Bone health in chronic kidney disease-mineral and bone disorder: a clinical case seminar and update.

The metabolic abnormalities affecting bone in the setting of chronic kidney disease (CKD) are complex with overlapping and interacting aetiologies and have challenging diagnostic and management strategies. Disturbances in calcium, phosphate, fibroblast growth factor 23, parathyroid hormone concentrations and vitamin D deficiency are commonly encountered and contribute to the clinical syndromes of bone disorders in CKD, including hyperparathyroidism, osteomalacia, osteoporosis and adynamic bone disease. Mineral and bone abnormalities may also persist or arise de novo post-renal transplantation. The Kidney Disease Improving Global Outcomes organisation describes these mineral metabolism derangements and skeletal abnormalities as 'CKD Mineral and Bone Disorder'. Patients with this disorder have an increased risk of fracture, cardiovascular events and overall increased mortality. In light of the recently updated 2017 guidelines from the Kidney Disease Improving Global Outcomes, we present a clinical case-based discussion to highlight the complexities of investigating and managing the bone health of patients with CKD with a focus on these updates.

Gender differences in presentation and outcome of nonfunctioning pituitary macroadenomas.

OBJECTIVES: Few data exist regarding gender differences in hormonal outcomes in nonfunctioning pituitary macroadenomas (NFPMA). The aim was to assess whether there are gender differences in hormonal outcomes in NFPMA following pituitary surgery at a single centre. DESIGN AND METHODS: Retrospective review of cases undergoing a first surgical procedure for NFPMA. Preoperative hormonal function was available for 122 cases at presentation and 94 cases 6 months postoperatively. Multiple hormone deficiency was defined as ≥2 hormonal axis losses. Tumour size and invasion on MRI scan were assessed independently by a single neuroradiologist. RESULTS: At presentation, men were more likely than women to have multiple hormonal deficiency (47% vs 28%, P = 0·038). Premenopausal women tended to have smaller adenomas than men, but neither adenoma size nor invasion was associated with multiple hormonal deficiency at presentation. Postoperatively, differences were observed with only 14% of premenopausal women exhibiting multiple hormone deficiency, compared with 36% of postmenopausal women and 46% of men (P = 0·03). Overall, postoperative hormonal recovery was observed in over one-third of cases. Greatest recovery occurred in the gonadal axis of 60% (6/10) premenopausal women compared with 19% (8/43) of other groups combined (P = 0·007). CONCLUSIONS: Premenopausal women with NFPMA appear to have favourable hormonal outcomes. This may be due to a complex interplay between smaller tumour size and shorter disease duration. There should be no hesitation in offering pituitary surgery to premenopausal women with NFPMA, who have the most to gain in terms of restoration of hormonal function.