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Lloret MJ, Fusaro M, Jørgensen HS, Haarhaus M, Gifre L, Alfieri CM, Massó E, D'Marco L, Evenepoel P, Bover J. Evaluating Osteoporosis in Chronic Kidney Disease: Both Bone Quantity and Quality Matter. J Clin Med 2024; 13:1010. [PMID: 38398323 PMCID: PMC10889712 DOI: 10.3390/jcm13041010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 01/28/2024] [Accepted: 02/04/2024] [Indexed: 02/25/2024] Open
Abstract
Bone strength is determined not only by bone quantity [bone mineral density (BMD)] but also by bone quality, including matrix composition, collagen fiber arrangement, microarchitecture, geometry, mineralization, and bone turnover, among others. These aspects influence elasticity, the load-bearing and repair capacity of bone, and microcrack propagation and are thus key to fractures and their avoidance. In chronic kidney disease (CKD)-associated osteoporosis, factors traditionally associated with a lower bone mass (advanced age or hypogonadism) often coexist with non-traditional factors specific to CKD (uremic toxins or renal osteodystrophy, among others), which will have an impact on bone quality. The gold standard for measuring BMD is dual-energy X-ray absorptiometry, which is widely accepted in the general population and is also capable of predicting fracture risk in CKD. Nevertheless, a significant number of fractures occur in the absence of densitometric World Health Organization (WHO) criteria for osteoporosis, suggesting that methods that also evaluate bone quality need to be considered in order to achieve a comprehensive assessment of fracture risk. The techniques for measuring bone quality are limited by their high cost or invasive nature, which has prevented their implementation in clinical practice. A bone biopsy, high-resolution peripheral quantitative computed tomography, and impact microindentation are some of the methods established to assess bone quality. Herein, we review the current evidence in the literature with the aim of exploring the factors that affect both bone quality and bone quantity in CKD and describing available techniques to assess them.
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Affiliation(s)
- Maria J Lloret
- Nephrology Department, Fundació Puigvert, Cartagena 340-350, 08025 Barcelona, Spain
- Institut de Recerca Sant Pau (IR-Sant-Pau), 08025 Barcelona, Spain
| | - Maria Fusaro
- National Research Council (CNR), Institute of Clinical Physiology, 56124 Pisa, Italy
- Department of Medicine, University of Padua, 35128 Padua, Italy
| | - Hanne S Jørgensen
- Institute of Clinical Medicine, Aarhus University, 8000 Aarhus, Denmark
- Department of Nephrology, Aalborg University Hospital, 9000 Aalborg, Denmark
| | - Mathias Haarhaus
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Huddinge, 141 86 Stockholm, Sweden
- Diaverum AB, Hyllie Boulevard 53, 215 37 Malmö, Sweden
| | - Laia Gifre
- Rheumatology Department, University Hospital Germans Trias I Pujol, Universitat Autònoma de Barcelona, 08193 Badalona, Spain
| | - Carlo M Alfieri
- Unit of Nephrology Dialysis and Renal Transplantation Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
| | - Elisabet Massó
- Nephrology Department, University Hospital Germans Trias I Pujol, REMAR-IGTP Group, Research Institute Germans Trias I Pujol (IGTP), Universitat Autònoma de Barcelona, 08193 Badalona, Spain
| | - Luis D'Marco
- Grupo de Investigación en Enfermedades Cardiorenales y Metabólicas, Departamento de Medicina y Cirugía, Facultad de Ciencias de la Salud, Universidad Cardenal Herrera-CEU, CEU Universities, 46115 Valencia, Spain
| | - Pieter Evenepoel
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium
| | - Jordi Bover
- Nephrology Department, University Hospital Germans Trias I Pujol, REMAR-IGTP Group, Research Institute Germans Trias I Pujol (IGTP), Universitat Autònoma de Barcelona, 08193 Badalona, Spain
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2
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Elkhouli E, Nagy E, Santos CGS, Barreto FC, Chaer J, Jorgetti V, El-Husseini A. Mixed uremic osteodystrophy: an ill-described common bone pathology in patients with chronic kidney disease. Osteoporos Int 2023; 34:2003-2012. [PMID: 37658999 DOI: 10.1007/s00198-023-06886-5] [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: 06/17/2023] [Accepted: 08/07/2023] [Indexed: 09/05/2023]
Abstract
Renal osteodystrophy (ROD) starts early and progresses with further loss of kidney function in patients with chronic kidney disease (CKD). There are four distinct types of ROD based on undecalcified bone biopsy results. Adynamic bone disease and osteomalacia are the predominant forms of low bone turnover, while hyperparathyroid bone disease and mixed uremic osteodystrophy (MUO) are typically associated with high bone turnover. MUO is a prevalent but poorly described pathology that demonstrates evidence of osteomalacia on top of the high bone formation/resorption. The prevalence of MUO ranges from 5 to 63% among different studies. The pathogenesis of MUO is multi-factorial. Altered phosphate homeostasis, hypocalcemia, vitamin D deficiency, increased FGF-23, interleukins 1 and 6, TNF-α, amyloid, and heavy metal accumulation are the main inducers of MUO. The clinical findings of MUO are usually non-specific. The use of non-invasive testing such as bone turnover markers and imaging techniques might help to suspect MUO. However, it is usually impossible to precisely diagnose this condition without performing bone biopsy. The principal management of MUO is to control the maladaptive hyperparathyroidism along with correcting any nutritional mineral deficiencies that may induce mineralization defect. MUO is a common but still poorly understood bone pathology category; it demonstrates the complexity and difficulty in understanding ROD. A large prospective bone biopsy-based studies are needed for better identification as proper diagnosis and management would improve the outcome of patients with MUO.
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Affiliation(s)
- Ekbal Elkhouli
- Mansoura pathology department, Mansoura University, Mansoura, Egypt
| | - Eman Nagy
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - Cassia Gomes S Santos
- Division of Nephrology, Department of Internal Medicine, Federal University of Paraná, Curitiba, Paraná, Brazil
| | - Fellype Carvalho Barreto
- Division of Nephrology, Department of Internal Medicine, Federal University of Paraná, Curitiba, Paraná, Brazil
| | - Juliana Chaer
- University of São Paulo, Department of Internal Medicine, São Paulo, Brazil
| | - Vanda Jorgetti
- University of São Paulo, Department of Internal Medicine, São Paulo, Brazil
| | - Amr El-Husseini
- Division of Nephrology & Bone and Mineral Metabolism, University of Kentucky, Lexington, USA.
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Schini M, Vilaca T, Gossiel F, Salam S, Eastell R. Bone Turnover Markers: Basic Biology to Clinical Applications. Endocr Rev 2022; 44:417-473. [PMID: 36510335 PMCID: PMC10166271 DOI: 10.1210/endrev/bnac031] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 11/26/2022] [Accepted: 12/05/2022] [Indexed: 12/15/2022]
Abstract
Bone turnover markers (BTMs) are used widely, in both research and clinical practice. In the last 20 years, much experience has been gained in measurement and interpretation of these markers, which include commonly used bone formation markers bone alkaline phosphatase, osteocalcin, and procollagen I N-propeptide; and commonly used resorption markers serum C-telopeptides of type I collagen, urinary N-telopeptides of type I collagen and tartrate resistant acid phosphatase type 5b. BTMs are usually measured by enzyme-linked immunosorbent assay or automated immunoassay. Sources contributing to BTM variability include uncontrollable components (e.g., age, gender, ethnicity) and controllable components, particularly relating to collection conditions (e.g., fasting/feeding state, and timing relative to circadian rhythms, menstrual cycling, and exercise). Pregnancy, season, drugs, and recent fracture(s) can also affect BTMs. BTMs correlate with other methods of assessing bone turnover, such as bone biopsies and radiotracer kinetics; and can usefully contribute to diagnosis and management of several diseases such as osteoporosis, osteomalacia, Paget's disease, fibrous dysplasia, hypophosphatasia, primary hyperparathyroidism, and chronic kidney disease-mineral bone disorder.
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Affiliation(s)
- Marian Schini
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK.,Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Tatiane Vilaca
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Fatma Gossiel
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Syazrah Salam
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK.,Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Richard Eastell
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
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4
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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.
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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
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Oliveira RBD, Barreto FC, Nunes LA, Custódio MR. Aluminum Intoxication in Chronic Kidney Disease. J Bras Nefrol 2021; 43:660-664. [PMID: 34910802 PMCID: PMC8823919 DOI: 10.1590/2175-8239-jbn-2021-s110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 07/02/2021] [Indexed: 11/22/2022] Open
Affiliation(s)
- Rodrigo Bueno de Oliveira
- Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Departamento de Clínica Médica, Serviço de Nefrologia, Campinas, SP, Brasil
| | - Fellype Carvalho Barreto
- Universidade Federal do Paraná, Complexo do Hospital de Clínicas, Serviço de Nefrologia, Curitiba, PR, Brasil
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Differentiating the causes of adynamic bone in advanced chronic kidney disease informs osteoporosis treatment. Kidney Int 2021; 100:546-558. [PMID: 34102219 DOI: 10.1016/j.kint.2021.04.043] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 04/15/2021] [Accepted: 04/20/2021] [Indexed: 12/15/2022]
Abstract
Patients with chronic kidney disease (CKD) have an increased fracture risk because of impaired bone quality and quantity. Low bone mineral density predicts fracture risk in all CKD stages, including advanced CKD (CKD G4-5D). Pharmacological therapy improves bone mineral density and reduces fracture risk in moderate CKD. Its efficacy in advanced CKD remains to be determined, although pilot studies suggest a positive effect on bone mineral density. Currently, antiresorptive agents are the most commonly prescribed drugs for the prevention and therapy of osteoporosis. Their use in advanced CKD has been limited by the lack of large clinical trials and fear of causing kidney dysfunction and adynamic bone disease. In recent decades, adynamic bone disease has evolved as the most predominant form of renal osteodystrophy, commonly associated with poor outcomes, including premature mortality and progression of vascular calcification. Evolving evidence indicates that reduction of bone turnover by parathyroidectomy or pharmacological therapies, such as calcimimetics and antiresorptive agents, are not associated with premature mortality or accelerated vascular calcification in CKD. In contrast, chronic inflammation, oxidative stress, malnutrition, and diabetes can induce low bone turnover and associate with poor prognosis. Thus, the conditions causing suppression of bone turnover rather than the low bone turnover per se may account for the perceived association with outcomes. Anabolic treatment, in contrast, has been suggested to improve turnover and bone mass in patients with advanced CKD and low bone turnover; however, uncertainty about safety even exceeds that of antiresorptive agents. Here, we critically review the pathophysiological concept of adynamic bone disease and discuss the effect of low bone turnover on the safety and efficacy of anti-osteoporosis pharmacotherapy in advanced CKD.
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7
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Jørgensen HS, David K, Salam S, Evenepoel P. Traditional and Non-traditional Risk Factors for Osteoporosis in CKD. Calcif Tissue Int 2021; 108:496-511. [PMID: 33586002 DOI: 10.1007/s00223-020-00786-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 12/02/2020] [Indexed: 12/11/2022]
Abstract
Osteoporosis is a state of bone fragility with reduced skeletal resistance to trauma, and consequently increased risk of fracture. A wide range of conditions, including traditional risk factors, lifestyle choices, diseases and their treatments may contribute to bone fragility. It is therefore not surprising that the multi-morbid patient with chronic kidney disease (CKD) is at a particularly high risk. CKD is associated with reduced bone quantity, as well as impaired bone quality. Bone fragility in CKD is a composite of primary osteoporosis, accumulation of traditional and uremia-related risk factors, assaults brought on by systemic disease, and detrimental effects of drugs. Some risk factors are modifiable and represent potential targets for intervention. This review provides an overview of the heterogeneity of bone fragility in CKD.
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Affiliation(s)
- Hanne Skou Jørgensen
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Karel David
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Laboratory of Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Syazrah Salam
- Sheffield Kidney Institute, Sheffield Teaching Hospitals National Health Service Foundation Trust, Sheffield, UK
- Academic Unit of Bone Metabolism and 3 Mellanby Centre for Bone Research, Medical School, University of Sheffield, Sheffield, UK
| | - Pieter Evenepoel
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium.
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Ferreira AC, Cohen-Solal M, D'Haese PC, Ferreira A. The Role of Bone Biopsy in the Management of CKD-MBD. Calcif Tissue Int 2021; 108:528-538. [PMID: 33772341 DOI: 10.1007/s00223-021-00838-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 03/11/2021] [Indexed: 01/12/2023]
Abstract
A bone biopsy is still considered the gold standard for diagnosis of renal osteodystrophy. It allows to measure both static and dynamic parameters of bone remodeling and is the only method able to evaluate mineralization and allows analysis of both cortical and trabecular bone. Although bone volume can be measured indirectly by dual-energy X-ray absorptiometry, mineralization defects, bone metal deposits, cellular number/activity, and even turnover abnormalities are difficult to determine by techniques other than qualitative bone histomorphometry. In this review, we evaluate the role of bone biopsy in the clinical practice.
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Affiliation(s)
- Ana Carina Ferreira
- Nephrology Department, Centro Hospitalar e Universitário de Lisboa Central, Rua da Beneficência no. 8, 1050-099, Lisbon, Portugal.
- Nova Medical School, Nova University, Lisbon, Portugal.
| | - Martine Cohen-Solal
- Bioscar, INSERM u1132, Paris, France
- Hopital Lariboisiere, Université de Paris, 75010, Paris, France
| | - Patrick C D'Haese
- Laboratory of Pathophysiology, Department of Biomedical Sciences, University of Antwerp, Antwerp, Belgium
| | - Aníbal Ferreira
- Nephrology Department, Centro Hospitalar e Universitário de Lisboa Central, Rua da Beneficência no. 8, 1050-099, Lisbon, Portugal
- Nova Medical School, Nova University, Lisbon, Portugal
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Carbonara CEM, dos Reis LM, Quadros KRDS, Roza NAV, Sano R, Carvalho AB, Jorgetti V, de Oliveira RB. Renal osteodystrophy and clinical outcomes: data from the Brazilian Registry of Bone Biopsies - REBRABO. J Bras Nefrol 2020; 42:138-146. [PMID: 32756862 PMCID: PMC7427645 DOI: 10.1590/2175-8239-jbn-2019-0045] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 07/15/2019] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Mineral and bone disorders (MBD) are major complications of chronic kidney disease (CKD)-related adverse outcomes. The Brazilian Registry of Bone Biopsy (REBRABO) is an electronic database that includes renal osteodystrophy (RO) data. We aimed to describe the epidemiological profile of RO in a sample of CKD-MBD Brazilian patients and understand its relationship with outcomes. METHODS Between August 2015 and March 2018, 260 CKD-MBD stage 3-5D patients who underwent bone biopsy were followed for 12 to 30 months. Clinical-demographic, laboratory, and histological data were analyzed. Bone fractures, hospitalizations, and death were considered the primary outcomes. RESULTS Osteitis fibrosa, mixed uremic osteodystrophy, adynamic bone disease, osteomalacia, osteoporosis, and aluminum (Al) accumulation were detected in 85, 43, 27, 10, 77, and 65 patients, respectively. The logistic regression showed that dialysis vintage was an independent predictor of osteoporosis (OR: 1.005; CI: 1.001-1.010; p = 0.01). The multivariate logistic regression revealed that hemodialysis treatment (OR: 11.24; CI: 1.227-100; p = 0.03), previous parathyroidectomy (OR: 4.97; CI: 1.422-17.241; p = 0.01), and female gender (OR: 2.88; CI: 1.080-7.679; p = 0.03) were independent predictors of Al accumulation; 115 patients were followed for 21 ± 5 months. There were 56 hospitalizations, 14 deaths, and 7 fractures during follow-up. The COX regression revealed that none of the variable related to the RO/turnover, mineralization and volume (TMV) classification was an independent predictor of the outcomes. CONCLUSION Hospitalization or death was not influenced by the type of RO, Al accumulation, or TMV classification. An elevated prevalence of osteoporosis and Al accumulation was detected.
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Affiliation(s)
- Cinthia Esbrile Moraes Carbonara
- Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Laboratório para o Estudo do Distúrbio Mineral e Ósseo em Nefrologia, Campinas, SP, Brasil
- Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Campinas, SP, Brasil
| | - Luciene Machado dos Reis
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Laboratório de Fisiopatologia Renal, São Paulo, SP, Brasil
| | - Kélcia Rosana da Silva Quadros
- Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Laboratório para o Estudo do Distúrbio Mineral e Ósseo em Nefrologia, Campinas, SP, Brasil
- Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Campinas, SP, Brasil
| | - Noemi Angelica Vieira Roza
- Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Laboratório para o Estudo do Distúrbio Mineral e Ósseo em Nefrologia, Campinas, SP, Brasil
- Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Campinas, SP, Brasil
| | - Rafael Sano
- Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Laboratório para o Estudo do Distúrbio Mineral e Ósseo em Nefrologia, Campinas, SP, Brasil
- Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Campinas, SP, Brasil
| | - Aluizio Barbosa Carvalho
- Sociedade Brasileira de Nefrologia, Departamento de Distúrbios do Metabolismo Ósseo Mineral na Doença Renal Crônica, São Paulo, SP, Brasil
- Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | - Vanda Jorgetti
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Laboratório de Fisiopatologia Renal, São Paulo, SP, Brasil
- Sociedade Brasileira de Nefrologia, Departamento de Distúrbios do Metabolismo Ósseo Mineral na Doença Renal Crônica, São Paulo, SP, Brasil
| | - Rodrigo Bueno de Oliveira
- Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Laboratório para o Estudo do Distúrbio Mineral e Ósseo em Nefrologia, Campinas, SP, Brasil
- Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Campinas, SP, Brasil
- Sociedade Brasileira de Nefrologia, Departamento de Distúrbios do Metabolismo Ósseo Mineral na Doença Renal Crônica, São Paulo, SP, Brasil
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10
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The unexpected presence of iron in bone biopsies of hemodialysis patients. Int Urol Nephrol 2018; 50:1907-1912. [PMID: 30136087 DOI: 10.1007/s11255-018-1936-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 07/06/2018] [Indexed: 12/20/2022]
Abstract
PURPOSE Bone biopsy defines classical diseases that constitute the renal osteodystrophy. There is a recent concern regarding other histological findings that are not appreciated by using the turnover, mineralization, and volume (TMV) classification. Iron (Fe) overload has been considered a new challenge and the real significance of the presence of this metal in bones is not completely elucidated. Therefore, the main goal of the current study was to not only to identify bone Fe, but also correlate its presence with demographic, and biochemical characteristics. METHODS This is a cross-sectional analysis of bone biopsies performed in 604 patients on dialysis from 2010 to 2014 in a tertiary academic Hospital. RESULTS Histomorphometric findings revealed the presence of Fe in 29.1%. Fe was associated with higher levels of serum ferritin and serum calcium. No TMV status was related to Fe bone overload. CONCLUSION Our study has highlighted that the presence of Fe in one-third of bone samples has unknown clinical significance. The lack of other contemporary bone biopsy study reporting Fe prevents us from comparison. The findings presented here should be specifically addressed in a future research and will require attention prior to implementation of any clinical guideline. If any proposed treatment, however, would change the bone Fe-related morbidity is undetermined.
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11
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Time to rethink the use of bone biopsy to prevent fractures in patients with chronic kidney disease. Curr Opin Nephrol Hypertens 2018; 27:243-250. [DOI: 10.1097/mnh.0000000000000418] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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12
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Meira RDD, Carbonara CEM, Quadros KRDS, Santos CUD, Schincariol P, Pêssoa GDS, Arruda MAZ, Jorgetti V, Oliveira RBD. The enigma of aluminum deposition in bone tissue from a patient with chronic kidney disease: a case report. ACTA ACUST UNITED AC 2018; 40:201-205. [PMID: 29927461 PMCID: PMC6533990 DOI: 10.1590/2175-8239-jbn-3882] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 09/24/2017] [Indexed: 11/21/2022]
Abstract
About four decades ago, the relationship between dialysis-dementia and aluminum (Al) began to be established. The restriction of drugs containing Al and improvements on water quality used for dialysis resulted in the clinical disappearance of Al intoxication. However, high prevalence of Al deposition in bone tissue from Brazilian dialysis patients is still being detected. Through the case report of a patient on hemodialysis (HD) for one year, presenting significant Al deposition in bone tissue, we speculated if this problem is not being underestimated. We used extensive investigation to identify potential sources of Al exposure with a careful review of medication history and water quality controls. Al concentration was measured by different methods, including mass spectrometry, in poly-electrolyte concentrate solutions and solution for peritoneal dialysis, in an attempt to elucidate the possible sources of contamination. The objective of this case report is to alert the medical community about a potential high prevalence of Al deposition in bone tissue and to discuss the possible sources of contamination in patients with chronic kidney disease (CKD).
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Affiliation(s)
- Rodrigo Dias de Meira
- Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Departamento de Medicina Interna, Campinas, SP, Brasil
| | - Cinthia Esbrile Moraes Carbonara
- Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Departamento de Medicina Interna, Campinas, SP, Brasil.,Universidade Estadual de Campinas, Departamento de Medicina Interna (Nefrologia) - Faculdade de Ciências Médicas, Laboratório para o Estudo do Distúrbio Mineral e Ósseo em Nefrologia (LEMON), Campinas, SP, Brasil
| | - Kélcia Rosana da Silva Quadros
- Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Departamento de Medicina Interna, Campinas, SP, Brasil.,Universidade Estadual de Campinas, Departamento de Medicina Interna (Nefrologia) - Faculdade de Ciências Médicas, Laboratório para o Estudo do Distúrbio Mineral e Ósseo em Nefrologia (LEMON), Campinas, SP, Brasil
| | - Carolina Urbini Dos Santos
- Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Departamento de Medicina Interna, Campinas, SP, Brasil
| | - Patrícia Schincariol
- Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Departamento de Medicina Interna, Campinas, SP, Brasil
| | - Gustavo de Souza Pêssoa
- Universidade Estadual de Campinas, Instituto de Química, Grupo de Espectrometria, Preparo de Amostras e Mecanização, Departamento de Química Analítica, Campinas, SP, Brasil
| | - Marco Aurélio Zezzi Arruda
- Universidade Estadual de Campinas, Instituto de Química, Grupo de Espectrometria, Preparo de Amostras e Mecanização, Departamento de Química Analítica, Campinas, SP, Brasil
| | - Vanda Jorgetti
- Universidade de São Paulo, Departamento de Medicina Interna, São Paulo, SP, Brasil
| | - Rodrigo Bueno de Oliveira
- Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Departamento de Medicina Interna, Campinas, SP, Brasil.,Universidade Estadual de Campinas, Departamento de Medicina Interna (Nefrologia) - Faculdade de Ciências Médicas, Laboratório para o Estudo do Distúrbio Mineral e Ósseo em Nefrologia (LEMON), Campinas, SP, Brasil
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Abrita RR, Pereira BDS, Fernandes NDS, Abrita R, Huaira RMNH, Bastos MG, Fernandes NMDS. Evaluation of prevalence, biochemical profile, and drugs associated with chronic kidney disease-mineral and bone disorder in 11 dialysis centers. ACTA ACUST UNITED AC 2018; 40:26-34. [PMID: 29796575 PMCID: PMC6533962 DOI: 10.1590/2175-8239-jbn-3527] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Accepted: 10/19/2017] [Indexed: 11/21/2022]
Abstract
Introduction: The diagnosis and treatment of mineral and bone disorder of chronic kidney
disease (CKD-MBD) is a challenge for nephrologists and health managers. The
aim of this study was to evaluate the prevalence, biochemical profile, and
drugs associated with CKD-MBD. Methods: Cross-sectional study between July and November 2013, with 1134 patients on
dialysis. Sociodemographic, clinical, and laboratory data were compared
between groups based on levels of intact parathyroid hormone (iPTH) (<
150, 150-300, 301-600, 601-1000, and > 1001 pg/mL). Results: The mean age was 57.3 ± 14.4 years. The prevalence of iPTH < 150 pg/mL was
23.4% and iPTH > 601 pg/mL was 27.1%. The comparison between the groups
showed that the level of iPTH decreased with increasing age. Diabetic
patients had a higher prevalence of iPTH < 150 pg/mL (27.6%).
Hyperphosphatemia (> 5.5 mg/dL) was observed in 35.8%. Calcium carbonate
was used by 50.5%, sevelamer by 14.7%, 40% of patients had used some form of
vitamin D and 3.5% used cinacalcet. Linear regression analysis showed a
significant negative association between iPTH, age, and diabetes
mellitus and a significant positive association between iPTH
and dialysis time. Conclusion: The prevalence of patients outside the target for iPTH was 50.5%. There was a
high prevalence of hyperphosphatemia (35.8%), and the minority of patients
were using active vitamin D, vitamin D analogs, selective vitamin D receptor
activators, and cinacalcet. These data indicate the need for better
compliance with clinical guidelines and public policies on the supply of
drugs associated with CKD-MBD.
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Affiliation(s)
| | | | | | - Renata Abrita
- Universidade Federal de Juiz de Fora, Juiz de Fora, MG, Brasil
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14
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Hanudel MR, Froch L, Gales B, Jüppner H, Salusky IB. Fractures and Osteomalacia in a Patient Treated With Frequent Home Hemodialysis. Am J Kidney Dis 2017; 70:445-448. [PMID: 28495360 DOI: 10.1053/j.ajkd.2017.03.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 03/06/2017] [Indexed: 11/11/2022]
Abstract
Bone deformities and fractures are common consequences of renal osteodystrophy in the dialysis population. Persistent hypophosphatemia may be observed with more frequent home hemodialysis regimens, but the specific effects on the skeleton are unknown. We present a patient with end-stage renal disease treated with frequent home hemodialysis who developed severe bone pain and multiple fractures, including a hip fracture and a tibia-fibula fracture complicated by nonunion, rendering her nonambulatory and wheelchair bound for more than a year. A bone biopsy revealed severe osteomalacia, likely secondary to chronic hypophosphatemia and hypocalcemia. Treatment changes included the addition of phosphate to the dialysate, a higher dialysate calcium concentration, and increased calcitriol dose. Several months later, the patient no longer required a wheelchair and was able to ambulate without pain. Repeat bone biopsy revealed marked improvements in bone mineralization and turnover parameters. Also, with increased dialysate phosphate and calcium concentrations, as well as increased calcitriol, circulating fibroblast growth factor 23 levels increased.
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Affiliation(s)
- Mark R Hanudel
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA.
| | - Larry Froch
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Barbara Gales
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Harald Jüppner
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Division of Pediatric Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Isidro B Salusky
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA
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15
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Hansen D, Olesen JB, Gislason GH, Abrahamsen B, Hommel K. Risk of fracture in adults on renal replacement therapy: a Danish national cohort study. Nephrol Dial Transplant 2016; 31:1654-62. [DOI: 10.1093/ndt/gfw073] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 02/22/2016] [Indexed: 11/13/2022] Open
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16
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When, How, and Why a Bone Biopsy Should Be Performed in Patients With Chronic Kidney Disease. Semin Nephrol 2014; 34:612-25. [DOI: 10.1016/j.semnephrol.2014.09.004] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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17
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Taksande SR, Worcester EM. Calcium supplementation in chronic kidney disease. Expert Opin Drug Saf 2014; 13:1175-85. [DOI: 10.1517/14740338.2014.937421] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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18
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Tentori F, McCullough K, Kilpatrick RD, Bradbury BD, Robinson BM, Kerr PG, Pisoni RL. High rates of death and hospitalization follow bone fracture among hemodialysis patients. Kidney Int 2014; 85:166-73. [PMID: 23903367 PMCID: PMC3910091 DOI: 10.1038/ki.2013.279] [Citation(s) in RCA: 231] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Revised: 05/16/2013] [Accepted: 05/23/2013] [Indexed: 11/22/2022]
Abstract
Altered bone structure and function contribute to the high rates of fractures in dialysis patients compared to the general population. Fracture events may increase the risk of subsequent adverse clinical outcomes. Here we assessed the incidence of post-fracture morbidity and mortality in an international cohort of 34,579 in-center hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS). We estimated country-specific rates of fractures requiring a hospital admission and associated length of stay in the hospital. Incidence rates of death and of a composite event of death/rehospitalization were estimated for 1 year after fracture. Overall, 3% of participants experienced a fracture. Fracture incidence varied across countries, from 12 events/1000 patient-years (PY) in Japan to 45/1000 PY in Belgium. In all countries, fracture rates were higher in the hemodialysis group compared to those reported for the general population. Median length of stay ranged from 7 to 37 days in the United States and Japan, respectively. In most countries, postfracture mortality rates exceeded 500/1000 PY and death/rehospitalization rates exceeded 1500/1000 PY. Fracture patients had higher unadjusted rates of death (3.7-fold) and death/rehospitalization (4.0-fold) compared to the overall DOPPS population. Mortality and hospitalization rates were highest in the first month after the fracture and declined thereafter. Thus, the high frequency of fractures and increased adverse outcomes following a fracture pose a significant health burden for dialysis patients. Fracture prevention strategies should be identified and applied broadly in nephrology practices.
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Affiliation(s)
- Francesca Tentori
- Arbor Research Collaborative for Health, Ann Arbor MI
- Vanderbilt University Medical Center, Nashville TN
| | | | | | - Brian D. Bradbury
- Center for Observational Research, Amgen, Inc., Thousand Oaks CA
- Department of Epidemiology, University of California, Los Angeles, Los Angeles CA
| | - Bruce M. Robinson
- Arbor Research Collaborative for Health, Ann Arbor MI
- University of Michigan, Ann Arbor MI
| | - Peter G. Kerr
- Monash Medical Centre and Monash University, Clayton Australia
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19
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Seck SM, Dahaba M, Ka EF, Cisse MM, Gueye S, Tal AOL. Mineral and bone disease in black african hemodialysis patients: a report from senegal. Nephrourol Mon 2012; 4:613-6. [PMID: 23573501 PMCID: PMC3614308 DOI: 10.5812/numonthly.4225] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Revised: 04/14/2012] [Accepted: 04/27/2012] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Chronic kidney disease related mineral and bone disease (CKD-MBD) is a worldwide challenge in hemodialysis patients. In Senegal, number of dialysis patients is growing but few data are available about their bone disorders. OBJECTIVES To describe patterns of CKD-MBD in Senegalese dialysis patients. PATIENTS AND METHODS We performed a cross-sectional study including patients from three dialysis centres in Senegal. Diagnosis of different types of CKD-MBD relied on clinical, biological and radiological data collected from medical records in dialysis. RESULTS We included 118 patients and 79 of them presented CKD-BMD (prevalence of was 66.9 %). Mean age of CKD-MBD patients was 47.8 ± 15.7 years (16-81 years) and sex-ratio (Male/Female) was 1.15. Secondary hyperparathyroidism was the most frequent disorder (57 patients) followed by adynamic bone disease (21 patients) and osteomalacia (1 patients). The main clinical manifestations were bone pain (17.5% of cases), pruritus (36.8% of cases) and pathological fractures (2.5% of cases). Bone biopsy was not available. Valvular and peripheral vascular calcification were present in 24.5% and 21.2% of patients respectively. Management of CKD-MBD included optimization of dialysis, calcium bicarbonate, sevelamer, vitamin D analogues and calcimimetics. The NKF/DOQI recommended levels of serum calcium, phosphate and parathormone PTH were not achieved in one third of patients. Six patients presented major cardiovascular events during their dialysis period. CONCLUSIONS CKD-MBD are frequent in Senegalese hemodialysis patients and they are dominated by high turn-over disease. Clinical and biological manifestations are unspecific and accurate diagnoses are often difficult in absence of histomorphometry. Treatment is suboptimal for many patients in a context of limited resources.
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Affiliation(s)
- Sidy Mohamed Seck
- Internal Medicine and Nephrology Department, Faculty of Health Sciences, University Gaston Berger, Saint-Louis, Senegal
| | | | - Elhadj Fary Ka
- Nephrology Department, University Hospital Aristide Le Dantec, Dakar, Senegal
| | | | - Seigne Gueye
- Nephrology Department, University Hospital Aristide Le Dantec, Dakar, Senegal
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20
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Ghosh B, Brojen T, Banerjee S, Singh N, Singh S, Sharma OP, Prakash J. The high prevalence of chronic kidney disease-mineral bone disorders: A hospital-based cross-sectional study. Indian J Nephrol 2012; 22:285-91. [PMID: 23162273 PMCID: PMC3495351 DOI: 10.4103/0971-4065.101249] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Mineral bone disorder (MBD) is an important complication of chronic kidney disease (CKD). However, there are limited data on the pattern of MBD in Indian CKD population. The aim of this study was to describe spectrum of MBD in patients with CKD in our center. This was a hospital-based cross-sectional observational study. Patients with stage 4 and 5 CKD were included in this study. Those receiving calcium supplement, vitamin D or its analogues, and calcimimetic were excluded. Serum/plasma levels of creatinine, albumin, calcium, phosphate, total alkaline phosphatase (TAP), intact parathormone (iPTH), and 25-OH vitaminD (25-vitD) were measured. Radiological survey of bones was carried out in all cases, and echocardiography done in selected patients. Statistical analysis was done using Sigmaplot 10.0 software. A total of 150 patients (114 males, 36 females) were included in this study. Mean age was 45.67±16.96 years. CKD stage 4 and 5D were found in 26% (n=39) and 74% (n=111) of study population, respectively. The most common underlying native kidney diseases in patients of CKD 4 and 5D were diabetic nephropathy (41.03%) and CGN (41.44%), respectively. Median (first quartile, third quartile) values for serum levels of corrected calcium (cCa), phosphate, cCaXPO4 product, TAP, plasma iPTH, and 25-vitD in stage 4 CKD were 8.36 (7.79, 8.91) mg/dL, 4.9 (3.92, 6.4) mg/dL, 41.11 (34.01, 53.81) mg(2)/dL(2), 97 (76.5, 184.25) IU/L, 231 (124.5, 430.75) pg/mL, and 12 (6.98, 23.55) ng/mL, respectively; and in stage 5D CKD were 8.36 (7.66, 8.95) mg/dL, 5.7 (4.23, 6.95) mg/dL, 46.5 (37.16, 54.47) mg(2)/dL(2), 180 (114.5, 276.25) IU/L, 288 (169.75, 625.0) pg/mL, and 18.4 (10.0, 26.4) ng/mL, respectively. Prevalence of hypocalcemia (56.41% vs. 54.95%), hyperphosphatemia (64.10% vs. 70.27%), and hyperparathyroidism (84.62% vs. 88.29%) was not different between patients with CKD 4 and 5D. However, iPTH level outside the target range and increased TAP level were significantly (P<0.001) more common in CKD stage 5D. Multiple logistic regression analysis for hyperparathyroidism revealed significant inverse correlation with cCa in CKD 5D. There were no significant differences in vitamin D status and prevalence of valvular calcification between CKD stage 4 and 5D. X-ray revealed renal osteodystrophy in 8 (5.33%) patients, while it was normal in 118 (78.67%) patients. Secondary hyperparathyroidism, hyperphosphatemia, hypocalcemia, increased TAP, and 25-OH vitamin D deficiency and insufficiency were quite common in CKD 4 and 5 patients. The commonest type of MBD in CKD 4 and 5D was secondary hyperparathyroidism.
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Affiliation(s)
- B. Ghosh
- Department of Nephrology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - T. Brojen
- Department of Nephrology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - S. Banerjee
- Department of Internal Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - N. Singh
- Department of Clinical Pathology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - S. Singh
- Department of Nephrology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - O. P. Sharma
- Department of Radiodiagnosis, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - J. Prakash
- Department of Nephrology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
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Araújo SMHA, Bruin VMS, Nunes AS, Pereira ENS, Mota ACM, Ribeiro MZD, Sobreira CTP, Daher EF. Multiple brown tumors causing spinal cord compression in association with secondary hyperparathyroidism. Int Urol Nephrol 2012; 45:913-6. [PMID: 22249370 DOI: 10.1007/s11255-012-0123-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Accepted: 01/05/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND Brown tumor, a non-neoplastic process resulting from excess osteoclast activity, is found in primary hyperparathyroidism (HPTP) and secondary hyperparathyroidism (HPTS). We report a rare case of multiple spinal cord compression by brown tumors. CASE REPORT A 47-year-old male with end-stage renal disease caused by hypertensive nephrosclerosis, on hemodialysis for 10 years and diagnosed with severe HPTS, developed back pain and sudden onset of gait difficulties progressing to paraplegia. A previous computed tomography (CT) of the lumbosacral spine demonstrated a solid lesion, located in the body of the sacrum, at S1-S2 level, with fine bone edge sclerosis, suggestive of brown tumor. A magnetic resonance imaging without gadolinium injection was performed. The examination revealed an insufflating bone lesion at thoracic level (T5/T6). Posterior laminectomy was followed by tumor excision. Histopathological analysis showed osteoid tissue streaked by fibroplasia with hemosiderin granulation. CONCLUSION Differential diagnosis of sudden neurologic deficits and paraplegia in renal patients with secondary HPPT must consider the possibility of brown tumor.
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Affiliation(s)
- Sônia M H A Araújo
- Department of Internal Medicine, Federal University of Ceará, Rua Professor Costa Mendes, no 2609, Fortaleza, CE, CEP 60430-040, Brazil.
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23
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Barreto FC, Araújo SMHA. Intoxicação alumínica na DRC. J Bras Nefrol 2011. [DOI: 10.1590/s0101-28002011000200016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Kansal S, Fried L. Bone disease in elderly individuals with CKD. Adv Chronic Kidney Dis 2010; 17:e41-51. [PMID: 20610353 DOI: 10.1053/j.ackd.2010.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2010] [Revised: 05/06/2010] [Accepted: 05/06/2010] [Indexed: 01/05/2023]
Abstract
Bone disease can lead to significant morbidity and mortality for those who are afflicted by it, irrespective of etiology. Two very prevalent causes of bone disease that contribute to this are osteoporosis and chronic kidney disease (CKD). The modern era has seen important advances in the understanding and management of these processes, but in elderly patients with CKD it remains a complex issue that has yet to be clearly defined. Changes in mineral metabolism that accompany the loss of renal function result in a spectrum of bone disease that occurs concomitantly with bone loss secondary to aging. As such, the traditional paradigms used to manage bone disease may not be appropriate for these patients. With the aging dialysis population, a better understanding of these 2 processes and their interplay deserves more attention.
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25
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Gordon PL, Frassetto LA. Management of osteoporosis in CKD Stages 3 to 5. Am J Kidney Dis 2010; 55:941-56. [PMID: 20438987 DOI: 10.1053/j.ajkd.2010.02.338] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2009] [Accepted: 02/08/2010] [Indexed: 01/03/2023]
Abstract
Osteoporosis and chronic kidney disease (CKD) are both common conditions of older adults and both may be associated with substantial morbidity. However, biochemical and histologic changes that occur with progressive kidney disease require specific interventions, some of which may be concordant with osteoporosis management in the general population, whereas others may be less relevant or perhaps even harmful. In this article, we review the diagnosis of and management strategies for osteoporosis in individuals with CKD, placing these into perspective with the recently published KDIGO (Kidney Disease: Improving Global Outcomes) guidelines for treatment of CKD-mineral and bone disorder (CKD-MBD). Specifically, we highlight osteoporosis treatment recommendations by CKD stage and discuss new avenues for osteoporosis treatment that may be useful in individuals with CKD.
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Jorgetti V. Review article: Bone biopsy in chronic kidney disease: patient level end-point or just another test? Nephrology (Carlton) 2009; 14:404-7. [PMID: 19563382 DOI: 10.1111/j.1440-1797.2009.01148.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The reduction of renal function in chronic kidney disease leads to disturbed calcium and phosphorus metabolism, impaired action of calcitriol, increased parathyroid hormone, FGF-23 levels and ultimately bone disorders. These disturbances have been traditionally termed renal osteodystrophy, which evaluation and diagnosis require a bone biopsy. In the last four decades, researchers from different countries have developed new techniques and have introduced concepts that allowed the development of bone histomorphometry, considered the key tool to study bone metabolism, remodelling and structure. In this review we focus on the relevance of bone biopsy and its respective histomorphometric analysis to help nephrologists to evaluate patients with chronic kidney disease.
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Affiliation(s)
- Vanda Jorgetti
- Nephrology Division, Hospital das Clínicas, Faculdade de Medicina, São Paulo University, São Paulo, Brazil.
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Abstract
On bone biopsies from patients with chronic kidney disease, measurements are made of the turnover, mineralization, and volume. Turnover depends on the bone formation rate and bone resorption rate; the former can be measured using tetracycline labelling. The osteoid width and bone apposition rate determine the mineralization rates. Bone volume includes both mineralized and unmineralized bone and is directly related to the porosity. Using these measurements, biopsies can be separated into the classic types of renal osteodystrophy: normal, adynamic, high-turnover, mixed, and osteomalacia. Fracture rates among these types are not consistent, but several studies have found high fracture rates with adynamic or osteomalacia. The bone density tests cannot distinguish between different types of bone histology.
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Affiliation(s)
- Susan M Ott
- Department of Medicine, University of Washington Medical Center, Seattle, WA 98195-6426, USA.
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30
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London GM, Marchais SJ, Guérin AP, Boutouyrie P, Métivier F, de Vernejoul MC. Association of bone activity, calcium load, aortic stiffness, and calcifications in ESRD. J Am Soc Nephrol 2008; 19:1827-35. [PMID: 18480316 DOI: 10.1681/asn.2007050622] [Citation(s) in RCA: 193] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
An inverse relationship between arterial calcifications and bone activity has been documented in patients with ESRD. Calcium overload is associated with arterial calcification, which is associated with arterial stiffening. Whether bone activity interacts with calcium load, aortic stiffness, or arterial calcification is unknown. This study assessed the impact of bone activity on the relationships between the dosage of calcium-containing phosphate binders and aortic stiffness (measured by pulse wave velocity) or abdominal aorta calcification score. Aortic stiffness and calcification were both positively associated with calcium load and negatively associated with bone activity. A significant interaction was found between dosage of calcium-containing phosphate binders and bone activity such that calcium load had a significantly greater influence on aortic calcifications and stiffening in the presence of adynamic bone disease. Independent of any other factor, including dosage of calcium-containing phosphate binders, adynamic bone was associated with greater aortic stiffening, suggesting cross-talk between the bone and arterial walls.
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Affiliation(s)
- Gérard M London
- Service de Néphrologie, Centre Hospitalier Manhès, Fleury Mérogis, France.
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31
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Rocha LA, Higa A, Barreto FC, dos Reis LM, Jorgetti V, Draibe SA, Carvalho AB. Variant of adynamic bone disease in hemodialysis patients: fact or fiction? Am J Kidney Dis 2006; 48:430-6. [PMID: 16931216 DOI: 10.1053/j.ajkd.2006.05.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2006] [Accepted: 05/30/2006] [Indexed: 11/11/2022]
Abstract
BACKGROUND Adynamic bone disease is a type of renal osteodystrophy characterized by low bone turnover and paucity of bone cells. It was proposed that a new type of this disease featuring high osteoclastic resorption without parathyroid hormone stimulus and designated adynamic bone disease variant occurs in hemodialysis patients. The present study is designed to evaluate the frequency and characteristics of both diseases in a large series of bone biopsy specimens. METHODS We reviewed 1,160 bone biopsy specimens from hemodialysis patients. Specimens in which adynamic bone disease was diagnosed were selected and categorized as classic or variant based on osteoclastic surface. RESULTS In 218 bone biopsy specimens (18.8%), adynamic bone disease was identified, whereas the variant form was identified in 35 specimens (38.8%). Biopsy specimens categorized as the variant form were from patients who were younger and had greater phosphorus and parathyroid hormone levels. Histologically, the variant form presented greater osteoid volume, fibrosis volume, osteoid surface, osteoblast surface, and eroded surface. Similarly, values for all dynamic parameters were greater in the variant group. Osteoclastic surface correlated with phosphorus level, parathyroid hormone level, and osteoblast surface. Age and osteoblast surface were identified as independent determinants of the variant form. CONCLUSION Adynamic bone disease variant seems to occur in younger hemodialysis patients with greater levels of parathyroid hormone, which acts on cell-covered bone surfaces. It probably is a transitional phase from low- to high-turnover status, rather than a true entity within the spectrum of renal osteodystrophy.
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Affiliation(s)
- Lillian A Rocha
- Nephrology Department, Federal University of São Paulo School of Medicine, Brazil.
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Lacativa PGS, de Mendonça LMC, de Mattos Patrício Filho PJ, Pimentel JR, da Cruz Gonçalves MD, Fleiuss de Farias ML. Risk factors for decreased total body and regional bone mineral density in hemodialysis patients with severe secondary hyperparathyroidism. J Clin Densitom 2005; 8:352-61. [PMID: 16055968 DOI: 10.1385/jcd:8:3:352] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2004] [Revised: 12/05/2004] [Accepted: 12/05/2004] [Indexed: 11/11/2022]
Abstract
Hyperparathyroidism contributes significantly to decreased bone mineral density (BMD) in end-stage renal disease patients, but this negative influence is not homogeneous throughout the skeleton. We studied the BMD by dual-energy X-ray absorptiometry on total body and on different regions of the skeleton in 42 patients with severe hyperparathyroidism on hemodialysis. We also evaluated the relationship between different risk factors and BMD found on the regions examined in these patients. The legs and other sites where cortical bone predominate were mostly affected, whereas trabecular bone was relatively preserved. This is probably the result of the different effects of hyperparathyroidism on cortical and trabecular bone, but we cannot rule out the interference of ectopic calcifications and sclerotic lesions of vertebral end-plates falsely increasing lumbar spine BMD. The main determinants of low total-body BMD were, in order of importance, immobility, high intact parathyroid hormone levels, low body mass index, and low albumin. Eleven patients presented with pathologic fractures, mainly in the legs, and BMD was lower in this group than in patients without fractures. In conclusion, our study makes clear that hyperparathyroidism is a great threat to bone density in hemodialysis patients, mainly in the legs, the site mostly affected by fragility fractures in our patients. Physicians must worry not only with high parathyroid hormone levels, but also with the nutritional state of these patients.
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Affiliation(s)
- Paulo Gustavo Sampaio Lacativa
- Endocrinology, Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
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Lacativa PGS, Patrício Filho PJM, Gonçalves MDC, Farias MLFD. Indicações de paratireoidectomia no hiperparatireoidismo secundário à insuficiência renal crônica. ACTA ACUST UNITED AC 2003. [DOI: 10.1590/s0004-27302003000600005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
O hiperparatireoidismo é uma manifestação comum na insuficiência renal crônica (IRC), com alta morbi-mortalidade e difícil manejo clínico. As indicações clássicas da paratireoidectomia são: hipercalcemia persistente, principalmente após transplante renal, prurido intratável, fraturas patológicas, dor óssea refratária ao tratamento medicamentoso e calcificação metastática. Infelizmente, esta última não responde à paratireoidectomia e a calcificação dos vasos está relacionada ao aumento da mortalidade. Assim, novos critérios para indicação mais precoce de paratireoidectomia são necessários. Níveis séricos de PTH maiores que 10 vezes o limite da normalidade, apesar da adequada reposição de cálcio e calcitriol, produto cálcio x fósforo maior que 70(mg/dl)2, tumor marrom quando é urgente a regressão da massa, artrite e/ou periartrite incapacitantes e ruptura de tendões estão entre outras indicações a serem consideradas. Alguns cuidados são necessários para excluir doenças ósseas concomitantes, como amiloidose e intoxicação por alumínio. Esta revisão visa a orientar os endocrinologistas sobre as indicações e melhor momento de realizar paratireoidectomia no hiperparatireoidismo da IRC.
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