What is your approach to using bisphosphonates in those with severe hypercalcemia and chronic kidney disease?  

Epocrates says for pamidronate under renal dosing "severe impairment avoid use". I have used it many times but at a reduced dose, 30 mg IV once, and wait, takes a few days to kick in. Maybe once I used 60 mg. Use at your own discretion, as it is not advised as above. I avoid zoledronic acid (even...