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Description:Open in a separate window Vitamin D deficiency can contribute to bone loss from decreased vitamin D—mediated intestinal calcium absorption and resultant secondary hyperparathyroidism HPT. This contributes to secondary HPT and metabolic bone disease. Superimposed nutritional deficiency may aggravate secondary HPT both directly as a result of low vitamin D levels and indirectly as a result of impaired vitamin D—mediated intestinal calcium absorption. Emerging evidence is challenging our understanding of bone and vascular health in stage IV to V CKD, such that vitamin D, calcitriol, or vitamin D analogs should be used according to current CKD guidelines and under the guidance of a nephrologist. It has been suggested that clinicians should routinely test for hypovitaminosis D in patients with musculoskeletal symptoms, such as bone pain, myalgias, and generalized weakness, because these symptoms are often associated with hypovitaminosis D and might be misdiagnosed as fibromyalgia, chronic fatigue, age-related weakness, or even depression. Furthermore, vitamin D status can be a surrogate marker of poor nutritional status such that the high prevalence of vitamin D deficiency in these populations may reflect suboptimal nutrition and lack of outdoor activity associated with chronic illness.