In Reply We thank Drs Schoenmakers and Fraser for their comments on our study. We reported the US experience with denosumab administration among dialysis-dependent patients, finding the weighted cumulative incidence of severe hypocalcemia (ie, <7.5 mg/dL or emergent care) at 12 weeks to be 41.1% with denosumab. We agree that treatment for osteoporosis in our study may have been initiated in some patients with poorly controlled CKD-MBD, highlighting the importance of increased attention to careful patient selection in clinical practice. However, careful patient selection alone may not prevent hypocalcemia, and ongoing careful monitoring is necessary. Hiramatsu et al reported that 12 of 47 dialysis-dependent patients (25.5%) with relatively well-controlled mineral abnormalities receiving supplementation with calcium and vitamin D developed denosumab-associated acute hypocalcemia (ie, ≤8 mg/dL) during a 2-year observational study in Japan.
