Abnormal bone turnover is common in CKD, but its effects on bone quality remain unclear. We qualitatively screened iliac crest bone specimens from patients on dialysis to identify those patients with low (n=18) or high (n=17) bone turnover. In addition, we obtained control bone specimens from 12 healthy volunteers with normal kidney function. In the patient and control specimens, Fourier transform infrared spectroscopy and nanoindentation quantified the material and mechanical properties of the specimens, and we used bone histomorphometry to assess parameters of bone microstructure and bone formation and resorption. Compared with high or normal turnover, bone with low turnover had microstructural abnormalities such as lower cancellous bone volume and reduced trabecular thickness. Compared with normal or low turnover, bone with high turnover had material and nanomechanical abnormalities such as reduced mineral to matrix ratio and lower stiffness. These data suggest that turnover-related alterations in bone quality may contribute to the diminished mechanical competence of bone in CKD, albeit through different mechanisms. Therapies tailored specifically to low-or high-turnover bone may treat renal osteodystrophy more effectively. Bone turnover abnormalities are well known in patients with chronic kidney disease (CKD). 1 These abnormalities encompass a spectrum from severely suppressed to markedly elevated bone turnover. Abnormal bone turnover occurs in approximately 85% of patients with CKD stage 5 on dialysis (CKD-5D), 2 and within this patient group, there is a greater risk of bone fracture than within the general population. [3][4][5] Although turnover abnormalities are well described, 1 little information is available on whether these abnormalities are associated with changes in bone quality. Bone quality is the contemporary term used to refer to the structural and material parameters that collectively enable bone to bear load and resist fracture or excessive deformation. 6,7 The potential link between bone turnover and bone quality is an important question meriting study because of the relatively high incidence of fractures reported to occur with abnormal turnover. [8][9][10][11][12][13][14] Thus, the specific aim of this study was to advance the understanding of this potential link by quantifying how the microstructural parameters, material composition, and nanomechanical properties vary in bone with low-or high-turnover renal osteodystrophy (ROD) compared with bone with normal turnover from normal volunteers.
RESULTSAmong 163 iliac crest bone biopsies sequentially screened from patients with CKD-5D on dialysis, 35