Bisphosphonates are synthetic substances that have the similar properties to that of organic phosphate. It helps in avoiding other complications related to the skeletal system of the body. Bisphosphonates don’t allow the calcium from the bones to loosen and get released into the blood making bones brittle and weak. Bisphosphonates are administered intravenously which has a bioavailability of nearly 100 percent. Oral administration gives the bioavailability of about 3 percent. 

It can be given to patients in the first, second, third, and fourth stages of chronic Kidney disease. There is no strong report of the adverse effect of bisphosphonates on the kidney. Study and research is in progress about using bisphosphonate therapy.

Bisphosphonate therapy is given to the patient on dialysis and after renal transplant to maintain the bone mineral density and to keep the skeletal system healthy.

In other bone conditions or kidney conditions, a biopsy of the necessary organ should be done. Bisphosphonates should be started only after the confirmation of the diagnosis.

About 70 percent of the bisphosphonates freely available in the blood are used up in the bones for maintaining their strength. But also it is eliminated easily.

Use of bisphosphonates in CKD.

• To avoid osteoporosis and pathological fractures: one of the main pathologies of osteoporosis is loss of calcium from the bone. When calcium is released from the bone the bone loses its strength and integrity. The process in which the contents of bones are loosened is called bone resorption. This, therefore, leads to easy fractures by very minimal trauma, etc. The structure of the bone and its contents are disturbed. To avoid the resorption of bone, bisphosphonates are administered. They act as the agents which don’t let the calcium out of the bone into the blood. This keeps the bones and the entire skeletal system strong and healthy.
• To avoid postural complications: weak bones lead to bad posture. Bad posture can be a stoop, tilt, or any other position. The postural abnormalities lead to respiratory complications as breathing pattern changes, secretions are not cleared and air entry is obstructed. This leads to various other issues. Bisphosphonates, therefore, help in maintaining posture by keeping the strength of the bones intact.
• To gain control: bisphosphonates keep the musculoskeletal system healthy which helps in maintaining control and balance of the body physically. When control and balance are normal, the case of falls or hits, or trauma is less hence reducing the chance of fractures.
• To avoid vascular calcification: it is proved that the calcification which occurs in the blood vessels due to stasis of the blood, in turn, leads to calcium deposits that are removed by bisphosphonate therapy. It avoids the risk of myocardial infarction and other life threatening complications for the patient.
• Old age patients with Chronic Kidney disease: The bone density is already low in such patients. Along with other interventions bisphosphonates are administered for better bone configuration.
•  7 percent of women or 6 percent of men are affected by low bone mineral density and the percentage increased with the kidney issues and they need interventions with bisphosphonate therapy.

Use of bisphosphonates in patients on dialysis and renal transplant.

• About 45 to 50 percent of patients on dialysis have been noticed to develop fractures. The bone mineral density is reduced to a higher extent which leads to pathological fractures. Bisphosphonates therapy is the treatment of choice to avoid this issue in patients on dialysis.
• The body loses its strength after major operations, so to get the patient back to his activities and daily life he or she has to get stronger, and hence bisphosphonates are administered to avoid bone resorption and to maintain the skeletal system functioning.
• Patients who undergo renal transplants are put on steroid therapy. This leads to osteoporosis in most of the cases. To avoid this complication, the patient is put on bisphosphonate therapy to not let osteoporosis occur.

The use of bisphosphonates in patients with low bone mineral density in CKD is usually associated with:

• A female patient post menopause.
• A patient who has had a sedentary lifestyle for a long time.
• A patient who consumes less calcium in the diet.
• The patient who has hyperthyroidism.
• The patient who has vitamin D deficiency.
• An old patient.

The benefit of bisphosphonate therapy.

• Along with the property which leads to enhancing bone minerals and bodily strength, it has the benefit of getting eliminated through the urine. 
• Hence, bisphosphonate toxicity is very rare or absent.
• It is an effective therapy for chronic kidney disease of mild to a moderate degree.
• It is the effective treatment for Paget’s disease, weak bones, and post menopausal osteoporosis too.
• It can be given to the conscious patient by the oral route of administration which has no side effects that the research has come across.
• It can be administered by IV route for unconscious patients or patients who cannot orally consume the medication due to any condition like vomiting, gastric complications, irritation, intubation, etc.

Bisphosphonate therapy indications.

• When blood calcium levels are high. This indicates that the calcium from the bone is getting depleted and is released into the blood. Hence, blood tests can be an indicator for bisphosphonate therapy.
• Abnormal creatinine levels indicate the need for this therapy.
• Prophylactic treatment to avoid loss of bone mass and minerals.
• Calciphylaxis.
• Vascular calcification.

Secondary uses of bisphosphonate therapy.

• It helps in avoiding calcium deposits in vessels and therefore cardiac arrest or stroke is avoided. Also, renal hypertension is avoided.
• It helps patients to fasten the process of recovery after the renal transplant or other procedures. 
• The patient gains strength in the bones and hence the patient gets back to his or her activities of daily living sooner.
• The quality of life of the patient is better with this therapy.
• The use of assistive devices for walking, reaching or other activities is reduced to some extent.
• Secondary complications of chronic Kidney disease are avoided.
• Calcium levels in the bones are maintained adequately.
• Blood calcium is maintained by not allowing it to rise.

How is bisphosphonate therapy useful in kidney disease?

Osteoclasts are cells that cause bone destruction. It causes the bone to release its contents into the blood. This activity is necessary to maintain proper bodily functioning. If this activity increases, it causes abnormalities. Osteoclastic activity increases in renal transplant and CKD patients. Bisphosphonates are the agents which kill or deactivate the activities of osteoclasts. This turn improves the quality of the bone.

It also prevents 

About bisphosphonate therapy.

• Studies suggest that the intravenously administered bisphosphonates are seen to have a few adverse effects in some patients such as carcinoma, bone necrosis, etc.
• Oral administration has been proven better for the patient.
• It causes gastrointestinal irritability or it has bad tolerance to the gastric system.

Adverse effects of bisphosphonate therapy are reported they are:

• Nephrotoxicity. If the elimination of bisphosphonates is not proper it leads to toxicity.
• Necrosis.
• Cancer
• Irritability in the gastrointestinal tract.
• Psychological disturbances.

In spite of these adverse effects, it is used widely because of its beneficial effects.

Where is bisphosphonate therapy useful?

• When the patient has the relevant disease and has weak bones.
• The patient does not fall under the contraindication category.
• The patient has been diagnosed properly.
• The patient takes the dose of treatment from time to time.
• There is no cancerous change in the bone.
• Intestinal absorption of it is adequate.
• There is no disease of the intestine where absorption of bisphosphonates is hampered.
• The patient does not develop an adverse reaction to the therapy.
• The patient does not take other medicines which counteract the action of bisphosphonates and nullifies its effects.
• When the course of the treatment is completed and maintained as required.

Summary:

• They are synthetic compounds.
• Used majorly in treating osteoporosis, avoiding pathological fractures, and so on.
• It acts by slowing down the action of osteoclasts and enhancing the bone constituents.
• They act by fixing the calcium in the bones and reducing blood calcium levels.
• As calcium is retained by the bone, it remains strong.
• Women need this treatment more than men.
• This can be given in any stage of kidney disease, patient on dialysis, transplant of kidney too.
• It is a supportive yet very important treatment.
• The patient may have some discomfort or irritation due to this treatment.
• Indications for its use are elevated serum calcium levels, osteoporotic changes, old age issues, chronic kidney disease, etc.
• This treatment will prove to be effective in making patients independent early and for a better quality of life and for reducing the hospital stay.
• Bisphosphonate therapy is very effective when taken properly, appropriately, and under the supervision of the doctor.