Time for Revival of Bone Biopsy with Histomorphometric Analysis in Chronic Kidney Disease (CKD): Moving from Skepticism to Pragmatism

Abstract

Bone Biopsy (BB) with histomorphometric analysis still represents the gold standard for the diagnosis and classification of different forms of renal osteodystrophy. Bone biopsy is the only technique able to provide comprehensive information on all bone parameters, measuring static and dynamic parameters of turnover, cortical and trabecular microarchitecture, and mineralization defects. In nephrological practice, bone biopsy yields relevant indications to support therapeutic choices in CKD, heavily impacting the management and prognosis of uremic patients. Unfortunately, the use of bone biopsy has decreased; a lack of expertise in performing and interpreting, perceived procedure invasiveness and pain, and reimbursement issues have all contributed to this decline. Nevertheless, both bone biomarkers and instrumental images cannot be considered reliable surrogates for histological findings, being insufficiently accurate to properly evaluate underlying mineral and bone disorders. This is a multidisciplinary position paper from the Nephrology and Osteoporosis Italian Scientific Societies with the purpose of restating the role of bone biopsy in CKD patient management and of providing strong solutions to allow diffusion of this technique in Italy, but potentially also in other countries. The Italian approach through the optimization and standardization of bone biopsy procedure, the construction of the Italian Hub and Spoke network, and a request for adjustment and national homogenization of reimbursement to the Italian Health Ministry has led the way to implement bone biopsy and to improve CKD patient management and prognosis.

Serum irisin levels and osteoporosis in patients with advanced chronic kidney disease and renal transplant recipients

“…DEXA also has some shortcomings in patients with advanced CKD. It cannot determine a specific pathologic subtype of ROD and might be affected by increased skeletal and extraskeletal calcification commonly seen in CKD patients [ 27 ]. Thus, it is still an ongoing need to find a reliable marker to inform us regarding the presence of osteoporosis in patients with CKD.…”

Chronic Kidney Disease with Mineral Bone Disorder and Vascular Calcification: An Overview

“…A bone biopsy can offer unique insights into bone architecture, turnover rate, and mineralization, providing valuable indices that no other tool can reliably offer simultaneously. Despite these advantages, bone biopsy is rarely performed due to the potential risk of complications, perceived invasiveness, and, most importantly, lack of experienced pathologists capable of accurately interpreting the results [ 57 , 58 ].…”

Current and Emerging Markers and Tools Used in the Diagnosis and Management of Chronic Kidney Disease–Mineral and Bone Disorder in Non-Dialysis Adult Patients

“…The benchmark for diagnosis of renal osteodystrophy is bone biopsy with histomorphometric analysis, which is the only technique capable of providing a full evaluation of dynamic bone parameters [15,16]. However, the use of bone biopsy has decreased in recent years due to a lack of proficiency in performing the procedure and interpreting the findings, perceived invasiveness of the technique and corresponding pain for patients, and issues surrounding healthcare reimbursement [15,16].…”