Abstract: Denosumab, a RANKL inhibitor, inhibiting osteoclast formation, can cause severe symptomatic hypocalcemia especially in cases with renal impairment stage 4 and 5 (1). MHRA safety alert warns that the patients with severe renal impairment with Creatinine clearance of ≤30ml/min or those who are receiving dialysis, are at the highest risk of hypocalcemia (1). In individuals with CKD stages 4-5, anti-resorptive bone protection therapy might cause harm with increase the risk of fracture and vascular calcifications in low bone turnover conditions by further inhibiting osteoclasts while high bone turnover diseases are more susceptible to hypocalcemia (3). The incidence of hypocalcemia in CKD is reported to be 14-15% (4).