Noninvasive Diagnosis of Uremic Osteodystrophy: Uses and Limitations

Abstract

45 bone biopsies from patients with chronic uremia were reviewed to define which noninvasive investigations were of value in predicting the histological diagnosis and to quantify the spectrum of uremic bone disease at a center that has consistently used an aluminum-free dialysis bath. 17 biopsies were taken postmortem. 15 patients received conservative treatment, the rest were on maintenance dialysis. 13 patients had symptomatic bone disease. Virtually all patients with a uremia duration greater than 3 years had uremic osteodystrophy. All patients with clinical bone disease, hypercalcemia or raised alkaline phosphatase activity had osteodystrophy, but the specific histology was not indicated. Greatly raised parathyroid levels suggested secondary hyperparathyroidism, but the test was only 100% specific when 20 times normal. Total aluminum consumption was highly indicative of bone aluminum concentration (p < 0.0001) and aluminum-related osteomalacia (5 cases), suggesting that a considerable proportion of uremic bone disease is iatrogenic. Serum aluminum was of some use in the diagnosis of aluminum-related osteomalacia, but was not wholly reliable. Bone mineral content (BMC) using both forearm measurements and total body bone mineral levels (TBBM) were assessed in 32 patients and were found to be reduced in 12, with a preponderance of secondary hyperparathyroidism. BMC and TBBM were negatively correlated to resorbing surfaces and bone formation rate, suggesting that secondary hyperparathyroidism is the uremic bone disease that represents the greatest threat to bone mass. It is concluded that while noninvasive investigations give considerable information, reliable diagnosis requires the use of histological methods.

Circulating levels of osteoprotegerin and receptor activator of NF-κB ligand in patients with chronic renal failure

“…This can be an occasionally painful intervention that might be complicated by local infection, and therefore is often refused by patients, even more so if repetitive biopsies were required for efficacy monitoring of therapy. Non-invasive evaluation of bone disease therefore has to be carried out by radiodensitometry and determination of serological biochemical markers of bone turnover; however, it has only been partially successful to date (10)(11)(12)(13).…”

Causes and Consequences of Adynamic Bone Disease

“…The condition was first described in the 1980s and was primarily ascribed to aluminum bone intoxication [1, 2, 3]. Even at the height of the aluminum epidemic, it was however clear that not all cases could be related to aluminum [4]. During the 1990s, aluminum hydroxide phosphate binders were replaced, mainly by calcium carbonate and calcium acetate.…”

Osteoporosis in renal failure: How accurate is the diagnosis and is there any role for bisphosphonates?

“…Helpful tests include bone turnover markers and double tetracycline-labeled bone biopsy. [15][16][17] The clinical utility of the latter procedure is limited however due to its invasive nature and other factors such as patients' acceptability and difficulties in finding experienced teams and appropriate laboratory facilities. Bone markers such as bone specific alkaline phosphatase (bAP), parathyroid hormone (PTH), osteocalcin (OC), and pyridinoline (PYD), are excellent markers of bone turnover in ERSD patients 18,19 and can distinguish the type of bone disease (high turnover vs. normal or low turnover).…”