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Abstract: PO0536

Call for Harmonization of the Histomorphometric Reference Ranges for Bone Turnover in Renal Osteodystrophy

Session Information

Category: Bone and Mineral Metabolism

  • 402 Bone and Mineral Metabolism: Clinical


  • Joergensen, Hanne Skou, Katholieke Universiteit Leuven, Leuven, Belgium
  • D'Haese, Patrick, Universiteit Antwerpen, Antwerpen, Belgium
  • Behets, Geert J., Universiteit Antwerpen, Antwerpen, Belgium
  • Cavalier, Etienne, Universite de Liege, Liege, Belgium
  • Evenepoel, Pieter, Katholieke Universiteit Leuven, Leuven, Flanders, Belgium

Group or Team Name

  • on behalf of the EUROD initiative of the CKD-MBD working group of the ERA-EDTA

Knowledge of bone turnover helps guide fracture preventive treatment in patients with chronic kidney disease (CKD). Bone histomorphometry remains the gold standard to assess bone turnover, while non-kidney retained bone biomarkers are considered a valid, but imperfect alternative. Published reports show marked variation in the histomorphometric reference values of bone turnover. Our aim was to investigate the impact of different diagnostic cutoffs on the categorization of bone turnover in a CKD population.


199 patients with successful bone biopsies before or after kidney transplantation were categorized for bone turnover according to diagnostic cut-offs as published by Salusky et al and Malluche et al, recently published normative histomorphometric data by Recker et al, as well as population-based normal ranges for bone-specific alkaline phosphatase (BsAP), tartrate-resistant acid phosphatase type 5b (TRAP5b), and trimeric procollagen type I N-terminal propeptide (Intact PINP; all IDS-iSYS).


Major differences in the distribution of bone turnover categories were seen depending on the reference method used, for both kidney transplant candidates (n = 80, Figure) and recipients (n = 119, data not shown). Compared to the categorizations based on biochemical bone turnover markers, the bone biopsy diagnosis was skewed towards lower bone turnover when using cut-offs as proposed by Salusky or Malluche.


These findings call for harmonization and calibration of bone histomorphometry for the categorization of bone turnover. This will require a collaborative effort to first, construct a repository of bone histomorphometric data from healthy controls across ages, sexes, and ethnicities, and second, to reach a consensus on the diagnostic cut-offs for bone turnover in renal osteodystrophy.

Figure Distribution of bone turnover by different references in kidney transplant candidates with chronic kidney disease stage 5-5D