1
|
Usmani S, Ahmed N, Gnanasegaran G, Marafi F, Bani-Mustafa A, Van den Wyngaert T. Assessment of regional and total skeletal metabolism using 18F-NaF PET/CT in patients with chronic kidney disease. Ann Nucl Med 2024; 38:563-573. [PMID: 38676905 DOI: 10.1007/s12149-024-01929-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 04/08/2024] [Indexed: 04/29/2024]
Abstract
OBJECTIVE The study aims to assess regional and total bone metabolic activity in patients with chronic kidney disease using Na[18F]F PET and correlation between semi-quantitative indices and blood parameters. METHODS Seventy-two subjects (mean age 61.8 ± 13.8 years) were included. Of these 24/72 patients had end-stage renal disease (ESRD) (GFR < 15 mL/min/1.73 m2), 38/72 had chronic kidney disease (CKD) (GFR between 60 and 15 mL/min/1.73 m2), and 10/72 were controls with normal renal function. All subjects underwent Na[18F]F PET-CT with a dose activity of 0.06 mCi/Kg. Regional and total skeletal metabolism were assessed with mean SUVs in a skeletal volume of interest (VOI), bone to soft tissue index (B/S), global SUV mean (GSUV mean) of the whole bone, and uptake in the femoral neck. RESULTS Statistically significant differences were observed in a number of 18F-NaF metrics like femoral neck metabolism in CKD and ERSD groups in comparison to control in right (P = 0.003) and left femur (P = 0.006), bone to soft tissue index in the femur (P = 0.016) and GSUV5 (P = 0.006). There is also a significant difference in SUV mean in lumbar vertebrae (L1-L4) among CKD, ESRD, and controls. There was a moderate correlation between 18F-NaF PET scan uptake and blood parameters such as ALP and PTH. Na[18F]F uptake parameters were significantly different in low versus high bone turnover state. CONCLUSIONS The assessment of total skeleton and regional metabolism and bone turnover in CKD patients is feasible with Na[18F]F PET. Na[18F]F can help to detect early changes in bone metabolism and assess the progression of bone disease in this complex condition. Quantification with Na[18F]F PET might provide better assessment of the bone turnover. The difference in Na[18F]F uptake in CKD compared to controls is likely related to a change in bone turnover which, however, requires further validation.
Collapse
Affiliation(s)
- Sharjeel Usmani
- Department of Nuclear Medicine, Sultan Qaboos Comprehensive Cancer Care and Research Center, Muscat, Oman.
- Hull York Medical School, Hull, UK.
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.
| | - Najeeb Ahmed
- Department of Nuclear Medicine, Jack Brignall PET/CT Centre, Castle Hill Hospital, Cottingham, UK
- Hull York Medical School, Hull, UK
| | | | - Fahad Marafi
- Department of Nuclear Medicine, Jaber Al-Ahmad Molecular Imaging Center, Kuwait, Kuwait
| | | | - Tim Van den Wyngaert
- Department of Nuclear Medicine, Antwerp University Hospital, Edegem, Belgium
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| |
Collapse
|
2
|
Sanoesan V, Phannajit J, Kingpetch K, Sawatnatee T, Phromphao B, Susantitaphong P, Sukprakun C, Khamwan K. Bone turnover prediction in patients with chronic kidney disease (CKD) undergoing hemodialysis using shortened dynamic 18F-NaF PET/CT K i-Patlak. Sci Rep 2024; 14:12536. [PMID: 38822011 PMCID: PMC11143219 DOI: 10.1038/s41598-024-63476-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 05/29/2024] [Indexed: 06/02/2024] Open
Abstract
This study investigated whether Ki-Patlak derived from a shortened scan time for dynamic 18F-NaF PET/CT in chronic kidney disease (CKD) patients undergoing hemodialysis can provide predictive accuracy comparable to that obtained from a longer scan. Twenty-seven patients on chronic hemodialysis, involving a total of 42 scans between December 2021 and August 2023 were recruited. Dynamic 18F-NaF PET/CT scans, lasting 60-90 min, were immediately acquired post-injection, covering the mid-twelfth thoracic vertebra to the pelvis region. Ki-Patlak analysis was performed on bone time-activity curves at 15, 30, 45, 60, and 90 min in the lumbar spine (L1-L4) and both anterior iliac crests. Spearman's rank correlation (rs) and interclass correlation coefficient were used to assess the correlation and agreement of Ki-Patlak between shortened and standard scan times. Bone-specific alkaline phosphatase (BsAP) and tartrate-resistant acid phosphatase isoform 5b (TRAP5b) were tested for their correlation with individual Ki-Patlak. Strong correlations and good agreement were observed between Ki-Patlak values from shortened 30-min scans and longer 60-90-min scans in both lumbar spine (rs = 0.858, p < 0.001) and anterior iliac crest regions (rs = 0.850, p < 0.001). The correlation between BsAP and Ki-Patlak in the anterior iliac crests was weak and statistically insignificant. This finding suggests that a proposed shortened dynamic 18F-NaF PET/CT scan is effective in assessing bone metabolic flux in CKD patients undergoing hemodialysis, offering a non-invasive alternative approach for bone turnover prediction.
Collapse
Affiliation(s)
- Viyada Sanoesan
- Medical Physics Program, Department of Radiology, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
- Chulalongkorn University Biomedical Imaging Group, Department of Radiology, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
- Department of Radiological Technology, Faculty of Sciences, Ramkhamhaeng University, Huamark, Bangkapi, Bangkok, 10240, Thailand
| | - Jeerath Phannajit
- Division of Clinical Epidemiology, Department of Medicine, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, 10330, Thailand
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
- Center of Excellence for Metabolic Bone Disease in CKD Patients, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
| | - Kanaungnit Kingpetch
- Division of Nuclear Medicine, Department of Radiology, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
| | - Thunyaluk Sawatnatee
- Division of Nuclear Medicine, Department of Radiology, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, 10330, Thailand
| | - Benchamat Phromphao
- Division of Nuclear Medicine, Department of Radiology, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, 10330, Thailand
| | - Paweena Susantitaphong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
- Center of Excellence for Metabolic Bone Disease in CKD Patients, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
| | - Chanan Sukprakun
- Division of Nuclear Medicine, Department of Radiology, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
| | - Kitiwat Khamwan
- Medical Physics Program, Department of Radiology, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand.
- Chulalongkorn University Biomedical Imaging Group, Department of Radiology, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand.
- Division of Nuclear Medicine, Department of Radiology, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand.
| |
Collapse
|
3
|
Jørgensen HS, Lloret MJ, Lalayiannis AD, Shroff R, Evenepoel P. Ten tips on how to assess bone health in patients with chronic kidney disease. Clin Kidney J 2024; 17:sfae093. [PMID: 38817914 PMCID: PMC11137676 DOI: 10.1093/ckj/sfae093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Indexed: 06/01/2024] Open
Abstract
Patients with chronic kidney disease (CKD) experience a several-fold increased risk of fracture. Despite the high incidence and the associated excess morbidity and premature mortality, bone fragility in CKD, or CKD-associated osteoporosis, remains a blind spot in nephrology with an immense treatment gap. Defining the bone phenotype is a prerequisite for the appropriate therapy of CKD-associated osteoporosis at the patient level. In the present review, we suggest 10 practical 'tips and tricks' for the assessment of bone health in patients with CKD. We describe the clinical, biochemical, and radiological evaluation of bone health, alongside the benefits and limitations of the available diagnostics. A bone biopsy, the gold standard for diagnosing renal bone disease, is invasive and not widely available; although useful in complex cases, we do not consider it an essential component of bone assessment in patients with CKD-associated osteoporosis. Furthermore, we advocate for the deployment of multidisciplinary expert teams at local, national, and potentially international level. Finally, we address the knowledge gaps in the diagnosis, particularly early detection, appropriate "real-time" monitoring of bone health in this highly vulnerable population, and emerging diagnostic tools, currently primarily used in research, that may be on the horizon of clinical practice.
Collapse
Affiliation(s)
- Hanne Skou Jørgensen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Nephrology, Aalborg University Hospital, Aalborg, Denmark
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Maria Jesús Lloret
- Department of Nephrology, Hospital Fundació Puigvert, Barcelona, Spain
- Institut de Recerca Sant-Pau (IR-Sant Pau), Barcelona, Spain
| | - Alexander D Lalayiannis
- Department of Pediatric Nephrology, Birmingham Women's and Children's Hospitals, Birmingham, UK
| | - Rukshana Shroff
- Renal Unit, UCL Great Ormond Street Hospital and Institute of Child Health, London, UK
| | - Pieter Evenepoel
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, Katholieke Universiteit Leuven, Leuven, Belgium
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| |
Collapse
|
4
|
de Oliveira RB, Carvalho AB, Jorgetti V. Bone aluminum accumulation in the current era. J Bras Nefrol 2024; 46:e20240023. [PMID: 38748946 PMCID: PMC11203949 DOI: 10.1590/2175-8239-jbn-2024-0023en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 03/22/2024] [Indexed: 06/28/2024] Open
Abstract
In the last few years, evidence from the Brazilian Registry of Bone Biopsy (REBRABO) has pointed out a high incidence of aluminum (Al) accumulation in the bones of patients with CKD under dialysis. This surprising finding does not appear to be merely a passive metal accumulation, as prospective data from REBRABO suggest that the presence of Al in bone may be independently associated with major adverse cardiovascular events. This information contrasts with the perception of epidemiologic control of this condition around the world. In this opinion paper, we discussed why the diagnosis of Al accumulation in bone is not reported in other parts of the world. We also discuss a range of possibilities to understand why bone Al accumulation still occurs, not as a classical syndrome with systemic signs of intoxication, as occurred it has in the past.
Collapse
Affiliation(s)
- Rodrigo Bueno de Oliveira
- Universidade Estadual de Campinas (Unicamp), Faculdade de Ciências Médicas, Laboratório para o Estudo Mineral e Ósseo em Nefrologia (LEMON), Campinas, SP, Brazil
- Universidade Estadual de Campinas (Unicamp), Faculdade de Ciências Médicas, Departamento de Clínica Médica, Divisão de Nefrologia, Campinas, SP, Brazil
| | - Aluízio Barbosa Carvalho
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Nefrologia, São Paulo, SP, Brazil
| | - Vanda Jorgetti
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Clínica Médica, Laboratório de Fisiopatologia Renal (LIM-16), São Paulo, SP, Brazil
| |
Collapse
|
5
|
Fuglø D, Drachmann ALP, Heltø KMM, Marner L, Hansen D. Bone Turnover in Patients with Chronic Kidney Disease Stage 5D and Healthy Controls - a Quantitative [ 18F]Fluoride PET Study. Mol Imaging Biol 2023; 25:815-823. [PMID: 37433895 PMCID: PMC10598153 DOI: 10.1007/s11307-023-01834-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 06/15/2023] [Accepted: 06/19/2023] [Indexed: 07/13/2023]
Abstract
BACKGROUND Chronic kidney disease (CKD) is prevalent in the aging population and increases the risk of fracture 2-4 times. We compared optimized quantitative [18F]fluoride PET/CT methods to the reference standard with arterial input function (AIF) to identify a clinically accessible method for evaluation of bone turnover in patients with CKD. METHODS Ten patients on chronic hemodialysis treatment and ten control patients were recruited. A dynamic 60-min [18F]fluoride PET scan was obtained from the 5th lumbar vertebra to the proximal femur simultaneously with arterial blood sampling to achieve an AIF. Individual AIFs were time-shifted to compute a population curve (PDIF). Bone and vascular volumes-of-interest (VOIs) were drawn, and an image-derived-input-function (IDIF) was extracted. PDIF and IDIF were scaled to plasma. Bone turnover (Ki) was calculated with the AIF, PDIF, and IDIF and bone VOIs using a Gjedde-Patlak plot. Input methods were compared using correlations and precision errors. RESULTS The calculated Ki from the five non-invasive methods all correlated to the Ki from the AIF method with the PDIF scaled to a single late plasma sample showing the highest correlations (r > 0.94), and the lowest precision error of 3-5%. Furthermore, the femoral bone VOI's correlated positively to p-PTH and showed significant differences between patients and controls. CONCLUSIONS Dynamic 30 min [18F]fluoride PET/CT with a population based input curve scaled to a single venous plasma sample is a feasible and precise non-invasive diagnostic method for the assessment of bone turnover in patients with CKD. The method may potentially allow for earlier and more precise diagnosis and may be useful for assessment of treatment effects, which is crucial for development of future treatment strategies.
Collapse
Affiliation(s)
- Dan Fuglø
- Department of Nuclear Medicine, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | | | - Kim Minh Michael Heltø
- Department of Anaesthesiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Lisbeth Marner
- Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark.
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - Ditte Hansen
- Department of Nephrology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
6
|
Puri T, Frost ML, Moore AEB, Choudhury A, Vinjamuri S, Mahajan A, Fynbo C, Vrist M, Theil J, Kairemo K, Wong J, Zaidi H, Revheim ME, Werner TJ, Alavi A, Cook GJR, Blake GM. Utility of a simplified [ 18F] sodium fluoride PET imaging method to quantify bone metabolic flux for a wide range of clinical applications. Front Endocrinol (Lausanne) 2023; 14:1236881. [PMID: 37780613 PMCID: PMC10534005 DOI: 10.3389/fendo.2023.1236881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 08/14/2023] [Indexed: 10/03/2023] Open
Abstract
We review the rationale, methodology, and clinical utility of quantitative [18F] sodium fluoride ([18F]NaF) positron emission tomography-computed tomography (PET-CT) imaging to measure bone metabolic flux (Ki, also known as bone plasma clearance), a measurement indicative of the local rate of bone formation at the chosen region of interest. We review the bone remodelling cycle and explain what aspects of bone remodelling are addressed by [18F]NaF PET-CT. We explain how the technique works, what measurements are involved, and what makes [18F]NaF PET-CT a useful tool for the study of bone remodelling. We discuss how these measurements can be simplified without loss of accuracy to make the technique more accessible. Finally, we briefly review some key clinical applications and discuss the potential for future developments. We hope that the simplified method described here will assist in promoting the wider use of the technique.
Collapse
Affiliation(s)
- Tanuj Puri
- Faculty of Biology, Medicine and Health, School of Medical Sciences, Division of Cancer Sciences, The University of Manchester, The Christie NHS Foundation Trust, Manchester, United Kingdom
- Department of Biomedical Engineering, School of Biomedical Engineering and Imaging Sciences, King’s College London, St. Thomas’ Hospital, London, United Kingdom
| | - Michelle L. Frost
- Institute of Cancer Research Clinical Trials & Statistics Unit (ICR-CTSU), The Institute of Cancer Research, Sutton, United Kingdom
| | - Amelia E. B. Moore
- Department of Cancer Imaging, and King’s College London and Guy’s and St Thomas’ PET Centre, School of Biomedical Engineering and Imaging Sciences, King’s College London, St. Thomas’ Hospital, London, United Kingdom
| | - Ananya Choudhury
- Faculty of Biology, Medicine and Health, School of Medical Sciences, Division of Cancer Sciences, The University of Manchester, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Sobhan Vinjamuri
- Nuclear Medicine Department, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, United Kingdom
| | - Abhishek Mahajan
- The Clatterbridge Cancer Centre NHS Foundation Trust, University of Liverpool, Liverpool, United Kingdom
| | - Claire Fynbo
- Clinic of Nuclear Medicine, Gødstrup Hospital, Herning, Denmark
| | - Marie Vrist
- University Clinic in Nephrology and Hypertension, Gødstrup Hospital, Herning, Denmark
| | - Jørn Theil
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Kalevi Kairemo
- Department of Nuclear Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - James Wong
- Department of Anaesthesia, St Bartholomew’s Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Habib Zaidi
- Geneva University Hospital, Division of Nuclear Medicine and Molecular Imaging, Geneva, Switzerland
| | - Mona-Elisabeth Revheim
- The Intervention Centre, Oslo University Hospital, Norway Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Thomas J. Werner
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Abass Alavi
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Gary J. R. Cook
- Department of Cancer Imaging, and King’s College London and Guy’s and St Thomas’ PET Centre, School of Biomedical Engineering and Imaging Sciences, King’s College London, St. Thomas’ Hospital, London, United Kingdom
| | - Glen M. Blake
- Department of Biomedical Engineering, School of Biomedical Engineering and Imaging Sciences, King’s College London, St. Thomas’ Hospital, London, United Kingdom
| |
Collapse
|
7
|
Suzuki T, Mizobuchi M, Yoshida S, Terado N, Aoki S, Sato N, Honda H. Romosozumab successfully regulated progressive osteoporosis in a patient with autosomal dominant polycystic kidney disease undergoing hemodialysis. Osteoporos Int 2022; 33:2649-2652. [PMID: 35980440 DOI: 10.1007/s00198-022-06534-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 08/13/2022] [Indexed: 10/15/2022]
Abstract
Osteoporosis is a crucial complication in patients with chronic kidney disease (CKD), similar to that in the general population. Although romosozumab, a monoclonal antibody targeting sclerostin, has been administered for patients with CKD, its clinical effectiveness in these patients, especially in patients on hemodialysis (HD), remains to be studied. Herein, we report the case of a 42-year-old man on HD who developed severe osteoporosis. Serum calcium levels were extremely high, bone metabolic markers were abnormal, and the patient had pathological fractures. The bone biopsy indicated a bone metabolism disorder and high bone turnover. We administered romosozumab once a month as an intervention for bone alteration. Through the 10-month usage, bone metabolic markers improved, and the decrease in bone mineral density was ameliorated. We hypothesized that romosozumab could be a therapeutic option for osteoporosis in patients undergoing HD, especially in those with bone mineralization disorders.
Collapse
Affiliation(s)
- Taihei Suzuki
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan.
| | - Masahide Mizobuchi
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan
| | - Shunsuke Yoshida
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan
| | - Narumi Terado
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan
| | - Shugo Aoki
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan
| | - Nozomi Sato
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan
| | - Hirokazu Honda
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan
| |
Collapse
|
8
|
Nagy E, Sobh MM, Abdalbary M, Elnagar S, Elrefaey R, Shabaka S, Elshabrawy N, Shemies R, Tawfik M, Santos CGS, Barreto FC, El-Husseini A. Is Adynamic Bone Always a Disease? Lessons from Patients with Chronic Kidney Disease. J Clin Med 2022; 11:jcm11237130. [PMID: 36498703 PMCID: PMC9736225 DOI: 10.3390/jcm11237130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 11/28/2022] [Indexed: 12/04/2022] Open
Abstract
Renal osteodystrophy (ROD) is a common complication of end-stage kidney disease that often starts early with loss of kidney function, and it is considered an integral part in management of patients with chronic kidney disease (CKD). Adynamic bone (ADB) is characterized by suppressed bone formation, low cellularity, and thin osteoid seams. There is accumulating evidence supporting increasing prevalence of ADB, particularly in early CKD. Contemporarily, it is not very clear whether it represents a true disease, an adaptive mechanism to prevent bone resorption, or just a transitional stage. Several co-players are incriminated in its pathogenesis, such as age, diabetes mellitus, malnutrition, uremic milieu, and iatrogenic factors. In the present review, we will discuss the up-to-date knowledge of the ADB and focus on its impact on bone health, fracture risk, vascular calcification, and long-term survival. Moreover, we will emphasize the proper preventive and management strategies of ADB that are pivotal issues in managing patients with CKD. It is still unclear whether ADB is always a pathologic condition or whether it can represent an adaptive process to suppress bone resorption and further bone loss. In this article, we tried to discuss this hard topic based on the available limited information in patients with CKD. More studies are needed to be able to clearly address this frequent ROD finding.
Collapse
Affiliation(s)
- Eman Nagy
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Mahmoud M. Sobh
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Mohamed Abdalbary
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Sherouk Elnagar
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Rabab Elrefaey
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Shimaa Shabaka
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Nehal Elshabrawy
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Rasha Shemies
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Mona Tawfik
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Cássia Gomes S. Santos
- Department of Internal Medicine, Division of Nephrology, Federal University of Paraná, Curitiba 80060-00, PR, Brazil
| | - Fellype C. Barreto
- Department of Internal Medicine, Division of Nephrology, Federal University of Paraná, Curitiba 80060-00, PR, Brazil
| | - Amr El-Husseini
- Division of Nephrology & Bone and Mineral Metabolism, University of Kentucky, Lexington, KY 40536-0298, USA
- Correspondence: ; Tel.: +1-859-218-0934; Fax: +1-859-323-0232
| |
Collapse
|
9
|
The Efficacy of Trabecular Titanium Cages to Induce Reparative Bone Activity after Lumbar Arthrodesis Studied through the 18f-Naf PET/CT Scan: Observational Clinical In-Vivo Study. Diagnostics (Basel) 2022; 12:diagnostics12102296. [PMID: 36291986 PMCID: PMC9600853 DOI: 10.3390/diagnostics12102296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 09/20/2022] [Accepted: 09/20/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Titanium trabecular cages (TTCs) are emerging implants designed to achieve immediate and long-term spinal fixation with early osseointegration. However, a clear radiological and clinical demonstration of their efficacy has not yet been obtained. The purpose of this study was to evaluate the reactive bone activity of adjacent plates after insertion of custom-made titanium trabecular cages for the lumbar interbody with positron emission tomography (PET)/computed tomography (CT) 18F sodium fluoride (18F-NaF). Methods: This was an observational clinical study that included patients who underwent surgery for degenerative disease with lumbar interbody fusion performed with custom-made TTCs. Data related to the metabolic-reparative reaction following the surgery and its relationship with clinical follow-up from PET/CT performed at different weeks were evaluated. PET/CTs provided reliable data, such as areas showing abnormally high increases in uptake using a volumetric region of interest (VOI) comprising the upper (UP) and lower (DOWN) limits of the cage. Results: A total of 15 patients was selected for PET examination. Timing of PET/CTs ranged from one week to a maximum of 100 weeks after surgery. The analysis showed a negative correlation between the variables SUVmaxDOWN/time (r = −0.48, p = 0.04), ratio-DOWN/time (r = −0.53, p = 0.02), and ratio-MEAN/time (r = −0.5, p = 0.03). Shapiro−Wilk normality tests showed significant results for the variables ratio-DOWN (p = 0.002), ratio-UP (0.013), and ratio-MEAN (0.002). Conclusions: 18F-NaF PET/CT has proven to be a reliable tool for investigating the metabolic-reparative reaction following implantation of TTCs, demonstrating radiologically how this type of cage can induce reparative osteoblastic activity at the level of the vertebral endplate surface. This study further confirms how electron-beam melting (EBM)-molded titanium trabecular cages represent a promising material for reducing hardware complication rates and promoting fusion.
Collapse
|
10
|
William Whitehouse R, Ahmad G, Kirwadi A, Matthew Howard J. Imaging of Chronic Kidney Disease-Mineral and Bone Disorder. Radiol Clin North Am 2022; 60:547-559. [PMID: 35672088 DOI: 10.1016/j.rcl.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The characteristic radiological appearances of metabolic bone and soft tissue diseases in chronic renal failure are described and illustrated in the context of advancing understanding of the complex metabolic changes that occur in chronic kidney disease and its management.
Collapse
Affiliation(s)
| | - Gulraiz Ahmad
- Department of Radiology, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
| | - Anand Kirwadi
- Department of Radiology, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
| | - James Matthew Howard
- Department of Radiology, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
| |
Collapse
|
11
|
Usmani S, Ahmed N, Gnanasegaran G, Marafi F, van den Wyngaert T. Update on imaging in chronic kidney disease-mineral and bone disorder: promising role of functional imaging. Skeletal Radiol 2022; 51:905-922. [PMID: 34524489 DOI: 10.1007/s00256-021-03905-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 09/07/2021] [Accepted: 09/07/2021] [Indexed: 02/02/2023]
Abstract
Disorders of mineral metabolism and bone disease are common complications in chronic kidney disease (CKD) patients and are associated with increased morbidity and mortality. Bone biopsies, bone scintigraphy, biochemical markers, and plain films have been used to assess bone disorders and bone turnover. Of these, functional imaging is less invasive than bone/marrow sampling, more specific than serum markers and is therefore ideally placed to assess total skeletal metabolism. 18F-sodium fluoride (NaF) PET/CT is an excellent bone-seeking agent superior to conventional bone scan in CKD patients due to its high bone uptake, rapid single-pass extraction, and minimal binding to serum proteins. Due to these properties, 18F-NaF can better assess the skeletal metabolism on primary diagnosis and following treatment in CKD patients. With the increased accessibility of PET scanners, it is likely that PET scanning with bone-specific tracers such as 18F-NaF will be used more regularly for clinical assessment and quantitation of bone kinetics. This article describes the pattern of scintigraphic/functional appearances secondary to musculoskeletal alterations that might occur in patients with CKD.
Collapse
Affiliation(s)
- Sharjeel Usmani
- Department of Nuclear Medicine, Kuwait Cancer Control Centre, Kuwait City, Kuwait.
| | - Najeeb Ahmed
- Jack Brignall PET/CT Centre, Castle Hill Hospital, Cottingham, UK.,Cancer Research Group, Hull York Medical School, University of Hull, York, UK
| | | | - Fahad Marafi
- Jaber Al-Ahmad Molecular Imaging Center, Kuwait City, Kuwait
| | | |
Collapse
|
12
|
Fusaro M, Re Sartò GV, Gallieni M, Cosmai L, Messa P, Rossini M, Chiodini I, Plebani M, Evenepoel P, Harvey N, Ferrari S, Cannata-Andía J, Trombetti A, Brandi ML, Ketteler M, Nickolas TL, Cunningham J, Salam S, Della Rocca C, Scarpa A, Minisola S, Malberti F, Cetani F, Cozzolino M, Mazzaferro S, Morrone L, Tripepi G, Zaninotto M, Mereu MC, Ravera M, Cianciolo G, La Manna G, Aghi A, Giannini S, Dalle Carbonare L. Time for Revival of Bone Biopsy with Histomorphometric Analysis in Chronic Kidney Disease (CKD): Moving from Skepticism to Pragmatism. Nutrients 2022; 14:1742. [PMID: 35565717 PMCID: PMC9103887 DOI: 10.3390/nu14091742] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/14/2022] [Accepted: 04/14/2022] [Indexed: 12/04/2022] Open
Abstract
Bone Biopsy (BB) with histomorphometric analysis still represents the gold standard for the diagnosis and classification of different forms of renal osteodystrophy. Bone biopsy is the only technique able to provide comprehensive information on all bone parameters, measuring static and dynamic parameters of turnover, cortical and trabecular microarchitecture, and mineralization defects. In nephrological practice, bone biopsy yields relevant indications to support therapeutic choices in CKD, heavily impacting the management and prognosis of uremic patients. Unfortunately, the use of bone biopsy has decreased; a lack of expertise in performing and interpreting, perceived procedure invasiveness and pain, and reimbursement issues have all contributed to this decline. Nevertheless, both bone biomarkers and instrumental images cannot be considered reliable surrogates for histological findings, being insufficiently accurate to properly evaluate underlying mineral and bone disorders. This is a multidisciplinary position paper from the Nephrology and Osteoporosis Italian Scientific Societies with the purpose of restating the role of bone biopsy in CKD patient management and of providing strong solutions to allow diffusion of this technique in Italy, but potentially also in other countries. The Italian approach through the optimization and standardization of bone biopsy procedure, the construction of the Italian Hub and Spoke network, and a request for adjustment and national homogenization of reimbursement to the Italian Health Ministry has led the way to implement bone biopsy and to improve CKD patient management and prognosis.
Collapse
Affiliation(s)
- Maria Fusaro
- National Research Council (CNR), Institute of Clinical Physiology (IFC), 56124 Pisa, Italy
- Department of Medicine, University of Padova, 35128 Padova, Italy
| | - Giulia Vanessa Re Sartò
- Post-Graduate School of Specialization in Nephrology, University of Milano, 20157 Milano, Italy; (G.V.R.S.); (M.G.)
| | - Maurizio Gallieni
- Post-Graduate School of Specialization in Nephrology, University of Milano, 20157 Milano, Italy; (G.V.R.S.); (M.G.)
- Department of Biomedical and Clinical Sciences, Università di Milano, 20157 Milano, Italy
- Nephrology Unit, ASST Fatebenefratelli Sacco, 20157 Milano, Italy;
| | - Laura Cosmai
- Nephrology Unit, ASST Fatebenefratelli Sacco, 20157 Milano, Italy;
| | - Piergiorgio Messa
- Unit of Nephrology, Dialysis and Kidney Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, 20157 Milano, Italy;
- Department of Clinical Sciences and Community Health, University of Milano, 20122 Milano, Italy
| | | | - Iacopo Chiodini
- Unit for Bone Metabolism Diseases and Diabetes & Lab of Endocrine and Metabolic Research, Istituto Auxologico Italiano, IRCCS, 20157 Milano, Italy;
| | - Mario Plebani
- Laboratory Medicine Unit, Department of Medicine, University of Padua, 35121 Padua, Italy; (M.P.); (M.Z.)
| | - Pieter Evenepoel
- Laboratory of Nephrology, Department of Immunology and Microbiology, KU Leuven, B-3000 Leuven, Belgium;
| | - Nicholas Harvey
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton SO16 6YD, UK;
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
| | - Serge Ferrari
- Service des Maladies Osseuses, Département de Médecine, HUG, 1205 Geneva, Switzerland;
| | - Jorge Cannata-Andía
- Bone and Mineral Research Unit, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), REDinREN del ISCIII, Hospital Universitario Central de Asturias, Universidad de Oviedo, 33003 Oviedo, Spain;
| | - Andrea Trombetti
- Division of Bone Diseases, Department of Medicine, Geneva University Hospitals and Faculty of Medicine, Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland;
| | - Maria Luisa Brandi
- Department of Surgery and Translational Medicine, University of Florence, Viale Pieraccini 6, 50139 Florence, Italy;
| | - Markus Ketteler
- Department of General Internal Medicine and Nephrology, Robert-Bosch-Krankenhaus, 70376 Stuttgart, Germany;
| | - Thomas L. Nickolas
- Division of Nephrology, Columbia University Irving Medical Center, New York, NY 10027, USA;
| | - John Cunningham
- Centre for Nephrology, The Royal Free Hospital and UCL Medical School, London WC1E 6BT, UK;
| | - Syazrah Salam
- Sheffield Kidney Institute, Sheffield Teaching Hospitals National Health Service Foundation Trust, Sheffield S10 2JF, UK;
| | - Carlo Della Rocca
- Department of Medico-Surgical Sciences and Biotechnology, Sapienza University, Polo Pontino, 00185 Rome, Italy;
| | - Aldo Scarpa
- ARC-Net Centre for Applied Research on Cancer, University and Hospital Trust of Verona, 37134 Verona, Italy;
- Department of Pathology and Diagnostics, University and Hospital Trust of Verona, 37134 Verona, Italy
| | - Salvatore Minisola
- Department of Clinical, Internal, Anaesthesiological and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy;
| | - Fabio Malberti
- UO Nefrologia e Dialisi ASST Cremona, 26100 Cremona, Italy;
| | - Filomena Cetani
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy;
| | - Mario Cozzolino
- Department of Health Sciences, Renal Division, San Paolo Hospital, University of Milan, 20142 Milan, Italy;
| | - Sandro Mazzaferro
- Nephrologic Unit, Department of Translational and Precision Medicine, University of Rome ‘La Sapienza’, 00185 Rome, Italy;
| | - Luigi Morrone
- Nephrology, Dialysis and Renal Transplantation Unit, University Hospital “Policlinico”, 70124 Bari, Italy;
| | - Giovanni Tripepi
- CNR-IFC, Clinical Epidemiology of Renal Diseases and Hypertension, Ospedali Riuniti, 89124 Reggio Calabria, Italy;
| | - Martina Zaninotto
- Laboratory Medicine Unit, Department of Medicine, University of Padua, 35121 Padua, Italy; (M.P.); (M.Z.)
| | | | | | - Giuseppe Cianciolo
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, 40126 Bologna, Italy; (G.C.); (G.L.M.)
| | - Gaetano La Manna
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, 40126 Bologna, Italy; (G.C.); (G.L.M.)
| | - Andrea Aghi
- Department of Medicine, Clinica Medica 1, University of Padua, 35128 Padua, Italy; (A.A.); (S.G.)
| | - Sandro Giannini
- Department of Medicine, Clinica Medica 1, University of Padua, 35128 Padua, Italy; (A.A.); (S.G.)
| | - Luca Dalle Carbonare
- Section of Internal Medicine, Department of Medicine, University of Verona, 37134 Verona, Italy;
| | | |
Collapse
|
13
|
Aaltonen L, Koivuviita N, Seppänen M, Kröger H, Tong X, Löyttyniemi E, Metsärinne K. Association between bone mineral metabolism and vascular calcification in end-stage renal disease. BMC Nephrol 2022; 23:12. [PMID: 34979983 PMCID: PMC8722315 DOI: 10.1186/s12882-021-02652-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 12/23/2021] [Indexed: 11/16/2022] Open
Abstract
Background Development of vascular calcification is accelerated in patients with end-stage renal disease. In addition to traditional risk factors of cardiovascular disease (CVD) abnormal bone and mineral metabolism together with many other factors contribute to the excess cardiovascular burden in patients on dialysis. Aortic calcification score and coronary calcification score are predictive of CVD and mortality. The aim of this study was to evaluate the possible relationship between arterial calcification and bone metabolism. Methods Thirty two patients on dialysis were included. All patients underwent a bone biopsy to assess bone histomorphometry and a 18F-NaF PET scan. Fluoride activity was measured in the lumbar spine (L1 – L4) and at the anterior iliac crest. Arterial calcification scores were assessed by computerized tomography for quantification of coronary artery calcification score and lateral lumbar radiography for aortic calcification score. Results This study group showed high prevalence of arterial calcification and 59% had verified CVD. Both CAC and AAC were significantly higher in patients with verified CVD. Only 22% had low turnover bone disease. There was a weak association between fluoride activity, which reflects bone turnover, measured in the lumbar spine, and CAC and between PTH and CAC. There was also a weak association between erosion surfaces and AAC. No significant association was found between calcification score and any other parameter measured. Conclusions The results in this study highlight the complexity, when evaluating the link between bone remodeling and vascular calcification in patients with multiple comorbidities and extensive atherosclerosis. Several studies suggest an impact of bone turnover on development of arterial calcification and there is some evidence of reduced progression of vascular calcification with improvement in bone status. The present study indicates an association between vascular calcification and bone turnover, even though many parameters of bone turnover failed to show significance. In the presence of multiple other factors contributing to the development of calcification, the impact of bone remodeling might be diminished. Trial registration The study is registered in ClinicalTrials.gov protocol registration and result system, ID is NCT02967042. Date of registration is 17/11/2016.
Collapse
Affiliation(s)
- Louise Aaltonen
- Kidney Center, Department of Medicine, Turku University Hospital, PL 52, Kiinamyllynkatu 4-8, 20521, Turku, Finland.
| | - Niina Koivuviita
- Kidney Center, Department of Medicine, Turku University Hospital, PL 52, Kiinamyllynkatu 4-8, 20521, Turku, Finland
| | - Marko Seppänen
- Turku PET Centre, University of Turku, Kiinamyllynkatu 4-8, 20521, Turku, Finland.,Department of Clinical Physiology, Nuclear Medicine, Turku University Hospital, PL 52, Kiinamyllynkatu 4-8, 20521, Turku, Finland
| | - Heikki Kröger
- Kuopio Musculoskeletal Research Unit (KMRU) Institute of Clinical Medicine, University of Eastern Finland, POB 1627, Kuopio, Finland.,Kuopio University Hospital, Kuopio, Finland
| | - Xiaoyu Tong
- Kuopio Musculoskeletal Research Unit (KMRU) Institute of Clinical Medicine, University of Eastern Finland, POB 1627, Kuopio, Finland
| | - Eliisa Löyttyniemi
- Department of Biostatistics, University of Turku, Kiinamyllynkatu 10, 20014, Turku, Finland
| | - Kaj Metsärinne
- Kidney Center, Department of Medicine, Turku University Hospital, PL 52, Kiinamyllynkatu 4-8, 20521, Turku, Finland
| |
Collapse
|
14
|
Puri T, Frost ML, Cook GJ, Blake GM. [ 18F] Sodium Fluoride PET Kinetic Parameters in Bone Imaging. Tomography 2021; 7:843-854. [PMID: 34941643 PMCID: PMC8708178 DOI: 10.3390/tomography7040071] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/19/2021] [Accepted: 11/20/2021] [Indexed: 11/16/2022] Open
Abstract
This report describes the significance of the kinetic parameters (k-values) obtained from the analysis of dynamic positron emission tomography (PET) scans using the Hawkins model describing the pharmacokinetics of sodium fluoride ([18F]NaF) to understand bone physiology. Dynamic [18F]NaF PET scans may be useful as an imaging biomarker in early phase clinical trials of novel drugs in development by permitting early detection of treatment-response signals that may help avoid late-stage attrition.
Collapse
Affiliation(s)
- Tanuj Puri
- Department of Biomedical Engineering, School of Biomedical Engineering and Imaging Sciences, King’s College London, London SE1 7EH, UK;
| | - Michelle L. Frost
- Institute of Cancer Research Clinical Trials & Statistics Unit (ICR-CTSU), Institute of Cancer Research, Sutton SM2 5NG, UK;
| | - Gary J. Cook
- Department of Cancer Imaging, School of Biomedical Engineering and Imaging Sciences, King’s College London, London SE1 7EH, UK;
| | - Glen M. Blake
- Department of Biomedical Engineering, School of Biomedical Engineering and Imaging Sciences, King’s College London, London SE1 7EH, UK;
- Correspondence: ; Tel.: +44-7762717295
| |
Collapse
|
15
|
Bone Biopsy for Histomorphometry in Chronic Kidney Disease (CKD): State-of-the-Art and New Perspectives. J Clin Med 2021; 10:jcm10194617. [PMID: 34640633 PMCID: PMC8509646 DOI: 10.3390/jcm10194617] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 10/03/2021] [Accepted: 10/04/2021] [Indexed: 01/31/2023] Open
Abstract
The use of bone biopsy for histomorphometric analysis is a quantitative histological examination aimed at obtaining quantitative information on bone remodeling, structure and microarchitecture. The labeling with tetracycline before the procedure also allows for a dynamic analysis of the osteoblastic activity and mineralization process. In the nephrological setting, bone biopsy is indicated to confirm the diagnosis of subclinical or focal osteomalacia and to characterize the different forms of renal osteodystrophy (ROD). Even if bone biopsy is the gold standard for the diagnosis and specific classification of ROD, the use of this approach is very limited. The main reasons for this are the lack of widespread expertise in performing or interpreting bone biopsy results and the cost, invasiveness and potential pain associated with the procedure. In this regard, the sedation, in addition to local anesthesia routinely applied in Italian protocol, significantly reduces pain and ameliorates the pain perception of patients. Concerning the lack of widespread expertise, in Italy a Hub/Spokes model is proposed to standardize the analyses, optimizing the approach to CKD patients and reducing the costs of the procedure. In addition, new tools offer the possibility to evaluate the osteogenic potential or the ability to form bone under normal and pathological conditions, analyzing mesenchymal stem cells and their ability to differentiate in the osteogenic lineage. In the same way, circulating microRNAs are suggested as a tool for exploring osteogenic potential. The combination of different diagnostic approaches and the optimization of the bioptic procedure represent a concrete solution to spread the use of bone biopsy and optimize CKD patient management.
Collapse
|