A comparative study of bone biopsies from the iliac crest, the tibial bone, and the lumbar spine

Abstract

BackgroundPatients with an impaired renal function show a high incidence of bone and mineral disturbances. These ‘chronic kidney disease – mineral and bone disorders’ (CKD-MBD) range from high turnover osteoporosis to adynamic bone disease. Currently, the histomorphometric analysis of a bone biopsy taken from the iliac crest is viewed as the gold standard for CKD-MBD subtype differentiation. However, the clinical relevance of such a biopsy is questionable since iliac crest fractures are an extremely rare finding. Therefore, we aimed to elucidate if the histomorphometric parameter ‘trabecular bone volume (BV/TV)’ from the iliac crest is representative for other biopsy locations. We chose two skeletal sites of higher fracture risk for testing, namely, the tibial bone and the lumbar spine, to examine if the current gold standard of bone biopsy is indeed golden.MethodsBone biopsies were taken from 12 embalmed body donors at the iliac crest, the proximal tibia, and the lumbar vertebral body, respectively. Masson-Goldner stained sections of methyl methacrylate embedded biopsies were used for trabecular bone volume calculation. Furthermore, exemplary μ-computed tomography (XtremeCT) scans with subsequent analysis were performed.ResultsMedian values of trabecular bone volume were comparable between all body donors with median (interquartile range, IQR) 18.3% (10.9–22.9%) at the iliac crest, 21.5% (9.5–40.1%) at the proximal tibia, and 16.3% (11.4–25.0%) at the lumbar spine. However, single values showed extensive intra-individual variation, which were also confirmed by XtremeCT imaging.ConclusionsDistinct intra-individual heterogeneity of trabecular bone volume elucidate why a bone biopsy from one site does not necessarily predict patient relevant endpoints like hip or spine fractures. Physicians interpreting bone biopsy results should know this limitation of the current gold standard for CKD-MBD diagnostic, especially, when systemic therapeutic decisions should be based on it.

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

“…Despite being the gold standard for diagnosing the underlying pathology in CKD‐MBD (known as ROD), it is performed in few specialised centres, and its processing and analysis require significant expertise and thus is seldom performed in routine clinical practice. It is also limited by its ability to only provide a measure of bone quality at a single site, and studies have shown significant discrepancies in the underlying ROD when samples have been concomitantly taken from the iliac crest, lumbar vertebra and proximal tibia . Furthermore, two or more bone biopsies are required to assess response to therapy, and no studies have demonstrated bone biopsy findings that provide fracture prediction.…”

“…It is also limited by its ability to only provide a measure of bone quality at a single site, and studies have shown significant discrepancies in the underlying ROD when samples have been concomitantly taken from the iliac crest, lumbar vertebra and proximal tibia. 32,33 Furthermore, two or more bone biopsies are required to assess response to therapy, and no studies have demonstrated bone biopsy findings that provide fracture prediction. The initial 2009 KDIGO guidelines necessitated a bone biopsy in patients with CKD-MBD prior to consideration of anti-resorptive therapy given theoretical concerns of inducing or worsening ABD in patients with already low bone-turnover states.…”

Bone Mineral Density Compared to Trabecular Bone Score in Primary Hyperparathyroidism

“…Iliac crest biopsies have also documented preserved trabecular bone in PHPT [6]. However, studies comparing cadaver biopsies from the LS and iliac crest have shown significant discrepancy between the two sites, suggesting that iliac crest histomorphometry may not accurately reflect lumbar spine microarchitecture [35,36].…”

Assessment of trabecular and cortical parameters using high-resolution peripheral quantitative computed tomography, histomorphometry and microCT of iliac crest bone core in hemodialysis patients

“…We did not find studies that evaluated whether clinical conditions, such as CKD, can determine the predominance of a specific pattern (rod × plate). While previous studies compared the various sites using only microtomography, Hiller et al (2017) performed this analysis using histomorphometry and microCT of the iliac crest, proximal tibia, and lumbar vertebra, wherein they observed variations in BV/TV and no correlation between them. The authors highlighted intra-individual and inter-individual differences.…”