Bone Turnover–Guided Treatment of Low Bone Density in Haemodialysis Patients Using Bone Biopsy and Fluoride Positron Emission Tomography Imaging

Aim Chronic kidney disease–mineral and bone disorder (CKD–MBD) contributes to skeletal fragility through abnormalities in bone turnover. This study evaluated turnover‐guided therapy using bone histomorphometry and 18 F‐NaF PET/CT in haemodialysis patients with low bone mineral density (BMD). Methods Adult haemodialysis patients at a single centre (2018–2024) underwent turnover assessment by bone biopsy ( n = 31) or PET/CT ( n = 27). Patients were grouped according to whether treatment followed an institutional turnover‐guided protocol introduced in 2020. Outcomes included changes in BMD, bone turnover markers (BTMs), and PET‐derived Ki values. For the biopsy cohort, multiple linear regression assessed treatment effects. Results In the biopsy cohort, protocol‐consistent treatment preserved distal radius BMD compared with historical controls. The annualised difference was +2.06% (95% CI 0.74–3.38; p = 0.005) unadjusted and +2.38% (95% CI 0.24–4.51; p = 0.033) adjusted. No significant effects were seen at spine, hip, or femoral neck. BTMs decreased in protocol‐treated patients (B‐ALP –32.2%, TRACP5b −48.1%), while controls showed no significant change. In the PET/CT cohort, high‐turnover patients ( n = 13) showed reductions in Ki at the iliac crest (−17.1%) and lumbar spine (−14.4%), alongside decreases in BTMs (B‐ALP –22.6%, TRACP5b −40.0%). Distal radius BMD improved at 1 year in patients whose turnover normalised (+2.1% vs. −2.4%; p = 0.04). Conclusion Turnover‐guided treatment was associated with improvements in BMD, BTMs, and PET‐derived metabolic activity. These findings suggest the potential utility of turnover‐informed therapy in CKD–MBD and support 18 F‐NaF PET/CT as a non‐invasive alternative to biopsy.