Volume 92, Issue 6, Pages 1343-1355 (December 2017) Fractures in patients with CKD—diagnosis, treatment, and prevention: a review by members of the European Calcified Tissue Society and the European Renal Association of Nephrology Dialysis and Transplantation  Ana Pimentel, Pablo Ureña-Torres, M. Carola Zillikens, Jordi Bover, Martine Cohen-Solal  Kidney International  Volume 92, Issue 6, Pages 1343-1355 (December 2017) DOI: 10.1016/j.kint.2017.07.021 Copyright © 2017 International Society of Nephrology Terms and Conditions

Figure 1 Factors determining bone quantity and quality. Several factors determine the rate of bone remodeling that influence the quality of the bone extracellular matrix, which is part of the bone strength. Bone architecture and bone mass are additional determinants. The failure of mechanical strength and falls combined with unstable conditions precipitate the occurrence of fractures. Kidney International 2017 92, 1343-1355DOI: (10.1016/j.kint.2017.07.021) Copyright © 2017 International Society of Nephrology Terms and Conditions

Figure 2 Assessment of fracture risk in chronic kidney disease. In the presence of a fracture, investigations include the collection of clinical risk factors, imaging (dual-energy X-ray absorptiometry [DEXA], high-resolution peripheral quantitative computed tomography [HRpQCT], if available) and biochemical tests. The 3 are required to properly evaluate the risk of further fractures. CTX, cross-linked collagen type I peptide; FRAX, Fracture Risk Assessment Tool; P1NP, procollagen type 1 N-terminal pro-peptide; PTH, parathyroid hormone; TRAP5B, tartrate-resistant acid phosphatase 5B. To optimize viewing of this image, please see the online version of this article at www.kidney-international.org. Kidney International 2017 92, 1343-1355DOI: (10.1016/j.kint.2017.07.021) Copyright © 2017 International Society of Nephrology Terms and Conditions

Figure 3 Guidelines for the management of fractures. A fragility fracture requires a deep analysis of mineral metabolism markers. First, the analysis aims to eliminate an osteomalacia or low turnover bone disease with the use of a bone biopsy. Then guidelines are proposed as a function of PTH levels. Reduction of PTH should be achieved before the introduction of any anti-resorbing agents. BSAP, bone-specific alkaline phosphatase; PTH, parathyroid hormone; ULN, upper limit of normal; VRDA, vitamin D receptor activators. Kidney International 2017 92, 1343-1355DOI: (10.1016/j.kint.2017.07.021) Copyright © 2017 International Society of Nephrology Terms and Conditions