The trabecular bone score is associated with bone mineral density, markers of bone turnover and prevalent fracture in patients with end stage kidney disease.

Fracture risk increases in end-stage kidney disease (ESKD), but bone mineral density (BMD) measurement is less predictive of risk than in the general population. In this study of patients with ESKD, a lower trabecular bone score (TBS), indicative of microarchitectural deterioration, was associated with higher bone turnover markers and prevalent non-vertebral fracture. INTRODUCTION: Declining renal function carries increased fracture risks, but BMD is less predictive of fracture for dialysis patients than the general population. The TBS, obtained from lumbar spine dual-energy X-ray absorptiometry (DXA) images, provides information on microarchitectural integrity not captured by BMD. The aim of this study was to assess associations of the TBS to clinical, DXA, radiological, and laboratory measures in patients with ESKD undergoing kidney and simultaneous pancreas kidney (SPK) transplantation. METHODS: A total of 147 patients with ESKD underwent pre-transplant laboratory testing, DXA, lateral spine X-ray, and structured history within 4 weeks of transplantation. Associations of the TBS to demographic data, prevalent fracture, BMD, and laboratory variables were assessed. RESULTS: Of 147 patients (60% male, mean age 48 ± 13 years), 36% had diabetes mellitus (DM) and 54 patients had fractures: 21 prevalent vertebral fractures only, 22 non-vertebral fractures only, and 11 had both. The mean TBS (1.345 ± 0.125) was lower in patients undergoing SPK than kidney-only transplants (1.292 vs. 1.364, p = 0.001). The TBS correlated to spine and total hip BMD, body mass index and inversely to parathyroid hormone, alkaline phosphatase and procollagen 1 N-propeptide. By multivariable logistic regression, lower TBS was significantly associated to prior non-vertebral fracture (p = 0.026). CONCLUSIONS: A lower TBS, suggestive of increased microarchitectural damage, was associated with type 1 DM, markers of higher bone turnover, and prevalent fracture. These data support the need for prospective studies to evaluate whether TBS inclusion improves fracture prediction in patients with ESKD.

Worsening of soft tissue dystrophic calcification in an osteoporotic patient treated with teriparatide.

Teriparatide, used for treatment of osteoporosis in patients at high risk of fracture risk, sometimes results in mild and transient hypercalcemia. There have been two recent reports of worsening dystrophic calcification in patients with autoimmune disorders following teriparatide treatment. We report a patient with severe osteoporosis and without a pre-existing autoimmune disorder, who developed symptomatic worsening of dystrophic calcification 4 months after teriparatide was initiated. Symptoms resolved within 1 week of teriparatide cessation.

A case report of disabling bone pain after long-term kidney transplantation.

A 77-year-old man, who received a renal transplant 13 years before for IgA glomerulonephritis, was referred after he developed bilateral mid-tibial aching pain that did not improve with simple analgesia. He had recently been changed from low-dose cyclosporine to tacrolimus, but the pain did not improve when this was reversed. He had a history of focal prostatic adenocarcinoma, cryptococcal lung infection, osteoporosis treated with alendronate for 2 years and multiple squamous cell carcinomas, including one requiring left neck dissection and radiotherapy. Upon physical examination, he had gouty tophi and marked bilateral tibial tenderness but had no other clinical findings. Laboratory investigations included an elevated intact parathyroid hormone value of 7.9 pmol/L (1.6 to 6.9), bone specific alkaline phosphatase of 22 µg/L (3.7 to 20.9), urinary deoxypyridinoline/creatinine ratio of 7.2 nmol/mmol (2.5 to 5.4) and C-reactive protein. Chest X-ray and tibial X-rays were normal, but there was marrow oedema and a prominent periosteal reaction on magnetic resonance imaging. A radionuclide bone scan showed increased symmetrical, linear uptake in both tibiae and the left femur, and uptake was also noted in both clinically asymptomatic humeri. Tibial bone biopsy disclosed small deposits of poorly differentiated metastatic cancer and a follow-up chest CT revealed a lung lesion. It was concluded that the bone pain and periostitis was caused by primary lung cancer with metastatic disease to bone, and an associated hypertrophic osteoarthropathy.

Association between 25-hydroxyvitamin D, somatic muscle weakness and falls risk in end-stage renal failure.

OBJECTIVE: Suboptimal levels of 25-hydroxyvitamin D (25OHD) are common in haemodialysis patients (Chronic Kidney disease-5D: CKD-5D) and may be associated with reduced muscle strength and increased falls risk. We tested the hypothesis that 25OHD levels may be independently associated with falls risk in CKD-5D. BACKGROUND: Supplementation with calcium and cholecalciferol reduces hip and other nonvertebral fractures in elderly individuals, and this effect may in part be attributable to reduction in falls frequency. The relationship between 25OHD and falls risk has not been investigated in CKD-5D. DESIGN AND PATIENTS: This is a cross-sectional study of 25 CKD-5D patients with predialysis 25OHD, 1,25-dihydroxyvitamin D (1,25(OH)(2)D) and intact parathyroid hormone (iPTH) measurement. Falls risk was assessed by quadriceps muscle strength, FallsScreen((c)) test (FST), Berg Balance Scale (BBS), timed 'up and go' (TUG) test, Modified Barthel Index (MBI) and Falls Efficacy Scale (FES). RESULTS: Mean age was 69.8 +/- 12.1 years, and median time on dialysis was 3.1 years. Median 25OHD level was 55.3 nmol/l (range 20.8-125.8 nmol/l). Muscle strength was significantly positively correlated with 25OHD (P = 0.024) but not with 1,25(OH)(2)D (P = 0.477) or PTH (P = 0.461). Statistically significant correlation between 25OHD levels and FST (P = 0.028) plus MBI (P = 0.0046) was noted. No significant correlation was detected between falls risk and 1,25(OH)(2)D or PTH. CONCLUSIONS: Suboptimal levels of 25OHD in CKD-5D are associated with reduced quadriceps muscle strength and increased falls risk. 25OHD may be more important than the active renal metabolite 1,25(OH)(2)D for muscle strength with implications for vitamin D choice and goals of supplementation. Further investigation is required to examine effectiveness of calciferol supplementation on the incidence of falls in CKD-5D.

Remission of transplanted melanoma--clinical course and tumour cell characterisation.

The recipient of a cadaveric kidney was found to have donor melanoma within the graft together with metastatic spread. After cessation of immunosuppression, the kidney rejected and was removed. One month later there was both clinical and radiological evidence of remission and at autopsy 5 months later there was no histological evidence of melanoma. The outcome for recipients of other organs from the same donor was varied. Tumour cells expressed HLA class 1 antigens mismatched in the recipient and mRNA for the costimulator B7, and the cytokines GM-CSF, IL-1 alpha and beta. These characteristics may have been important in the host immunological response.

Poor technetium-99m-DMSA renal uptake with near normal technetium-99m-DTPA uptake caused by tubulointerstitial renal disease.

We present a patient with tubulointerstitial renal disease and poor renal 99mTc-DMSA uptake. A 99mTc-DTPA scan was normal and the creatinine clearance only minimally decreased. In this case, 99mTc-DMSA uptake did not correlate with "global renal function," but rather with the functioning tubular mass.

Detection of lymphocytotoxic antibodies in relatives of patients with type I diabetes.

Concentrations of lymphocytotoxic antibodies were measured in serum samples from 19 patients recently diagnosed as having type I diabetes and 43 healthy relatives (33 consanguineous and 10 non-consanguineous). The specificity of the reaction was tested at 15 degrees C and 37 degrees C against T lymphocytes and purified helper/inducer and cytotoxic/suppressor subsets. The concentrations of lymphocytotoxic antibodies in each of the three test groups were significantly higher than those in controls (type I patients, p less than 0.005; consanguineous relatives, p less than 0.001; and non-consanguineous relatives, p less than 0.002). The frequency of detection of the antibodies was also greater in each of the study groups (p less than 0.01, p less than 0.01, and p less than 0.05, respectively). Cytotoxicity affected both subsets at 15 degrees C but only cytotoxic/suppressor cells at 37 degrees C. The findings of lymphocytotoxic antibodies in healthy relatives of type I diabetics, irrespective of consanguinity, suggests that an environmental agent such as a virus is at least partially responsible for this lymphocytotoxic effect. Furthermore, the residual cytotoxic/suppressor cell killing at 37 degrees C could explain the defect of suppressor cells observed in these patients.