Diagnostic Accuracy of Bone Turnover Markers and Bone Histology in Patients With CKD Treated by Dialysis

Am J Kidney Dis. 2016 Apr;67(4):559-66. doi: 10.1053/j.ajkd.2015.06.023. Epub 2015 Aug 25.


Background: The management of chronic kidney disease-mineral and bone disorder requires the assessment of bone turnover, which most often is based on parathyroid hormone (PTH) concentration, the utility of which remains controversial.

Study design: Cross-sectional retrospective diagnostic test study.

Setting & participants: 492 dialysis patients from Brazil, Portugal, Turkey, and Venezuela with prior bone biopsy and stored (-20 °C) serum.

Index tests: Samples were analyzed for PTH (intact [iPTH] and whole PTH), bone-specific alkaline phosphatase (bALP), and amino-terminal propeptide of type 1 procollagen (P1NP).

Reference test: Bone histomorphometric assessment of turnover (bone formation rate/bone surface [BFR/BS]) and receiver operating characteristic curves for discriminating diagnostic ability.

Results: The biomarkers iPTH and bALP or combinations thereof allowed discrimination of low from nonlow and high from nonhigh BFR/BS, with an area under the receiver operating characteristic curve > 0.70 but < 0.80. Using iPTH level, the best cutoff to discriminate low from nonlow BFR/BS was <103.8 pg/mL, and to discriminate high from nonhigh BFR/BS was >323.0 pg/mL. The best cutoff for bALP to discriminate low from nonlow BFR/BS was <33.1 U/L, and for high from nonhigh BFR/BS, 42.1U/L. Using the KDIGO practice guideline PTH values of greater than 2 but less than 9 times the upper limit of normal, sensitivity and specificity of iPTH level to discriminate low from nonlow turnover bone disease were 65.7% and 65.3%, and to discriminate high from nonhigh were 37.0% and 85.8%, respectively.

Limitations: Cross-sectional design without consideration of therapy. Potential limited generalizability with samples from 4 countries.

Conclusions: The serum biomarkers iPTH, whole PTH, and bALP were able to discriminate low from nonlow BFR/BS, whereas iPTH and bALP were able to discriminate high from nonhigh BFR/BS. Prospective studies are required to determine whether evaluating trends in biomarker concentrations could guide therapeutic decisions.

Keywords: BSAP); Sensitivity and specificity; alkaline phosphatases; bone histomorphometry; bone-specific alkaline phosphatase (bALP; chronic kidney disease–mineral bone disorder (CKD-MBD); parathyroid hormone (PTH); procollagen type 1 N propeptide (P1NP); renal osteodystrophy.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Alkaline Phosphatase / blood
  • Biomarkers / blood
  • Bone Remodeling / physiology*
  • Bone and Bones / pathology*
  • Collagen Type I / blood
  • Cross-Sectional Studies
  • Female
  • Humans
  • Male
  • Middle Aged
  • Parathyroid Hormone / blood
  • Predictive Value of Tests
  • Renal Dialysis*
  • Renal Insufficiency, Chronic / blood*
  • Renal Insufficiency, Chronic / physiopathology*
  • Renal Insufficiency, Chronic / therapy
  • Reproducibility of Results
  • Retrospective Studies


  • Biomarkers
  • Collagen Type I
  • Parathyroid Hormone
  • Alkaline Phosphatase