RESUMEN
Presentamos tres casos de pacientes en etapa cinco ERC en hemodiálisis que presentaron hiperparatiroidismo secundario en el curso de su enfermedad renal. Ante la falta de respuesta al tratamiento médico con carbonato de calcio, calcitriol, quelantes del fosforo y análogos de la vitamina D se decidió efectuar tratamiento quirúrgico. Se efectuaron dos paratiroidectomías totales, una de ellas con implante inmediato y una subtotal, obteniéndose con el tiempo valores útiles de PTH. Concluimos que no existe evidencia actual en cuanto a la superioridad de una técnica sobre la otra. La criopreservación de tejido paratiroideo para un eventual transplante diferido, sería una opción útil en algunos casos
We present three cases of stage five chronic kidney disease (CKD) patients on hemodialysis that presented secondary hy-perparathoyroidism in the course of renal disease. Given the lack of response to medical treatment with calcium carbonate, calcitriol, phosphate binders and vitamin D analogues was decided to make surgical treatment. There were three Total Parathyroidectomies, one with immediate implant and a subtotal, obtaining useful overtime PTH values. We conclude that there is no current evidence regarding the superiority of one technique over another. Cryopreservation of parathyroid tissue for eventual transplantation deferred, would be a useful option in some cases
Asunto(s)
Humanos , Masculino , Adulto , Criopreservación , Hiperparatiroidismo Secundario/cirugía , Hiperparatiroidismo Secundario/terapia , Insuficiencia Renal Crónica/complicaciones , Insuficiencia Renal Crónica/patología , Insuficiencia Renal Crónica/terapia , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/clasificación , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/etiología , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/patología , ParatiroidectomíaRESUMEN
Presentamos tres casos de pacientes en etapa cinco ERC en hemodiálisis que presentaron hiperparatiroidismo secundario en el curso de su enfermedad renal. Ante la falta de respuesta al tratamiento médico con carbonato de calcio, calcitriol, quelantes del fosforo y análogos de la vitamina D se decidió efectuar tratamiento quirúrgico. Se efectuaron dos paratiroidectomías totales, una de ellas con implante inmediato y una subtotal, obteniéndose con el tiempo valores útiles de PTH. Concluimos que no existe evidencia actual en cuanto a la superioridad de una técnica sobre la otra. La criopreservación de tejido paratiroideo para un eventual transplante diferido, sería una opción útil en algunos casos (AU)
We present three cases of stage five chronic kidney disease (CKD) patients on hemodialysis that presented secondary hy-perparathoyroidism in the course of renal disease. Given the lack of response to medical treatment with calcium carbonate, calcitriol, phosphate binders and vitamin D analogues was decided to make surgical treatment. There were three Total Parathyroidectomies, one with immediate implant and a subtotal, obtaining useful overtime PTH values. We conclude that there is no current evidence regarding the superiority of one technique over another. Cryopreservation of parathyroid tissue for eventual transplantation deferred, would be a useful option in some cases (AU)
Asunto(s)
Humanos , Masculino , Adulto , Insuficiencia Renal Crónica/complicaciones , Insuficiencia Renal Crónica/patología , Insuficiencia Renal Crónica/terapia , Hiperparatiroidismo Secundario/cirugía , Hiperparatiroidismo Secundario/terapia , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/clasificación , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/etiología , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/patología , Paratiroidectomía , CriopreservaciónRESUMEN
Recent clinical studies have indicated that mineral metabolism disorder in chronic kidney disease (CKD) is not a disease confined to bone, but a systemic disease that determine the prognosis by promoting vascular calcification. In the context of this paradigm shift, KDIGO (Kidney Disease : Improving Global Outcomes) introduced a new disease entity "CKD-bone and mineral disorder (MBD) " in 2005, and released clinical practice guideline on the management of CKD-MBD in 2009. This guideline is based on strict systemic evidence review and has had considerable effect on clinical practice. However, on the other hand, it became apparent that only a few clinical studies could support the recommendation of this guideline with high-quality evidence. There is a compelling need for accumulation of clinical findings with high-quality evidence.
Asunto(s)
Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica , Enfermedades Renales , Minerales/metabolismo , Guías de Práctica Clínica como Asunto , Enfermedad Crónica , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/clasificación , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/etiología , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/terapia , Medicina Basada en la Evidencia , Humanos , Enfermedades Renales/metabolismo , Enfermedades Renales/terapia , Ensayos Clínicos Controlados Aleatorios como Asunto , Resultado del TratamientoRESUMEN
In the KDIGO CKD-MBD guideline, the disorder "renal osteodystrophy" is defined as bone histological changes, which can be diagnosed only by bone biopsy. New bone diagnosis method, "TMV classification" is introduced instead of classical classification system. In order to diagnose TMV classification, undecalcified bone specimen after tetracycline double labeling is required. In TMV classification, "T" stands for bone turnover and is evaluated by bone formation rate (BFR/BS) or activation frequency (Acf) . "M" stands for bone mineralization and is evaluated by mean osteoid thickness (O.Th) and mineralization lag time (Mlt) . "V" stands for cancellous bone volume and is diagnosed by total bone volume (BV/TV) .
Asunto(s)
Biopsia/métodos , Huesos/patología , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/diagnóstico , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/etiología , Enfermedades Renales/complicaciones , Huesos/metabolismo , Calcificación Fisiológica , Enfermedad Crónica , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/clasificación , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/patología , Humanos , Osteogénesis , Factores de TiempoAsunto(s)
Remodelación Ósea , Calcificación Fisiológica , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/clasificación , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/diagnóstico , Indicadores de Salud , Ilion/patología , Terminología como Asunto , Algoritmos , Fosfatasa Alcalina/sangre , Biomarcadores/sangre , Biopsia , Calcio/sangre , Niño , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/sangre , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/patología , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/terapia , Humanos , Ilion/metabolismo , Tamaño de los Órganos , Hormona Paratiroidea/sangre , Diálisis Peritoneal , Valor Predictivo de las PruebasRESUMEN
BACKGROUND AND OBJECTIVES: Although lesions of renal osteodystrophy have traditionally been defined by bone turnover, alterations in skeletal mineralization and volume are also prevalent and may contribute to significant morbidity in patients with chronic kidney disease (CKD). The study presented here was undertaken to compare the traditional spectrum of renal osteodystrophy defined by bone turnover to a new classification system that includes T (turnover), M (mineralization), and V (volume) and to determine the value of biochemical parameters as predictors of specific TMV lesions. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Pediatric patients (n = 161) treated with peritoneal dialysis were enrolled into the study. RESULTS: Increased bone turnover and abnormal mineralization were prevalent (57% and 48%, respectively); bone volume was normal or increased in all subjects. Predictive algorithms for different skeletal diagnoses were established by Classification and regression tree analysis. Serum parathyroid hormone (PTH) less than 400 pg/ml in combination with alkaline phosphatase values less than 400 IU/L provided the highest correct prediction rate for patients with both normal bone turnover and normal mineralization. Levels of PTH were higher and serum calcium levels were lower in patients with defective mineralization, irrespective of bone turnover. CONCLUSIONS: Although no single biochemical marker is able to provide a complete assessment of renal osteodystrophy, a combination of serum calcium, alkaline phosphatase, and PTH levels may lead to a more precise noninvasive assessment of turnover and mineralization abnormalities in this population.
Asunto(s)
Remodelación Ósea , Calcificación Fisiológica , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/clasificación , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/diagnóstico , Indicadores de Salud , Ilion/patología , Terminología como Asunto , Adolescente , Algoritmos , Fosfatasa Alcalina/sangre , Biomarcadores/sangre , Biopsia , Calcio/sangre , Distribución de Chi-Cuadrado , Niño , Preescolar , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/sangre , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/patología , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/terapia , Femenino , Humanos , Ilion/metabolismo , Lactante , Los Angeles , Masculino , Tamaño de los Órganos , Hormona Paratiroidea/sangre , Diálisis Peritoneal , Valor Predictivo de las Pruebas , Análisis de Regresión , Adulto JovenRESUMEN
The global widespread of the chronic kidney disease (CKD) is a worldwide health problem. Its increasing incidence and prevalence and adverse outcomes (including decreased quality of life, increased morbidity and mortality) represents a huge challenge for all recent health are systems. Reflecting this situation, the new, global initiative (KDIGO) was established to enhance communication and clinical decision-making, promote the use of evidence based medicine and facilitate clinical research. The new definition, evaluation and classification of "renal osteodystrophy"; has been one of the first outcome of this initiative, suggesting the topic of chronic kidney disease--mineral and bone disorder (CKD-MBD) to be a hot problem of recent nephrology. The new terminology is consistent with a recent view on this topic and describes CKD-MBD as a complex syndrome, including abnormal mineral and PTH metabolism, altered bone structure as far as extra-skeletal calcifications.
Asunto(s)
Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/diagnóstico , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/terapia , Fallo Renal Crónico/complicaciones , Nefrología/métodos , Guías de Práctica Clínica como Asunto , Terminología como Asunto , Academias e Institutos/organización & administración , Calcinosis/etiología , Calcinosis/terapia , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/clasificación , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/epidemiología , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/etiología , Costo de Enfermedad , Medicina Basada en la Evidencia , Salud Global , Humanos , Incidencia , Fallo Renal Crónico/epidemiología , Nefrología/normas , Nefrología/tendencias , Objetivos Organizacionales , Evaluación de Resultado en la Atención de Salud , Prevalencia , Factores de Riesgo , Índice de Severidad de la Enfermedad , Gestión de la Calidad Total/organización & administraciónRESUMEN
Disturbances in mineral and bone metabolism are prevalent in chronic kidney disease and an important cause of morbidity, decreased quality of life, and extraskeletal calcification that have been associated with increased cardiovascular mortality. Kidney Disease: Improving Global Outcomes (KDIGO)'s Global Mineral and Bone Initiative has sought to update the definition, evaluation, and classification of this mineral and bone disorder; improve standardization of assessment tools; enhance education about these complications; and stimulate research. In addition, this international organization sponsored a Controversies Conference in 2005 to define these complications better. The recommendations from that conference were that (1) the term "renal osteodystrophy" be used exclusively to define alterations in bone morphology that are associated with chronic kidney disease and (2) the term "chronic kidney disease-mineral and bone disorder" (CKD-MBD) can be used to describe the broader clinical syndrome that develops as a systemic disorder of mineral and bone metabolism as a result of chronic kidney disease. Chronic kidney disease-related mineral and bone disorders is manifested by an abnormality of any one or a combination of the following: Laboratory (abnormalities of calcium, phosphorus, parathyroid hormone, or vitamin D metabolism), bone (changes in bone turnover, mineralization, volume, linear growth, or strength), and calcification (vascular or other soft tissue calcification). The use of a common, internationally accepted terminology should ease the comparison of studies in this field and eventually improve patient care worldwide.
Asunto(s)
Enfermedades Óseas Metabólicas/etiología , Enfermedades Renales/metabolismo , Minerales/metabolismo , Huesos/metabolismo , Calcinosis/etiología , Enfermedad Crónica , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/clasificación , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/diagnóstico , Humanos , Enfermedades Renales/complicaciones , Guías de Práctica Clínica como AsuntoRESUMEN
Disturbances in mineral and bone metabolism due to loss of kidney function greatly influence morbidity and quality of life, so Kidney Disease: Improving Global Outcomes (KDIGO) proposed the concept of chronic kidney disease-mineral and bone disorder (CKD-MBD). Japanese Society for Dialysis Therapy has created guidelines for the management of secondary hyperparathyroidism associated prognosis in hemodialysis patients, and we are managing parathyroid function of hemodialysis patients under this guideline. Bone biopsy is not recommended as part of routine evaluation for CKD-MBD because bone biopsy is the invasive examination. KDIGO proposed new histological classification of renal osteodystrophy, TMV classification, for standardizing a result of bone histomorphometry. We expect that new guideline improve the prognosis of hemodialysis patients.
Asunto(s)
Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/etiología , Hiperparatiroidismo Secundario/etiología , Hiperparatiroidismo Secundario/terapia , Fallo Renal Crónico/complicaciones , Diálisis Renal/efectos adversos , Biomarcadores/sangre , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/clasificación , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/diagnóstico , Humanos , Hiperparatiroidismo Secundario/diagnóstico , Hormona Paratiroidea/sangre , Guías de Práctica Clínica como Asunto , Pronóstico , Calidad de VidaRESUMEN
Renal transplantation is the treatment of choice for patients with end-stage renal disease. It corrects most of the metabolic abnormalities that cause renal osteodystrophy. Nevertheless, renal osteodystrophy persists in many transplant recipients. The aim of this study was to investigate frequency and histomorphometric pattern of bone disease after renal transplantation. Bone biopsy specimens were taken from the iliac crest of 57 patients, including 28 women (26-70 years old) and 29 men (27-67 years old). Indications for biopsy were hypercalcemia, elevation of parathyroid hormone, and, in 19 cases, without suspected bone abnormalities based on laboratory parameters. The mean time of dialysis prior to renal transplantation was 43 months (range, 6-91 months in women and 10-111 months in men) and the mean interval between transplantation and bone biopsy was 53.5 months (range, 4-191 months in women and 5-90 months in men). Fourteen patients were treated with either 25-hydroxyvitamin D3 and/or 1-alpha hydroxyvitamin D3 or 1,25 dihydroxyvitamin D3, 3 with phosphate-binding agents. The immunosuppression consisted of cyclosporine, azathioprine, and prednisolone. The cumulative dosage of corticosteroids was 5569+/-5305 mg. For static and dynamic histomorphometry, we used American Society of Bone and Mineral Research nomenclature. Mild osteitis fibrosa and osteitis fibrosa, the most frequent forms of renal osteodystrophy, were observed in 13. (22.8%) and 14 patients (24.6%), respectively. Mixed uremic osteodystrophy was found in 7 patients (12.3%), adynamic renal bone disease in 3 patients (5.3%), and osteomalacia in 2 patients (3.5%). In 13 patients (22.8%), reduced bone mass and structural damage without typical signs of renal osteodystrophy, such as endosteal fibrosis or osteoclasia, were detected, and 5 patients (8.7%) showed normal histomorphometric parameters. We concluded that renal osteodystrophy, especially forms with high bone turnover, persisted in many patients after successful renal transplantation. This finding may be due to preexisting conditions, such as duration of dialysis and degree of hyperparathyroidism. Bone disease is increased by corticosteroid and immunosuppressive therapy after renal transplantation and requires close monitoring.
Asunto(s)
Huesos/patología , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/epidemiología , Trasplante de Riñón/efectos adversos , Adulto , Anciano , Biopsia , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/clasificación , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/patología , Femenino , Humanos , Hipercalcemia/patología , Ilion/patología , Trasplante de Riñón/patología , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/patología , Estudios RetrospectivosAsunto(s)
Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/clasificación , Terminología como Asunto , Enfermedades Óseas/clasificación , Enfermedades Óseas/etiología , Enfermedad Crónica , Humanos , Enfermedades Renales/complicaciones , Enfermedades Metabólicas/clasificación , Enfermedades Metabólicas/etiología , Minerales/metabolismoRESUMEN
Disturbances in mineral and bone metabolism are prevalent in chronic kidney disease (CKD) and an important cause of morbidity, decreased quality of life, and extraskeletal calcification that have been associated with increased cardiovascular mortality. These disturbances have traditionally been termed renal osteodystrophy and classified on the basis of bone biopsy. Kidney Disease: Improving Global Outcomes (KDIGO) recently sponsored a Controversies Conference to evaluate this definition. The recommendations were that (1) the term renal osteodystrophy be used exclusively to define alterations in bone morphology associated with CKD and (2) the term CKD-mineral and bone disorder (CKD-MBD) be used to describe the broader clinical syndrome that develops as a systemic disorder of mineral and bone metabolism as a result of CKD. CKD-MBD is manifested by an abnormality of any one or a combination of the following: laboratory-abnormalities of calcium, phosphorus, PTH, or vitamin D metabolism; bone-changes in bone turnover, mineralization, volume, linear growth, or strength; and calcification-vascular or other soft-tissue calcification. The pathogenesis and clinical manifestations of these components of CKD-MBD are described in detail in this issue of Advances in Chronic Kidney Disease.
Asunto(s)
Enfermedades Óseas Metabólicas/patología , Calcinosis/etiología , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/clasificación , Enfermedades Renales/metabolismo , Minerales/metabolismo , Enfermedades Óseas Metabólicas/clasificación , Enfermedades Óseas Metabólicas/diagnóstico , Calcinosis/clasificación , Calcinosis/diagnóstico , Enfermedad Crónica , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/diagnóstico , Humanos , Fallo Renal Crónico/diagnóstico , Fallo Renal Crónico/metabolismo , Fallo Renal Crónico/patología , MasculinoAsunto(s)
Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica , Aluminio/aislamiento & purificación , Calcitriol/administración & dosificación , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/clasificación , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/diagnóstico , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/etiología , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/terapia , Etanol/administración & dosificación , Tasa de Filtración Glomerular , Humanos , Hipocalcemia/etiología , Inyecciones Intralesiones , Hormona Paratiroidea/metabolismo , Fósforo/sangre , Fósforo/aislamiento & purificación , Deficiencia de Vitamina D/etiologíaRESUMEN
Renal osteodystrophy begins early in the course of chronic kidney disease and occurs almost without exception in all patients with Stage 5 disease (CKD-5). Bone biopsies and evaluation of mineralized bone sections after double tetracycline-labeling are currently considered the gold standard for diagnosis and classification of renal osteodystrophy. Nevertheless, bone biopsies are rarely employed. This is, at least in part, related to the paucity of nephrologists trained in performance of the procedure and the fact that reports of the histologic results are not easily translatable to clinical practice. Results are usually given qualitatively, using non-uniform classifications or by histomorphometric evaluations which are esoteric to most nephrologists. We suggest here that histomorphometric evaluation can be reserved for research and special situations. Also, the customarily used qualitative classification should be replaced by a clinically useful nomenclature, provided the interpretation is done by an individual with sufficient experience in bone pathology. We present a new interactive nomenclature for renal osteodystrophy that addresses abnormalities of turnover, abnormalities of bone balance, and abnormalities of mineralization. The new nomenclature, thus, includes disorders of high- and low-turnover with consideration of the interrelation with positive or negative bone balance with or without mineralization defect. In this schema, changes in bone status are described as deviations from a norm, and treatment is geared toward normalizing values rather than creating any absolute change in one direction or another. It is hoped that such a classification will be easily usable, clinically more relevant, and more amenable to individualized treatment guidance.
Asunto(s)
Remodelación Ósea/fisiología , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/clasificación , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/fisiopatología , Modelos Biológicos , Terminología como Asunto , Calcificación Fisiológica/fisiología , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/patología , HumanosRESUMEN
Disturbances in mineral and bone metabolism are prevalent in chronic kidney disease (CKD) and are an important cause of morbidity, decreased quality of life, and extraskeletal calcification that have been associated with increased cardiovascular mortality. These disturbances have traditionally been termed renal osteodystrophy and classified based on bone biopsy. Kidney Disease: Improving Global Outcomes (KDIGO) sponsored a Controversies Conference on Renal Osteodystrophy to (1) develop a clear, clinically relevant, and internationally acceptable definition and classification system, (2) develop a consensus for bone biopsy evaluation and classification, and (3) evaluate laboratory and imaging markers for the clinical assessment of patients with CKD. It is recommended that (1) the term renal osteodystrophy be used exclusively to define alterations in bone morphology associated with CKD, which can be further assessed by histomorphometry, and the results reported based on a unified classification system that includes parameters of turnover, mineralization, and volume, and (2) the term CKD-Mineral and Bone Disorder (CKD-MBD) be used to describe a broader clinical syndrome that develops as a systemic disorder of mineral and bone metabolism due to CKD, which is manifested by abnormalities in bone and mineral metabolism and/or extra-skeletal calcification. The international adoption of these recommendations will greatly enhance communication, facilitate clinical decision-making, and promote the evolution of evidence-based clinical practice guidelines worldwide.
Asunto(s)
Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/clasificación , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/diagnóstico , Terminología como Asunto , HumanosRESUMEN
Bone histomorphometry is essential to diagnosis of renal osteodystrophy. Sherrard et al classified renal osteodystrophy into the 5 groups according to Fb.V/TV, OV/BV and BFR/TV of cancellous bone (Osteitis fibrosa, Mixed uremic osteodystrophy, Osteomalacia, Mild lesion, Aplastic disease). In addition, because endocortical bone loss is generally irreversible, the evaluation of this region in the transiliac bone biopsy specimen also seems to be important.
Asunto(s)
Huesos/patología , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/clasificación , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/diagnóstico , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/etiología , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/patología , HumanosAsunto(s)
Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/clasificación , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/diagnóstico , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/etiología , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/terapia , Diagnóstico Diferencial , Compuestos Epoxi/uso terapéutico , Etanol/administración & dosificación , Humanos , Hiperparatiroidismo Secundario/etiología , Hiperparatiroidismo Secundario/terapia , Paratiroidectomía , Poliaminas , Polietilenos/uso terapéutico , Pronóstico , Sevelamer , Vitamina D/administración & dosificaciónRESUMEN
BACKGROUND: During the last few years the spectrum of renal osteodystrophy (ROD) in dialysis patients has been studied thoroughly and the prevalence of the various types of ROD has changed considerably. Whereas until a decade ago most patients presented with secondary hyperparathyroidism (HPTH), adynamic bone (ABD) has become the most common lesion within the dialysis population over the last few years. Much less is known about the spectrum of ROD in end-stage renal failure (ESRF) patients not yet on dialysis. METHODS: Transiliac bone biopsies were taken in an unselected group of 84 ESRF patients (44 male, age 54+/-12 years) before enrolment in a dialysis programme. All patients were recruited within a time period of 10 months from various centres (n=18) in Macedonia. Calcium carbonate was the only prescribed medication in patients followed up by the outpatient clinic. RESULTS: HPTH was found in only 9% of the patients, whilst ABD appeared to be the most frequent renal bone disease as it was observed in 23% of the cases next to normal bone (38%). A relatively high number of patients (n=10; 12%) fulfilled the criteria of osteomalacia (OM). Mixed osteodystrophy (MX) was diagnosed in 18% of the subjects. There was no significant difference between groups in age, creatinine, or serum and bone strontium and aluminium levels. Patient characteristics associated with ABD included male gender and diabetes, whilst OM was associated with older age (>58 years). CONCLUSIONS: In an unselected population of ESRF patients already, 62% of them have an abnormal bone histology. ABD is the most prevalent type of ROD in this population. In the absence of aluminium or strontium accumulation the relatively high prevalence of a low bone turnover as expressed by either normal bone or ABD and OM is striking.
Asunto(s)
Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/epidemiología , Fallo Renal Crónico/complicaciones , Osteomalacia/epidemiología , Adulto , Anciano , Remodelación Ósea , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/clasificación , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/etiología , Trastorno Mineral y Óseo Asociado a la Enfermedad Renal Crónica/patología , Creatinina/sangre , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Osteomalacia/etiología , Prevalencia , Estudios Prospectivos , Diálisis Renal , República de Macedonia del Norte , Factores de RiesgoRESUMEN
Renal transplant osteodystrophy encompasses several histologic subtypes. Bone histomorphometric examination reliably distinguishes these groups but is invasive, is time-consuming, and delays diagnosis. Establishing a noninvasive method of correctly predicting histologic subtype in an individual to direct management is an attractive proposition. We identified 19 female renal transplant recipients with histologic evidence of hyperparathyroid bone disease (HPTH) and 14 with adynamic bone (ADB). We evaluated serum osteocalcin and bone-specific alkaline phosphatase as bone formation markers and urinary hydroxyproline (Hypro) and deoxypyridinoline cross-links as bone resorption markers. Mean concentrations for all markers were higher in the HPTH group, reaching significance for Hypro (HPTH, 24.8 +/- 4.2 micromol/mmol creatinine; ADB, 13.2 +/- 5.0 micromol/mmol creatinine; P = 0.01). A cutoff of 16.4 micromol/mmol creatinine for Hypro (Youden's index, 0.65) gave a sensitivity of 93% and specificity and positive predictive value (PPV) of 72% in predicting HPTH. In combination, Hypro greater than 16.4 micromol/mmol creatinine and parathyroid hormone greater than 80 pg/mL gave a specificity of 100%, sensitivity of 32%, and PPV of 100%. Conversely, for predicting ADB, Hypro less than 15.1 micromol/mmol creatinine (Youden's index, 0.45) gave a specificity of 93%, sensitivity of 53%, and PPV of 91%. Hypro less than 15.1 micromol/mmol creatinine plus osteocalcin less than 6.8 microg/L gave a specificity of 84.2%, sensitivity of 64.3%, and PPV of 75%. Significant associations between markers and histomorphometry were evident only for Hypro and osteocalcin (with osteoblast surface) and all markers (except deoxypyridinoline cross-links) with cortical volume. Markers have limited utility in identifying histologic subtype (Hypro was most effective) and, with the exception of Hypro and osteocalcin, showed little association with cell surface markers of bone cell activity.