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Bone disease is one of the major long-term complications of end stage renal disease (ESRD). Loss of renal function upsets normal homeostasis of the two minerals stored in the bones, calcium, and phosphate. It affects the two hormones, vitamin D and parathyroid hormone (PTH) that help maintain healthy bones, and may result in excess aluminum being deposited in bones. Treatments of these imbalances in the past had an adverse effect on bones; present-day treatments are not without complications. New understanding of the pathogenesis of the two classifications of osteodystrophy, high turnover versus low turnover, have important implications for prevention and treatment of the disease.