We reported a case of adynamic bone disease (ABD) in an older woman with chronic kidney disease, stage-4 (CKD-4), with an estimate of 29ml/min glomerular filtration rate (eGFR). Similarly, the patient presented with bone pain and osteoporosis as well as intact parathyroid hormone (PTH) was suppressed (<6ng/dl) secondary to the use of vitamin D analogs for secondary hyperparathyroidism (SHPT) of CKD. Furthermore, the hypercalcemia of (11.1 mg/dl), and her dual-energy X-ray absorptiometry (DEXA) scan showed bone mineral density (BMD) of -2.6 SD. Low levels of PTH induces a state of low turnover bone disease. Numerous, factors are involved in this process in patients with ESRD on dialysis. Among these factors are the use of vitamin D analogs, the ill-effects high calcium baths, treatment of osteoporosis with bisphosphonates, etc. All these factors can singly or in combination suppress PTH and render the bone resistant to its action with the end results of a dynamic bone disease. The vitamin D analogs were stopped to allow recovery of the PTH and activation of the osteocytes and osteoblasts. Six months after stopping active vitamin D analogs, her hypercalcemia was resolved, and the PTH increased to 172 ng/dl. Her bone pain has resolved.

We reported a case of severe anemia in a patient with end-stage kidney disease (ESKD) on dialysis. The anemia developed when the patient is switched from hemodialysis (HD) to peritoneal dialysis (PD) when the intra-venous erythropoietin stimulating agent (ESA, Epogen) was changed into subcutaneous injection of darbepoetin. The patient's hemoglobin dropped 2 grams in about two months during this period. Extensive work-up including, bleeding disorders, hemolysis, iron deficiency, infections including CMV, Epstein-Bar virus, parvo-19 virus infection were unrevealing The anti-Epogen neutralizing antibodies were not measured due to unavailability. Bone marrow biopsy and aspirate were negative for infiltrations or myelodysplastic syndrome (MDS). The leukocyte and platelet counts were normal. Even though anti-ESA antibodies were not measured in this case, all tentative causes of his anemia were excluded by laboratory investigations. The patient's anemia was treated symptomatically with blood transfusion and discontinuation of the ESA treatment. He made a remarkable recovery.

We reported here a case of anticoagulant-related nephropathy (ARN) in an elderly patient with background history of chronic kidney disease (CKD-stage 4, with an estimated glomerular filtration rate (eGFR) of <24 ml/min). He presented with an acute kidney injury on background of chronic kidney disease (AKI/CKD) with eGFR of 9 ml/min and serum creatinine of 6.0 mg/dl.