patients with CKD most commonly have osteitis fibrosa cystica , however, some patient may have adynamic bone disease. A bone biopsy is indicated to differentiate the types of bone disease. Bone disease develops as the kidny fail to eliminate phosphorus. The body tries to maintain the calcium and phosphorus balance by pulling calcium from the bones and by producing increased parathyroid hormone to increase the absorption of calcium in the gut. Unfortunately, as CKD progresses, the process becomes a losing battle, and drug management becomes the next best option. Because newer therapies may provide for slowing or possibly preventing this process from robbing the bone of calcium and damaging the skeleton, it is important to assess and treat bone disease early in the CKD disease process.