Renal osteodystrophy and clinical outcomes: a prospective cohort study / Osteodistrofia renal e desfechos clínicos: um estudo de coorte prospectivo

Abstract Introduction: Renal osteodystrophy (ROD) refers to a group of bone morphological patterns that derive from distinct pathophysiological mechanisms. Whether the ROD subtypes influence long-term outcomes is unknown. Our objective was to explore the relationship between ROD and clinical outcomes. Methods: This study is a subanalysis of the Brazilian Registry of Bone Biopsies (REBRABO). Samples from individual patients were classified as having osteitis fibrosa (OF), mixed uremic osteodystrophy (MUO), adynamic bone disease (ABD), osteomalacia (OM), normal/minor alterations, and according to turnover/mineralization/volume (TMV) system. Patients were followed for 3.4 yrs. Clinical outcomes were: bone fractures, hospitalization, major adverse cardiovascular events (MACE), and death. Results: We enrolled 275 participants, of which 248 (90%) were on dialysis. At follow-up, 28 bone fractures, 97 hospitalizations, 44 MACE, and 70 deaths were recorded. ROD subtypes were not related to outcomes. Conclusion: The incidence of clinical outcomes did not differ between the types of ROD.

Resumo Introdução: Osteodistrofia renal (OR) refere-se a um grupo de padrões morfológicos ósseos que decorrem de mecanismos fisiopatológicos distintos. É desconhecido se os subtipos de OR influenciam desfechos em longo prazo. Nosso objetivo foi explorar as relações entre OR e desfechos. Métodos: Este estudo é uma subanálise do Registro Brasileiro de Biópsias Ósseas (REBRABO). As amostras de cada paciente foram classificadas em osteíte fibrosa (OF), osteodistrofia urêmica mista (MUO), doença óssea adinâmica (ABD), osteomalácia (OM), alterações normais/menores, e pelo sistema Remodelação / Mineralização / Volume (RMV). Os pacientes foram acompanhados por 3,4 anos. Os eventos clínicos foram: fraturas ósseas, hospitalizações, eventos cardiovasculares adversos maiores (MACE), e óbito. Resultados: Analisamos 275 indivíduos, 248 (90%) deles estavam em diálise. No acompanhamento, 28 fraturas ósseas, 97 hospitalizações, 44 MACE e 70 óbitos foram registrados. Os subtipos de OR não foram relacionados aos desfechos clínicos. Conclusão: A incidência de desfechos clínicos não diferiu entre os tipos de OR.

Marcadores FGF-23 y Klotho en enfermedad renal crónica y su implicación cardiovascular, una revisión sistemática / FGF-23 and Klotho markers in chronic kidney disease and its cardiovascular implication, a systematic review

La principal causa de mortalidad en enfermedad renal crónica (ERC), en el 80% de pacientes se da por enfermedad cardiovascular asociada, los parámetros bioquímicos clásicos del metabolismo óseomineral aún no logran explicar la progresión patológica por tanto, se ha empezado a estudiar nuevos marcadores con relación al daño cardiovascular, donde se ha encontrado al marcador FGF-23 y su correceptor Klotho, implicados en la génesis del daño cardiovascular y enfermedad óseomineral asociada al fosforo, que en conjunto causan remodelamiento cardiovascular, lo que ha empezado aclarecer aún más esta dinámica fisiopatológica. Esta revision busca conocer la implicación de los marcadores FGF-23 y Klotho en ERC y el riesgo cardiovascular asociado y para ello realizó una revision sistemática de literatura, indagando en bases biomédicas como COCHRANE, Embase, LILACS, Scielo, Pub-Med, EBSCO, Hinari, Sociedades médicas, así como tesauros MeSH propios de esta investigación.

The main cause of mortality in chronic kidney disease (CKD), in 80% of patients, is due to associated cardiovascular disease, the classic biochemical parameters of bone-mineral metabolism will not yet be able to explain the pathological progression, therefore, new markers have begun to be studied in relation to cardiovascular damage, where the marker FGF-23 and its co-receptor Klotho have been found, involved in the genesis of cardiovascular damage and bone-mineral disease associated with phosphorus, which together cause cardiovascular remodeling , which has begun to further clarify this pathophysiological dynamic.This review seeks to know the implication of the FGF-23 and Klotho markers in CKD and the associated cardiovascular risk and for this purpose, a systematic review of the literature was carried out, investigating biomedical bases such as COCHRANE, Embase, LILACS, Scielo, Pub-Med, EBSCO, Hinari, Medical Societies, as well as MeSH thesauri specific to this research.

Manejo de vía aérea en paciente con leontiasis ossea. Reporte de caso / Airway management in a patient with leontiasis ossea. Case report

Leontiasis ossea is an uncommon complication of advanced chronic kidney disease that alters the facial bone and the airway, making its perioperative management more complex. We present a clinical case of a female with Leontiasis ossea presenting a difficult airway which requires parathyroidectomy. Assessment, planning and management of the airway by awake intubation is described.

La leontiasis ossea es una complicación infrecuente de la enfermedad renal crónica avanzada que altera el macizo facial óseo y la vía aérea, complejizando su manejo perioperatorio. Presentamos caso clínico de mujer portadora de leontiasis ossea con vía aérea difícil requiriendo paratiroidectomía. Se describe valoración, planificación y manejo de vía aérea mediante intubación vigil.

Pathological fracture of subtrochanter femur, soft tissue infection along the fracture site, shaft femur bone cortex thickening and blastic lession on contralateral shaft femur due to renal osteodystrophy on the end stage renal disease patient: a case report

Renal osteodystrophy (ROD) is a skeletal complication resulting from pathologic alterations in calcium, phosphate, and bone metabolism. The potential link between bone turnover and bone quality is an important question meriting study because of the relatively high incidence of fractures reported. In this case presents a pathological fracture on a routinely hemodialyzed woman. She complained pain on her left subtrochanteric area after low energy trauma accident. A thickening of the shaft femoral bone cortex was also found, reflecting the osteosclerosis event due to imbalance of proliferation and differentiation of osteoblast with increase bone formation. She also had a blastic lesion on her contralateral shaft femoral during the bone survey, but this finding remains asymptomatic. Decreased osteoclastic activity may contribute to cortical thickening, resulting in overall bone mass increase, which may lead to decreased elasticity of the bone or impaired repair capabilities, therefore increasing the risk of fracture. The blastic lesion that occurred on contralateral side may indicated effect of ROD or primary bone lesion. Careful assessment and holistic management of patients with kidney disease is necessary to achieve optimal outcome. The prevention of falls is also an important strategy to prevent pathological fractures. End stage renal disease (ESRD) have reduced bone mineral density, a risk factor for fracture incidence. Careful anamnesis and clinical examination are needed for diagnosis and management.

Experiencia con paratiroidectomía quirúrgica en pacientes con enfermedad renal crónica e hiperparatiroidismo terciario / Experience with surgical parathyroidectomy in patients with chronic kidney disease and tertiary hyperparathyroidism

Resumen Introducción: el hiperparatiroidismo terciario es la consecuencia final de las alteraciones del metabolismo calcio-fósforo en pacientes con enfermedad renal crónica. Aquellos pacientes que no logran controlarlo con el tratamiento médico, requieren paratiroidectomía. Objetivo: describir la evolución clínica y paraclínica en pacientes con enfermedad renal crónica y diagnóstico de hiperparatiroidismo terciario, que fueron llevados a paratiroidectomía. Metodología: estudio prospectivo, que incluyó pacientes con hiperparatiroidismo terciario llevados a paratiroidectomía entre los años 2006 y 2015. Se realizaron estudios bioquímicos pre y post quirúrgicos y se evaluó la presencia y progresión de síntomas. Resultados: se incluyeron 32 pacientes, 68.8% mujeres, con media de edad de 46.2 años. Se identificaron diferencias estadísticamente significativas en el cambio en los valores de calcio, fósforo y PTH pre y post quirúrgicos. El 81.5% de los pacientes reportaron presencia de síntomas. El 34.6, 26.9, y 23% presentaron mejoría total de dolor óseo, dolor articular y prurito, respectivamente. El 28% presentaron hipocalcemia sintomática post operatoria. No hubo casos de muerte durante el seguimiento. Conclusiones: la paratiroidectomía se constituye en un alternativa segura y confiable para los pacientes con hiperparatiroidismo terciario, mejorando significativamente los síntomas y las alteraciones en el metabolismo óseo y mineral. Vigilar los niveles de calcio en el post operatorio es importante para evitar las complicaciones del síndrome de hueso hambriento.

Abstract Introduction: tertiary hyperparathyroidism is the final consequence of alterations in calcium-phosphorus metabolism in patients with chronic kidney disease. Those patients who fail to control it with medical treatment require parathyroidectomy. Objective: go describe the clinical and paraclinical evolution in patients with chronic kidney disease and diagnosis of tertiary hyperparathyroidism, who underwent parathyroidectomy. Methodology: prospective study, which included patients with tertiary hyperparathyroidism taken to parathyroidectomy between 2006 and 2015. Pre and post-surgical biochemical studies were performed and the presence and progression of symptoms was evaluated. Results: 32 patients were included. 68.8 (%) were women with an average age of 46.2 years. Statistically significant differences were identified in the change in calcium, phosphorus and PTH values before and after surgery. 81.5% of patients reported the presence of symptoms. 34.6, 26.9, and 23% presented total improvement of bone pain, joint pain and pruritus, respectively. 28% presented postoperative symptomatic hypocalcemia. There were no deaths during follow-up. Conclusions: parathyroidectomy is a safe and reliable alternative for patients with tertiary hyper-parathyroidism, significantly improving symptoms and alterations in bone and mineral metabolism. Monitoring calcium levels in the postoperative period is important to avoid the complications of the hungry bone syndrome.

Mineral and bone metabolism disorder in an adenine-induced rat model of chronic kidney disease / 中国比较医学杂志

Objective To investigate the characteristic changes of biochemical markers of mineral metabolism, vascular calcification, and renal osteodystrophy in an adenine-induced rat model of chronic kidney disease (CKD). Methods A total of 20 male Sprague Dawley rats (SD rats) were randomly divided into two groups: the normal group fed with a diet without adenine, and the CKD group fed with an adenine-containing diet (7. 5 g/kg) for the first 4 weeks and then a diet without adenine for the following 2 weeks. At the end of the 2nd week, serum biochemical markers were detected. At the end of the 6th week, the SD rats were sacrificed and serum biochemical markers were detected once again. The aortas were collected for pathological examination and detection of vascular calcium and phosphorus contents. Femurs and the fifth lumbar vertebrae were taken for bone mineral density (BMD) measurement and bone histomorphometric analysis. Results At the end of the 2nd and 6th weeks, compared with the normal control group, the levels of serum creatinine, urea nitrogen, phosphorus and parathyroid hormone (PTH) in the CKD group were significantly increased (P＜0. 05 or P＜ 0. 01), and the level of serum calcium was significantly decreased (P＜ 0. 05 or P＜ 0. 01). Medial layer vascular calcification of the aorta occurred in 50％ of the rats in the CKD group, but was not observed in the normal control group. Vascular calcium and phosphorus contents were significantly higher in the CKD group compared with the normal control group (P＜ 0. 05). The BMD of total femur, cortical and trabecular bone tissues of the femur, and the fifth lumbar vertebra was significantly decreased in the CKD group (P＜ 0. 05 or P＜ 0. 01). The histomorphometric analysis showed that both bone resorption and bone formation of the trabecular bone in the CKD group were increased, indicating a high bone turnover status. The volumes of both trabecular and cortical bones of rats in the CKD group were significantly lower than that of the normal control group (P ＜ 0. 05 or P ＜ 0. 01). However, the trabecular bone mineralization was not significantly different between the two groups. Conclusions The adenine-induced rat model of chronic kidney disease (CKD) established in this study shows reduced serum calcium and increased serum phosphorus and PTH, and medial layer vascular calcification of the aorta. With respect to renal osteodystrophy, this model shows a high trabecular bone turnover, normal trabecular bone mineralization, and low bone volume of cortical and trabecular bone, which meets the characteristics of osteitis fibrosa. This model may become a useful tool for future study of chronic kidney disease-mineral and bone disorder (CKD-MBD).

Risk factors of bone density disorder and vascular calcification in non-dialysis chronic kidney disease patients / 中华肾脏病杂志

Objective To explore the risk factors of bone density disorder and vascular calcification in non-dialysis chronic kidney disease (CKD) patients.Methods Clinical data of nondialysis CKD patients who were admitted to the First Affiliated Hospital of Fujian Medical University between January 2013 and June 2014 were retrospectively analyzed.Using dual energy X-ray absorptiometry to evaluate their bone mineral density (BMD) and T value.Patients were divided into normal BMD group (T≥-1),osteopenia group (-2.5 ＜ T ＜-1) and osteoporosis group (T≤-2.5).The vascular calcification was evaluated by pectoral computed tomography.Multi-factor stepwise logistic regression analysis was used to assess the risk factors for low bone density and vascular calcification in non-dialysis CKD patients.Results A total of 337 non-dialysis CKD patients were enrolled.There were 110 (32.6％) patients with normal BMD,and 146(43.3％) patients with osteopenia,and 81(24.0％) patients with osteoporosis.Gender,history of hypertension,25-hydroxy vitamin D and N-terminal osteocalcin shown statistical differences among three groups (all P ＜ 0.05).The incidence rate of 25-hydroxy vitamin D deficiency shown statistical difference among three groups (P=0.012).Further,the rates were increased with the decreased bone mass (x2=7.100,P=0.008).The other mineral bone disorders,such as hypocalcemia,hyperphosphatemia,low intact parathyroid hormone (iPTH) and high iPTH had no statistical difference among three groups (all P ＞ 0.05).Multi-factor stepwise logistic regression analysis revealed that increased iPTH (OR=1.938),and low bone density (OR=1.724) were independent risk factors for CKD patients with vascular calcification (all P ＜ 0.05),while women (OR=3.312) and vascular calcification (OR=1.742) were independent risk factors for CKD patients with low bone density (all P ＜ 0.05).Conclusion Increased iPTH and low bone density are independent risk factors for non-dialysis CKD patients with vascular calcification,while women and vascular calcification are independent risk factors for non-dialysis CKD patients with low bone density.

Osteodistrofia renal y trastornos del metabolismo y la mineralización ósea asociados a enfermedad renal crónica: manifestaciones en radiología / Renal osteodystrophy and disorders of bone metabolism and mineralisation associated with chronic kidney disease: radiological manifestations

Abstract. Chronic kidney disease is a public health problem worldwide, with disorders of bone mineralisation and metabolism being common problems associated with this disease, causing significant morbidity and impaired quality of life. The expression of the findings in the chronic kidney disease can be categorised based on the classification proposed by the international conference Kidney Disease: Improving Global Outcomes, that divides them into metabolic disorders of calcium and phosphorus (without findings in radiology), bone structure and composition disorders, and extra-skeletal calcifications. These conditions give characteristic radiographic patterns, such as bone resorption and sclerosis, brown tumours, osteomalacia-rickets, osteopenia, and extra-skeletal calcifications, in addition to treatment related disorders of chronic kidney failure. In this article, concepts related to metabolism disorders and bone mineralisation associated with chronic renal disease and renal osteodystrophy will be categorised and updated, showing their various manifestations in radiology.

La enfermedad renal crónica es un problema de salud pública a nivel mundial, siendo los trastornos de la mineralización y el metabolismo óseo problemas comunes asociados a esta enfermedad, que causan una importante morbilidad y un deterioro de la calidad de vida. La expresión de los hallazgos en la enfermedad renal crónica puede sistematizarse con base en la clasificación propuesta por la conferencia internacional Kidney Disease: Improving Global Outcomes, que las divide en trastornos del metabolismo del calcio y el fósforo (sin hallazgos en imágenes), alteración de la estructura y la composición del hueso, y calcificaciones extraesqueléticas. Estos trastornos otorgan patrones radiológicos característicos, como son la resorción y esclerosis ósea, tumores pardos, osteomalacia-raquitismo, osteopenia y calcificaciones extraesqueléticas, además de los trastornos asociados al tratamiento de la falla renal crónica. En el presente artículo se sistematizarán y actualizarán los conceptos relacionados con los trastornos del metabolismo y la mineralización ósea, asociados a la enfermedad renal crónica y la osteodistrofia renal, mostrando sus diversas manifestaciones en radiología.

Clinical characteristics of elderly patients on maintenance hemodialysis in Anhui Province / 中华老年医学杂志

Objective To understand the clinical characteristics of elderly patients aged 60 years and over in Anhui Province who receive maintenance hemodialysis (MHD).Methods Clinical data of MHD patients in hemodialysis centers of 26 hospitals in Anhui Province from March 31, 2014 to January 1, 2014 were collected.With non-elderly MHD patients (aged over 18 old and under 60) serving as controls, similarities and differences in the primary disease, vascular access, nutritional status, mineral and bone disorders (MBD), and other related aspects in MHD patients were compared.Results The top three original diseases for elderly patients were chronic glomerulonephritis (CGN) (32.8 ％), hypertensive nephrosclerosis (HNS) (27.7 ％) and diabetic nephropathy (DN) (26.2％).The proportion of patients with DN and HNS in the elderly was higher than in the control group (P ＜ 0.001).Vascular access types in elderly MHD patients were arteriovenous fistula (AVF) (89.4 ％), tunneled cuffed catheter (TCC) (8.9 ％), and temporary venous catheter (1.3％).The proportion of patients with AVF was lower (P＜0.001) and the proportion of patients with TCC was higher (P＜0.001) in the elderly group than in the control group.The incidence of anemia was higher in the elderly patients than in the control group (P＜0.05);the proportion of elderly patients with hemoglobin (Hb) levels was 30.3％, in which had no significant difference as compared with the control group (P ＞ 0.05).The incidence of hypoalbuminemia was 21.2％ in elderly patients, which was higher than in the control group.The proportions of elderly MHD patients with normal levels of adjusted serum calcium, serum phosphorus, and intact parathyroid hormone (iPTH) were 52.0％, 27.9％ (higher than in the control group, P＜0.001), and 47.9％, respectively, while there was no difference in adjusted serum calcium and iPTH between the two groups (P＞0.05).The treatment rates for low serum calcium,hyperphosphatemia and secondary hyperparathyroidism (SHPT) in elderly patients were 50.6％,51.6％ and 71.5％, respectively, which had no significant difference as compared with those in the control group (P＞0.05).Conclusions Elderly patients with MHD show distinct characteristics in primary diseases, vascular access types, and nutrition and MBD status, including higher proportions of HNS and DN as their primary diseases.The type of vascular access is still dominated by AVF, and the proportion of TCC is higher.The nutritional status is poor, with a lower incidence of high phosphorus and a higher incidence of low iPTH.Efforts should be made to promote compliance in elderly patients to better control MBD, improve nutritional status and increase safety and effectiveness of treatment.

Study on the related factors for mineral metabolism in elderly patients with maintenance hemodialysis / 中华老年医学杂志

Objective To investigate the present state of mineral metabolism and its related factors in elderly patients with maintenance hemodialysis (MHD),in order to improve the quality of life and survival rate in elderly patients with MHD in Xinxiang.Methods Clinical data of 466 patients with treatment of MHD for over 3 months in 4 hospitals in Xinxiang district were enrolled from January 2012 to August 2013 in this study,and the patients were divided into the elderly group (n=159,aged ≥ 60 years) and the non-elderly group (n =307,aged ＜ 60 years).The evaluation indexes for mineral metabolism were determinated,such as serum levels of calcium,phosphorus,intact parathyroid hormone (iPTH) and alkaline phosphatase (ALP).The present state of mineral metabolism and its relationships with anemia,dialysis ages,adequacy of dialysis,malnutrition and inflammatory factors were analyzed in elderly patients with MHD.Results Among 466 patients,the serum levels of calcium,phosphorus and iPTH in MHD patients were (1.95 ± 0.34) mmol/L,(2.54±1.38) mmol/L and (409.5±345.6) ng/L respectively,and their control rates were 34.3％,20.4％ and 25.5％ respectively.And in patients with hemodialysis three times a week,the control rates were 50.8％,31.4％ and 32.2％ respectively.The serum levels of phosphorus,iPTH,ALP,albumin and transferrin saturation were lower in elderly group than in non-elderly group (all P＜0.01),and the serum levels of pre-albumin,hemoglobin and feritin were lower in elderly group than in non-elderly group (all P＜0.05).But the serum levels of calcium and C-reactive protein (CRP)were higher in elderly group than in non-elderly group (all P＜0.05).Conclusions The elderly patients with MHD exhibit unique clinical manifestations of abnormal mineral metabolism,and low bone transformation osteopathy is the main manifestation.The micro-inflammation,malnutrition and anemia are more severe in elderly patients than in non elderly patients.

Relationship between the changes of biochemical markers of bone turnover and renal osteodystrophy in patients with primary nephrotic syndrome / 中华核医学与分子影像杂志

Objective To investigate the relationship between the biochemical markers of bone turnover and renal osteodystrophy (ROD) in patients with primary nephrotic syndrome (PNS).Methods A total of 30 patients with PNS and 50 healthy subjects (controls) were included in the study.The BMD of lumbar vertebrae and femur was measured by dual-energy X-ray absorptiometry.The levels of total procollagen type Ⅰ amino-terminal propeptide (TP Ⅰ NP),β-isomerized carboxyterminal propeptide (β-CTx),intact PTH (iPTH),serum calcium,serum phosphorus,ALP,25-OH-Vitamin D3 (25-OH-VD3),β2-micro-globulin(β2-MG),and ratio of urinary to creatinine (UA/Cr) were measured and calculated.The risk factors related to ROD in PNS patients were analyzed.Two-sample t test,multiple linear regression and partial correlation analysis were used to analyze data.Results The BMD values of lumbar vertebrae and femur in the PNS group were significantly decreased compared with those in controls (t =6.162,5.583,3.891 (＜40 years),5.923,5.324,3.129 (≥40 years),all P＜0.05) and the serum levels of TPⅠNP,β-CTx,iPTH,ALP,β2-MG and UA/Cr in the PNS group were significantly higher than those in controls (t:2.738-10.129(＜40 years),3.226-12.581 (≥40 years),all P＜0.05),and the levels of serum calcium and 25-OH-VD3 in the PNS group were significantly lower than those in controls (t =3.624,7.223 (＜40 years),2.011,2.564 (≥40 years),all P＜0.05).But there was no significant difference for serum phosphorus between the 2 groups (t=0.811,0.513,both P＞0.05).TP Ⅰ NP was positively correlated with β-CTx,iPTH,ALP,UA/Cr,β2-MG(r:0.512-0.682,all P＜0.01),and TP Ⅰ NP was negatively correlated with serum calcium and 25-OH-VD3(r=-0.314,-0.562,both P＜0.01)in the PNS group.β-CTx was positively correlated with iPTH,ALP,UA./Cr,β2-MG(r:0.459-0.618,all P＜0.01),and negatively correlated with serum calcium and 25-OH-VD3(r=-0.212,-0.589,both P＜0.01).The iPTH was positively correlated with ALP,UA/Cr and β2-MG (r =0.410,0.606,0.508,all P＜0.05),and negatively correlated with serum calcium and 25-OH-VD3(r=-0.315,-0.516,both P＜0.05).Conclusions The BMD in PNS patients is lower than that in healthy subjects.Combined measurement of TP Ⅰ NP,β-CTx and the BMD is helpful for the diagnosis of ROD in PNS patients.

Progress in diagnosis and treatment of chronic kidney disease-mineral and bone metabolism abnormalities / 中华实用儿科临床杂志

Chronic kidney disease-mineral and bone disorder (CKD-MBD) refers to a series of clinical symptoms and biochemical and imaging abnormalities caused by minerals and calcium phosphorus metabolic disorder,which is associated with chronic kidney disease (CKD).Since 2006 ,the concept of CKD-MBD was put forward for the first time,doctors are increasingly paying more attention to it.This review introduces the epidemiological characteristics, clinical manifestation, examination methods, diagnostic criteria and the research progress of treatment and prevention of CKD-MBD.

Bilateral spontaneous fracturing of the femoral neck in a patient with renal osteodystrophy

We report a case of bilateral fracturing of the femoral neck in a patient with renal osteodystrophy who was treated by means of osteosynthesis. In this type of patient, there is a need to remain watchful for the possibility of occurrences of spontaneous fracturing of the femoral neck, even if the initial radiographic examination is normal...

Relatamos um caso de fratura bilateral do colo femoral em paciente com osteodistrofia renal tratada com osteossíntese. Nesse tipo de paciente, é necessário estar atento à possibilidade de ocorrência de fraturas espontâneas do colo femoral, mesmo com exame radiográfico inicial normal...

Association between indoxyl sulfate and bone histomorphometry in pre-dialysis chronic kidney disease patients / Associação entre indoxil sulfato e histomorfometria óssea em pacientes renais crônicos pré-diálise

Introduction: Experimental studies have suggested that indoxyl sulfate (IS), a protein-bound uremic toxin, may be involved in the development of renal osteodystrophy. Objective: evaluate the association between IS levels and biochemical parameters related to mineral metabolism and bone histomorphometry in a cohort of pre-dialysis chronic kidney disease (CKD) patients. Methods: This is a post-hoc analysis of an observational study evaluating the association between coronary calcification and bone biopsy findings in 49 patients (age: 52 ± 10 years; 67% male; estimated glomerular filtration rate: 36 ± 17 ml/min). Serum levels of IS were measured. Results: Patients at CKD stages 2 and 3 presented remarkably low bone formation rate. Patients at CKD stages 4 and 5 presented significantly higher osteoid volume, osteoblast and osteoclast surface, bone fibrosis volume and bone formation rate and a lower mineralization lag time than CKD stage 2 and 3 patients. We observed a positive association between IS levels on one hand and the bone formation rate, osteoid volume, osteoblast surface and bone fibrosis volume on the other. Multivariate regression models confirmed that the associations between IS levels and osteoblast surface and bone fibrosis volume were both independent of demographic and biochemical characteristics of the study population. A similar trend was observed for the bone formation rate. Conclusion: Our findings demonstrated that IS is positively associated with bone formation rate in pre-dialysis CKD patients. .

Introdução: Estudos experimentais indicam que o indoxil sulfato (IS), uma toxina urêmica ligada à proteína, pode estar envolvido no desenvolvimento da osteodistrofia renal. Objetivo: Avaliar a associação entre os níveis séricos de IS e parâmetros bioquímicos do metabolismo mineral e da histomorfometria óssea em uma coorte de pacientes com doença renal crônica (DRC) pré-diálise. Métodos: Análise post-hoc de um estudo que avaliou a associação entre calcificação coronariana e histomorfometria óssea em 49 pacientes (idade: 52 ± 10 anos; 67% sexo masculino; taxa de filtração glomerular estimada: 36 ± 17 ml/min). Os níveis séricos de IS foram dosados. Resultados: Pacientes com DRC estágio 2 e 3 apresentaram uma taxa de formação óssea baixa. Pacientes com DRC estágio 4 e 5 apresentaram volume osteoide, superfícies osteoblástica e osteoclástica, volume de fibrose e taxa de formação óssea significativamente maiores e intervalo de mineralização significativamente menor que os pacientes com DRC estágio 2 e 3. Os níveis séricos de IS associaram-se positivamente com a taxa de formação óssea, volume osteoide, superfície osteoblástica e volume de fibrose. A análise de regressão multivariada identificou que o IS é um fator independente determinante da superfície osteoblástica e fibrose. Uma tendência similar foi observada para a taxa de formação óssea. Conclusão: Nosso estudo sugere que, na DRC pré-dialítica, o IS correlaciona-se positivamente com a formação óssea. .

Cuidados paliativos para dor originada da doença mineral óssea da insuficiência renal crônica / Los cuidados paliativos para el dolor proveniente de la enfermedad ósea en la insuficiencia renal crónica / Palliative care for pain originated from the bone mineral disease of chronic renal failure

Objective: Identifying which effective palliative cares to the minimization of pain are used in household levelby patients with Mineral and bone Disease of Chronic Kidney Disease. Method: a descriptive research, of cross-sectional and quantitative approach and held in a hemodialysis clinic in the city of Natal, Rio Grande do Norte. The data collection occurred from December 2011 to January 2012, using a semi-structured questionnaire with 35 patients. Results: the patients had painful process damaging the quality of life and mostly used at home oral analgesics and anti-inflammatories, cold compress and resting place. Conclusion: due to the good efficiency of non-medicated palliative care, we propose, in this study, the use of rest and cold compresses as a choice of primary care, relegating to conduct drug as secondary or supporting options.

Objetivo: Identificar quais os cuidados paliativos que são eficazes à minimização da dor que são utilizados, em nível domiciliar, por pacientes portadores de Doença Mineral e Óssea da Doença Renal Crônica. Método: Pesquisa descritiva, de abordagem quantitativa e transversal, realizada em uma clínica de hemodiálise na cidade de Natal-RN. A coleta de dados ocorreu de dezembro de 2011 a janeiro de 2012, utilizando um questionário semiestruturado com 35 pacientes. Resultados:Os pacientes apresentaram processo doloroso prejudicial à qualidade de vida e,em maioria, utilizam em domicílio medicações analgésicas e anti-inflamatórias orais, compressa fria local e repouso. Conclusão: Devido à boa eficiência dos cuidados paliativos não medicamentosos, propomos, nestes estudos, a utilização do repouso e compressas frias como escolha de cuidado primário, relegando às condutas medicamentosas como opções secundárias ou coadjuvantes.

Objetivo: Determinar cuales los cuidados paliativos que son eficaces para reducir al mínimo el dolor que se utilizan en domicilio, por los pacientes con enfermedades óseas e minerales de la Enfermedad Renal Crónica. Método: Una investigación descriptiva, con enfoque cuantitativo y transversal, realizada en una clínica de hemodiálisis en la ciudad de Natal, Río Grande do Norte. Los datos fueron recolectados a partir de diciembre de 2011 hasta enero de 2012, mediante un cuestionario semi-estructurado con 35 pacientes. Resultados: Los pacientes presentaron un doloroso proceso dañoso a la calidad de vida y se utilizan, principalmente, en casa analgésicos orales y antiinflamatorios, compresas frías y descanso. Conclusión: Debido a la gran eficacia de los cuidados paliativos no medicamentosos, se propone, en este estudio, el uso de descanso y compresas frías para elegir la atención primaria, relegando a cabo las drogas como opciones secundarias o de apoyo.

The clinical diagnosis value of parathyroid hormone and bone transport indexes detection in renal osteodystrophy in maintenance hemodialysis patients / 中国医师进修杂志

Objective To investigate the clinical diagnosis value of parathyroid hormone and bone transport indexes detection in renal osteodystrophy in maintenance hemodialysis (MHD) patients.Methods Seventy-six cases of MHD patients were selected as observation group,and 60 cases of healthy people were selected as control group.Serum intact parathyroid hormone (iPTH),parathyroid hormone 7-84 (PTH7-84),bone alkaline phosphatase (BALP) and osteocalcin (OC) were detected by enzyme-linked immunosorbent assay,and iPTH/PTH7-84 was calculated.Results Urea nitrogen,creatinine,phosphorus,alkaline phosphatase,BALP,iPTH,PTH7-84 and OC in observation group were significantly higher than those in control group (P ＜ 0.01 or ＜ 0.05).But calcium and albumin levels in observation group were significantly lower than those in control group (P ＜ 0.01).There was positive correlation between iPTH and BALP,OC,PTH7-84 (r =0.419,0.457,0.662;P ＜ 0.01);and there was positive correlation between PTH7-84 and BALP,OC (r =0.358,0.312;P ＜ 0.01).In observation group,the patients were divided into ＜ 300 ng/L group (36 cases) and ≥ 300 ng/L group (40 cases) according to the levels of iPTH.The age in ＜ 300 ng/L group was significantly higher than that in ≥300 ng/L group [(69.6 ± 11.2) years vs.(59.4 ± 10.1) years,P＜ 0.05].OC and BALP levels in ＜ 300 ng/L group were (9.32 ± 2.03) ng/L and (14.55 ± 9.01) U/L,and those in ≥300 ng/L group were (10.49 ± 2.76) ng/L and (23.81 ± 15.92) U/L,and there were significant differences between the 2 groups (P＜0.01 or ＜0.05).iPTH/PTH7-84 in ＜300 ng/L group was 0.57 ± 0.39,and that in ≥300 ng/L group was 1.12 ±0.58,and there was significant difference between the 2 groups (P ＜ 0.01).Conclusion Detection of serum BALP,OC,iPTH and PTH7-84 can reflect the actual situation of bone transport in MHD patients,and differentiate the type of renal osteodystrophy,which is a non-invasive diagnosis indicator of renal osteodystrophy and could be used to guide clinical treatment.

Effect of hemodiafiltration combined with low dose calcitriol on high turnover osteodystrophy in maintenance hemodialysis patients / 重庆医学

Objective To compare the clinic efficacy and safety of renal osteodystrophy between hemodiafiltration (HDF)com-bined low dose calcitriol and high flux hemodialysis combined high dose Calcitriol .Methods 25 patients ,who were in accordance with the inclusion criteria ,were randomly divided into HDF combined low dose Calcitriol group (group HDF) (n=13) and high flux hemodialysis combined high dose Calcitriol (group VitD)(n=12) .Patients in group HDF took Calcitriol for 0 .5μg after every dialysis session ,while those in group VitD took it for 1 .0 μg after dialysis at first ,then the dose would be adjusted every 4 weeks according to the level of blood Calcium .The intervention continued for 16 weeks in total .Then detecting the levels of intact parathy-roid hormone (iPTH) ,bone alkaline phosphatase (BAP) ,serum calcium (Ca) ,serum phosphorus (P) ,and calculating Ca × P sedi-mentation and clinical symptom score .Results he level of Ca in group HDF and group VitD increased significantly after interven-tion (P= 0 .000) .No difference was no statistically significant between the two groups (P= 0 .141) .The P ,iPTH ,BAP of two groups were significantly decreased (P<0 .05) .P in group HDF decreased more significantly(P=0 .003) .iPTH and BAP in group VitD decreased more significantly (P=0 .034 ,0 .046);Ca × P in group HDF decreased significantly (P=0 .031) ,but increased obvi-ously in group VitD(P=0 .037) ,which was much higher than group HDF(P=0 .001) .Clinical symptom in the two groups im-proved significantly after intervention(P<0 .05) ,There were no significant difference between the two groups(P=0 .632) .Conclu-sion The clinic efficacy of HDF combined low dose calcitriol is same as that of high flux hemodialysis combined high dose calcitri-ol .It could also reduce calcitriol side-effect ,which is an effective theraphy for high turnover osteodystrophy .

Facial lesions caused by renal osteodystrophy in a patient with chronic renal insufficiency: a case report / Lesões faciais por osteodistrofia renal em paciente com insuficiência renal crônica: relato de caso

PURPOSE: Chronic renal insufficiency (CRI) is the last stage of a chronic renal condition in which the kidney loses its filtration and endocrine functions. Chronic endocrine hypofunction causes generalized damage to the body known as Uremic Syndrome, which affects the central nervous system as well as the cardiovascular, hematologic, dermatologic, ophthalmic, endocrine, respiratory, gastrointestinal and skeletal systems. The present study reports the case of a female patient with CRI who presented facial osteodystrophy of the osteitis fibrosa type, and highlights the main features of this condition. CASE DESCRIPTION: A 24-year old, female, Caucasian patient presented chronic glomerulonephritis recurrence and lost the transplanted kidney five years before, undergoing arteriovenous fistula hemodialysis three times a week. She presented swelling of the left masseter area with a hard consistency on palpation, covered by intact skin, swelling at the bottom of the left atrium, with a hard consistency on palpation, a mucosa-like color and absence of inflammation signs, suggesting expansive bone lesions on the face. These features were compatible with hyperparathyroidism brown tumor and/or osteodystrophy. The CT scan showed expansive bone lesions of heterogeneous appearance on the left jaw, maxilla/nasal floor, and right frontotemporal suture areas. The clinical and histopathological characteristics of the lesion, in association with PHT hormone high serum levels led to renal osteodystrophy diagnosis. The patient was referred to the nephrology services. CONCLUSION: Osteodystrophic bone alterations have a high prevalence in renal disease patients, and the dentist must take these alterations into consideration in bone lesion diagnosis for this specific group of patients.

OBJETIVO: A Insuficiência Renal Crônica (IRC) é o último estágio da doença renal crônica, na qual o rim perde sua função de filtração e endócrina. A hipofunção endócrina renal ocasiona danos generalizados ao organismo, que no conjunto são conhecidos como Síndrome Urêmica, sendo composta por danos que comprometem o sistema nervoso central, assim como os sistemas cardiovasculares, hematológicos, dermatológicos, oftálmicos, endócrinos, respiratórios, gastrointestinais e ósseos. O presente estudo irá relatar o caso de uma paciente portadora de IRC apresentando osteodistrofia em face do tipo osteíte fibrosa, evidenciando as principais características dessa doença. DESCRIÇÃO DO CASO: Uma paciente de 24 anos, sexo feminino, caucasiana, apresentou glomerulonefrite recorrente após perda do rim transplantado, estando sob hemodiálise três vezes por semana. Apresentou inchaço da área do m. masseter esquerdo com consistência dura à palpação, coberto por pelo de aspecto normal, inchaço do átrio esquerdo, com consistência dura e ausência de sinais inflamatórios, sugerindo lesões ósseas na face. Estas características eram compatíveis com tumor marrom de hiperparatireoidismo e/ou osteodistrofia. A imagem de tomografia computadorizada mostrou lesões ósseas expansivas de aparência heterogênea na mandíbula esquerda, assoalho da maxila e nasal, e nas áreas de sutura frontotemporal direita. As características clínicas e histopatológicas da lesão, em associação com níveis séricos elevados de hormônio PHT conduziram ao diagnóstico de osteodistrofia renal. A paciente foi encaminhada para o serviço de nefrologia. CONCLUSÃO: As alterações ósseas osteodistróficas são de grande prevalência em pessoas com doença renal, tendo o cirurgião-dentista o dever de levá-las em consideração no diagnóstico de lesões ósseas neste grupo específico de pessoas.

Oral manifestations and radiographic changes in the jaw-bones of patients with end-stage renal disease onmaintenance hemodialysis: a descriptive study / Estudo descritivo das manifestações bucais e alterações radiográficas em maxilares de pacientes com doençarenal terminal e sob hemodiálise

Objectives: The purpose of the present study was to assess the oral manifestations and radiographic changes in the jawbones of patients undergoing hemodialysis, diagnosed with end-stage renal disease (ESRD). Methods: Forty patients on maintenance hemodialysis were clinically examined for oral manifestations and evaluated for radiographic changes in the jaws with panoramic and intra-oral periapical radiographs. Results were expressed as Percentage. Results: Out of 40 patients, 37 patients (92.5%) showed at least one or more oral manifestations. The most common oral manifestations were mucosal pallor (70%), xerostomia (57.5%), petechiae and ecchymoses (37.5%), and less common were taste alterations (15%), uremic odor (7.5%), coated tongue (10%) and mucosal pain (2.5%). Radiographic changes seen were loss of lamina dura (22.2%), altered trabecular pattern (5.5%), multiple radiolucent lesions (5%), and pulp calcification (2.7%). Conclusions: Most of the patients presented with oral signs and symptoms. However it was observed that patients demonstrating radiographic changes were mostly those who were on dialysis for a relatively long duration.

Objetivos: O objetivo do presente estudo foi avaliar as manifestações orais e alterações radiográficas nos maxilares de pacientes submetidos à hemodiálise e com diagnóstico de doença renal em estágio terminal (DRET). Métodos: 40 pacientes em hemodiálise de manutenção foram examinados clinicamente e avaliados radiograficamente por meio de radiografias panorâmicas e periapicais em busca de manifestações orais nas mandíbulas. Resultados: Dos 40 pacientes, 37 pacientes (92,5%) apresentaram pelo menos uma ou mais manifestações orais. As manifestações orais mais comuns foram: palidez da mucosa (70%), xerostomia (57,5%), petéquias e equimoses (37,5%); e menos comuns: alterações do paladar (15%), odor urêmico (7,5%), língua saburrosa (10%) e mucosa dolorida (2,5%). As alterações radiográficas observadas foram a perda da lâmina dura (22,2%), padrão trabecular alterado (5,5%), lesões radiolúcidas múltiplas (5%) e calcificação pulpar (2,7%). Conclusões: A maioria dos pacientes apresentava sinais e sintomas orais. Entretanto, foi observado que os pacientes demonstrando alterações radiográficas foram principalmente aqueles que estavam em diálise por um período relativamente longo.

Maxillofacial Enlargement in Secondary Hyperparathyroidism Successfully Treated by Limited Parathyroidectomy and Paricalcitol / 대한신장학회지

Maxillary enlargement is a rare complication of secondary hyperparathyroidism (SHPT). A 35-year-old Korean man undergoing chronic hemodialysis presented with a painless enlargement involving the maxilla and mandible. Plain radiography and CT scan showed bony expansion at the maxilla and mandible with multiple radiolucency. Serum intact parathyroid hormone (iPTH) was >1,600 pg/mL. Tc-99m sestamibi (MIBI) parathyroid scan and neck sonogram were compatible with SHPT. He underwent limited parathyroidectomy and commenced a course of paricalcitol. Fifteen months after surgery, maxillary enlargement and bony resorptions involving both hands markedly improved. Thirty-six months after the surgery, the serum iPTH level was 109.3 pg/mL. This is the first report in Korea documenting a patient with maxillary enlargement in SHPT who was successfully treated with limited parathyroidectomy and paricalcitol.