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A case of hypophosphatemia in a 55-year-old black female on maintenance hemodialysis is described. She developed multiple bone fractures and congestive heart failure during her 10-year period on hemodialysis. Iliac crest bone biopsy revealed osteomalacia with absent aluminum stores. Management was difficult due to her noncompliance secondary to severe depression. Though osteomalacia and cardiomyopathy due to hypophosphatemia are described in patients with end stage renal disease on dialysis, it is an uncommon entity.

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