Dual X-ray absorptiometry is the standard diagnostic modality for identification of low bone mineral density, a finding which is in the general population usually indicative of osteopenia or osteoporosis. However, chronic kidney disease (CKD) patients diagnosed with osteopenia or osteoporosis may in actual fact have renal osteodystrophy with high or low bone turnover. While bisphosphonates are currently prescribed for the prevention of fractures in osteoporosis and high-risk osteopenic patients, the clinical utility of bisphosphonate therapy in CKD has not been established. Furthermore, bisphosphonates accumulate in bone, inhibit osteoclasts, and may cause or exacerbate low-turnover (adynamic) bone disease - particularly in patients presenting with low parathyroid hormone (PTH) levels or receiving treatment for secondary hyperparathyroidism. Bone biopsy with non-decalcified histopathology remains the gold standard for the identification and evaluation of bone disorders, including osteoporosis and renal osteodystrophy. Thirteen CKD patients (stage II-IV), referred to our clinic over a 12-month period, were identified as having taken bisphosphonates from 4 to >60 months after a diagnosis of osteopenia or osteoporosis. All patients underwent biopsies of trabecular bone from the iliac crest following oral administration of time-separated doses of doxycycline and tetracycline. Bone pathology was assessed after processing for mineralized histology. For all patients, clinical data collection included assessment of likely causes of kidney disease, MDRD glomerular filtration rate, calcium-phosphate product, intact PTH level, alkaline phosphatase, and bisphosphonate exposure. All 13 patients were diagnosed with adynamic bone on biopsy evaluation. Eleven biopsies revealed decreased cancellous bone mass; 8 showed decreased osteoid surface; 8 disclosed decreased osteoid thickness, and all 13 demonstrated low or low-normal osteoclast/osteoblast interface. Assessment of dynamic bone formation demonstrated decreased or absent single- or double-labeled osteoid in all 13 bone specimens. Based on these observations, the use of bisphosphonates in CKD cannot be recommended.