Histomorphometric analysis of iliac bone samples is a key tool for studying bone metabolism and, to a lesser extent, bone mass and structure. Two types of bone metabolic activity can be distinguished: modeling and remodeling. Both processes are performed by the same effector cells, osteoblasts and osteoclasts, but differ in the way these cells are arranged. The main effect of remodeling is to renew bone, whereas modeling can lead to rapid changes in bone shape, size and mass. Standard histomorphometric analysis focuses on trabecular bone and therefore mainly provides information on remodeling. Remodeling activity changes markedly with age during development. This must be taken into account when histomorphometry is used in the pediatric setting. Remodeling disorders encountered in the context of pediatric renal bone disease include mineralization defects, as well as abnormally high remodeling activity due to secondary hyperparathyroidism or suppressed remodeling activity as a consequence of over-treatment. Children and adolescents with severe bone fragility should have a bone biopsy unless the diagnosis is obvious from noninvasive examinations. Histomorphometric analysis of transiliac bone biopsy samples is especially valuable in clinical studies, as this method provides safety and efficacy data that cannot be obtained in any other way.