Guidelines for the assessment, diagnosis and therapy of the alterations that characterize the CKD-MBD are an important support in the clinical practice of the nephrologist. Compared to the KDIGO guidelines published in 2009, the 2017 update made changes on some topics on which there was previously no strong evidence both in terms of diagnosis and therapy. The recommendations include the diagnosis of bone anomalies in CKD-MBD and the treatment of mineral metabolism abnormalities with particular regard to hyperphosphataemia, calcium levels, secondary hyperparathyroidism and anti-resorptive therapies. The Italian Study Group on Mineral Metabolism, in reviewing the 2017 recommendations, aimed to assess the weight of the evidence that led to this update. In fact, on some topics there has not been a substantial difference on the degree of evidence compared to the previous guidelines. The Italian Study Group emphasizes the points that may still reserve critical issues, including interpretation, and invites an evaluation that is articulated and personalized for each patient.

Osteoporosis is a condition in which bone resorption by osteoclasts overtakes bone formation by osteoblasts ; as a result, bone density is reduced, the bone microarchitecture is damaged, and the risk of fractures is increased. To date, the increase in bone resorption has been explained by a reduction in female hormones, which control the activity of osteoclasts. More recently, however, it has become clear that a reduction in male hormones from middle age onwards, increasing age, and an increase in oxidative stress related to lifestyle-related diseases can also activate osteoclasts and reduce osteoblast function. These changes lead to both qualitative and quantitative abnormalities in collagen, which is the major bone matrix protein. In contrast to microstructure and calcification levels, among other bone-density and bone-matrix factors, which are controlled by bone remodeling, the intermolecular cross-link formation of collagen, which regulates bone-material attributes, is a mechanism independent of bone remodeling. In other words, cross-link formation is controlled by the environment surrounding the bone matrix, comprising cellular functions, oxidative stress, carbonyl stress, and glycation level. Therefore, bone quality is regulated both by bone remodeling and by a remodeling-independent mechanism, and markers for evaluating bone quality should be established.

The bone is continuously renewed throughout adult life by the coordinated action of osteoclastic bone resorption and osteoblastic bone formation in response to various hormones, cytokines, chemokines and biomechanical external stimuli. This process, called bone remodeling, is a prerequisite for the normal bone homeostasis that maintains both bone quality and strength. An imbalance of bone resorption and bone formation is often central to metabolic bone diseases. Aging, various diseases including life-style-related diseases, and loss of mechanical stress lead to an excessive bone resorption, resulting in osteoporosis due to decreased bone mineral density and deterioration of bone quality. Therefore, the activity of both osteoclasts and osteoblasts must be tightly regulated during bone remodeling. Understanding the regulatory mechanisms of bone cells and signal transduction through bone cell communication is important for treating osteoporosis.

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Glucocorticoid-induced osteoporosis and fractures are the most frequent adverse effects of this class of medication. Recent advances in the pathophysiology, epidemiology, detection, and prevention of this complication of therapy provide hope for its amelioration in patients who require treatment with glucocorticoids. A number of effective pharmacologic agents are available and/or under study, and scientific organizations now provide guidelines for the prevention and treatment of glucocorticoid-induced osteoporosis. Unfortunately, consistent application of these guidelines remains suboptimal in many practice settings.

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Fixed prosthetic implant reconstruction of the edentulous maxilla demands skill and state-of-the-art techniques of both the surgeon and the restorative dentist. As discussed in Part I (Implant Dent. 1999;8: 186-193), accurate diagnosis and treatment planning are essential to successful, predictable clinical results. How and where implants are placed have a lasting impact on the quality and prognosis of the final restoration. A series of clinical guidelines and considerations is reviewed with illustrative clinical treatment protocols of edentulous maxillae of unfavorable anatomy including attendant prosthetic difficulties. This article addresses the fixed implant rehabilitation of edentulous maxillas with inadequate posterior bone and favorable arch position, inadequate posterior bone and unfavorable arch position, and inadequate anterior and posterior bone and unfavorable arch position.