Erosive azotemic osteoarthropathy

Abstract

Fifty-nine patients with end-stage renal disease undergoing long-term dialysis were studied prospectively for joint disease. Radiographic assessment allowed division of patients into 3 groups: group 1 included 12 patients with renal osteodystrophy and erosions of the metacarpophalangeal, proximal interphalangeal, distal interphalangeal, shoulder, wrist, and knee joints; group 2 had 11 patients with renal osteodystrophy without articular erosions; group 3 included 36 patients without osteodystrophy or erosions. Clinical manifestations were frequent in patients of group 1 and included episodes of arthralgias of the metacarpophalangeal, wrist, proximal interphalangeal, and knee joints. Patients of groups 1 and 2, particularly those of group 1, had a longer mean duration of dialysis and a higher mean serum alkaline phosphatase level compared with group 3 patients. The study indicates that there is a relatively high incidence (20%) of erosive arthropathy in dialysis patients. Renal osteodystrophy, more specifically, secondary hyperparathyroidism, and duration of dialysis are important factors in the development of this articular disorder. A number of skeletal and articular abnormalities have been described in patients with chronic renal failure who were undergoing maintenance dialysis (1-4). Included among these are changes of renal osteodystrophy (secondary hyperparathyroidism, osteomalacia, osteosclerosis, and osteoporosis), periarticular calcifications, ischemic osteonecrosis, and crystalinduced arthritis (1-4).Recently, an erosive arthritis of the hands and wrists has been reported in patients with renal failure and secondary hyperparathyroidism (5-8). In order to determine the prevalence and significance of these osteoarticular abnormalities, we conducted a clinical, radiographic, and laboratory study of 59 patients with end-stage renal disease w h o were undergoing maintenance dialysis. PATIENTS AND METHODSFifty-nine consecutive patients with chronic renal failure who were undergoing maintenance dialysis at Sunnybrook Medical Centre between 1979 and 1982 were studied.There were 38 men and 21 women, with a mean age of 54.5 years (range 24-79). Forty-one patients were being treated by hemodialysis, and 18 were being treated by peritoneal dialysis. The renal failure etiologies included 19 patients with glomerulonephritis, 12 with hypertensive nephropathy, 9 with polycystic kidney diseass.,? with chronic pyelonephritis, 2 with Alport's syndrome, 2 with obstructive uropathy, and 8 with etiology unknown. None of the patients had clinical or serologic evidence of a systemic disorder or a generalized connective tissue disease known to be associated with a rheumatic syndrome, e.g., systemic lupus erythematosus, scleroderma, etc.Rheumatologic evaluations were conducted by 2 assessors (LAR and AGF) on every patient at study entry and, subsequently, on those who developed joint symptoms. Particular attention was directed to the presence of joint

Destructive Spondylarthropathy in Hemodialyzed Patients

“…and therefore differed significantly from the vertebral disc lesions observed in our dialysis patients. Erosive arthritis of peripheral joints has been recently reported in dialysis patients (7,8), but to the best of our knowledge, there is no report in the literature of such lesions affecting the spine. The radiologic aspect of thc lesions observed in our patients at first strongly suggested infectious discitis, since dialysis patients are known to be prone to frequent infectious complications ( I ) .…”

Clinical Studies of Destructive Spondyloarthropathy in Long-Term Hemodialysis Patients

“…Alcaiay et al [6] and McCarthy et al [7] proposed that S-HPT might be essential to the development of DSA. S-HPT causes subpe riosteal and subchondral resorption of bone, leading to erosive azotemic osteoarthropathy as described by Rubin et al [23]. In the spine, subchondral resorption of bone is associated with substitutive fibrosis, secondary fragmenta tion of cartilaginous end plates, and extensive herniation of disk material into vertebral bodies such as Schmorl's nodes [24][25][26].…”

Is chronic renal failure a risk factor for the development of erosive osteoarthritis?

“…Although this condition has been described previously in patients receiving long term haemodialysis, it has not been described in patients who have undergone successful renal transplantation after only a relatively short period of haemodialysis. A number of authors have described juxtaarticular erosions in the finger joints without associated degenerative change in patients with chronic renal disease,3 4 and this has usually been attributed to secondary hyperparathyroidism. In contrast, others have described a destructive arthropathy resembling erosive OA,2 5 and there is disagreement as to whether this is a separate entity or part of the spectrum of hyperparathyroidism.…”