Bisphosphonates have become a standard treatment for osteoporosis and malignant bone disease. Most are contraindicated in severe renal insufficiency because they are eliminated exclusively by the kidneys. However, the marked impairment of bone metabolism in many dialysis patients provides a rationale for their judicious use in this setting. Animal studies reveal that bisphosphonates inhibit hyperparathyroid bone changes. Clodronate, pamidronate and ibandronate are also readily dialyzable, enabling them to be used in dialysis patients. Initial pilot studies in dialysis patients have confirmed the positive effect on hyperparathyroid bone disease observed in animal models. However, large randomized placebo-controlled trials are required before the use of bisphosphonates in renal osteopathy can be generally recommended.