considered rather than assuming uncomplicated postmenopausal osteoporosis. NICE recommends measurement of calcium, phosphate and parathyroid hormone in people with GFR below 30 mL/min/1.73 m² and advises specialist input where there is uncertainty. Alendronate is not recommended when creatinine clearance is below 35 mL/min. Intravenous zoledronic acid is contraindicated below this threshold. Denosumab does not require dose adjustment, but severe renal impairment substantially increases the risk of hypocalcaemia and associated PTH elevation; it should not be selected empirically before characterising mineral metabolism and obtaining specialist advice. Colecalciferol alone is inappropriate because vitamin D is already sufficient and it does not address her immediate high fracture risk.

Reference: NICE NG203: Chronic kidney disease: assessment and management — Bone metabolism and osteoporosis (2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations Alendronic Acid 70 mg Film-coated Tablets — Summary of Product Characteristics (18 March 2026) — https://www.medicines.org.uk/emc/product/101969/smpc Aclasta 5 mg solution for infusion — Summary of Product Characteristics (July 2026) — https://www.medicines.org.uk/emc/product/210/smpc