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Pharmacologic strategies to prevent fractures in the general population with osteoporosis include calcium, vitamin D, antiresorptive agents, and bone anabolic drugs. In patients with chronic kidney disease (CKD) stages 2-3, post hoc analyses suggest that bisphosphonates, 1 raloxifene, denosumab, 2, 3 or teriparatide may be effective for fracture prevention. 4 However, there is limited published experience with these medications in patients with CKD stages 4-5 (estimated glomerular filtration rate [eGFR]< 30 mL/min/1.73 m2). 5 For these patients, experts suggest evaluating bone turnover by serologic markers and to consider antiresorptive agents for those with evidence of normal-or high-turnover disease. 6 Providers treating patients with CKD stages 4-5 and osteoporosis must balance the potential benefit of available pharmacologic options in fracture prevention against the largely unstudied potential side effects …