Patients with end-stage kidney disease (ESKD) constitute a high-morbidity population.1 In addition to contending with high cardiovascular disease burden, the ESKD population experiences fractures at much higher rates and with worse outcomes compared to the general population.2,3 Because extremely high parathyroid hormone (PTH) levels contribute to hyperparathyroid bone disease and are associated with increased fracture rates,4 reduction of elevated PTH levels through medications or parathyroidectomy has been the mainstay of treatment to protect bone strength in patients with ESKD.