RENAL OSTEODYSTROPHY
- comprises a continuum of diseases ranging from low turn over bone disease like osteomalacia – to high turn over disease like 20hyperparathyroidism
Pathology
- renal disease – PTH -Vit D axis is deranged – hydroxylation to form 1,25 dihydroxy VitD decreased – impairs calcium absorption in gut – increased calcium excretion – hypocalcemia – effect of PTH on kidney decreased
- impaired renal clearance – hyperphosphatemia
High turnover form
- hyperphosphatemia – secondary hyperparathyroidism – increase bone resorption
- osteitis fibrosa – fibrous tissue accumulates in bone
- osteoblast activity increases – osteoid is woven – increased turnover
- bone pain, brown tumors, ulcers
- classic salt and pepper skull, soft tissue calcification, osteopenia next to osteosclerosis, erosions of phalangeal tuft, distal clavicle
- children – metaphyseal and epiphyseal changes – rickets like
- unlike rickets – premature genu valgum, SCFE common
- epiphyseal slippage also in distal femoral or proximal tibial
Low turnover form
- due to Al toxicity in aluminum contaminated water in dialysis
- also Al in phosphate binders to prevent hyperphosphatemia and 20hyperparathyroidism
- Al deposited along mineralization front – impair calcification of osteoid – decrease in number of osteoblasts
- histologically – excessive osteoid (unmineralized collagen)
- prevented by use of CaCO3 - to buffer high phosphate in blood
Symptoms
- patients rarely have one extreme form of disease – mixed pattern is common
- bone pain, muscle weakness, skeletal deformities, ectopic calcification, growth retardation
- ectopic calcification – more in adults - periarticular
- skeletal deformities – children both axial and appendicular – adult mostly axial esp. in Al toxicity
- children up to 4yrs – resembles Vit D deff rickets
- 4- 10yrs – bowing of tibia and femur, genu valgum, SCFE
Amyloidosis
- complication of long term renal disease
- CTS most common presenting syndrome
- pathologic fracture
- scapulohumeral periarthritis
- arthritis of MCP, IP, shoulder, hand, wrist, knee
- bone cysts – femoral head, acetabulam, humerus, radius, carpal bone, tibial plateau, pubis – resembles brown tumor
- no adequate treatment options
Treatment
- primary treatment of renal osteodystrophy – restriction of phosphorous intake in diet to 400-800 mg/day
- PO4 binding antacids
- Calcium supplements as CaCO3 – increases available Ca for absorption and also act as PO4 binders
- Ca supplements given only when PO serum level fall to 6.5mg/dl – to minimize risk of extra skeletal calcification
- Vit D derivatives – Oral calcitriol (0.25 to 1.5microgm/day) – improve muscle strength, decrease bone pain, growth increase in ureamic children – risk of hypercalcemia
- 20 hyperparathyroidism – surgery – in case of persistent hypercalcemia, intractable pruritus, progressive ectopic calcification, severe skeletal pain/ fractures
- Al toxicity – chelator deferoxamine – only in symptomatic Al toxicity cases
- Pinning for SCFE
- bracing or osteotomy in bowing of long bones
- pseudofractures causing bone pain – weight restriction and analgesics
- rule out fractures – treat fractures accordingly
- surgery for CTS
- Arthroplasty only cemented – high incidence of prosthesis loosening
- surgery planning – r/o clotting abnormalities, anemia, arteriovenous fistula, infections
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