Renal osteodystrophy is well recognized complication of end stage renal disease(ESRD) and is associated with a marked morbidity. To evaluate bone loss in renal osteodystrophy, we measured bone mineral density(BMD) in distal radius by quantitative computed tomography in 43 ESRD patients on starting hemodialysis(HD) and in 84 healthy controls matched for age and sex. We also measured intact parathyroid hormone(iPTH), serum total alkaline phosphatase(T-ALP), osteocalcin(OC) and urine deoxypyridinoline(U-DPD) as bone turn-over markers. 1) The mean age of ESRD patients and control groups were 49.8 and 49.7 years. M:F ratio were 1:1.1 and 1:1.3 on each groups. There was no significant differences on each groups. 2) Serum T-ALP and OC were 263.9+/-264.5U/L, 43.5+/-27.6ng/mL in ESRD patients and 167.4+/-46.6U/ L, 8.8+/-3.9ng/mL in control groups. These were significantly higher in ESRD patients(P<0.001, P< 0.001), while U-DPD were not significant difference on each groups(5.3+/-4.1 vs 5.4+/-1.9nM/mM. Cr.). 3) Serum iPTH and aluminum were 296.8+/-263.4pg/mL, 10.1+/-11.6ng/mL in ESRD patients. 4) Total density, trabecular density and cortical density were 340.4+/-83.6, 172.9+/-48.4, 477.2+/-123.5mg/ cm3 in ESRD patients and 393.2+/-49.1, 210.6+/-32.9, 541.3+/-76.2mg/cm3 in control groups. BMD was statistically significantly reduced in ESRD patients (P<0.001, P<0.001, P<0.001, respectively). Z score of total density and trabecular density were -0.62+/-1.12, -0.91+/-0.95 in ESRD patients and 0.19+/-0.68, 0.06+/-0.59 in control groups. It was significantly reduced in ESRD patients(P<0.001, P<0.001, P<0.001, respectively). 5) In ESRD patients, serum T-ALP, iPTH, OC, U-DPD were not correlated with BMD and Z score. But in control groups, serum OC was correlated inversly with BMD, and U-DPD was only correlated inversely with trabecular density. 6) In ESRD patients(n=22) who were having iPTH above 300pg/mL, serum OC and U-DPD were significantly higher than in ESRD patients(n=21) who were having iPTH below 300pg/mL(52.6+/-28.8ng/ mL, 6.8+/-5.1nM/mM.Cr. vs. 33.9+/-23.3ng/mL, 3.7+/-1.9 nM/mM.Cr. P<0.05, P<0.05 repectively). But serum aluminum, and T-ALP were not significant difference on each groups. BMD and Z score were also not difference on each groups. 7) In ESRD patients who were having iPTH above 300pg/mL, iPTH and serum OC were inversely correlated with BMD but U-DPD were only inversely correlated with trabecular density. In ESRD patients who were having iPTH below 300pg/mL, bone turn-over markers were not correlated with BMD. In ESRD patients on starting HD, BMD were significantly reduced, but serum T-ALP, OC, iPTH and U-DPD were not correlated with BMD. In ESRD patients who were having iPTH above 300 pg/mL, BMD were significantly inversely correlated with serum OC, iPTH.
Aluminum ; Bone Density* ; Humans ; Kidney Failure, Chronic* ; Radius ; Renal Dialysis* ; Renal Osteodystrophy

BACKGROUND/AIMS: Whereas higher dialysate calcium (Ca) levels may pose a risk of hypercalcemia, lower levels may induce a negative Ca balance. We evaluated the effect of lowering dialysate Ca levels from 1.75 to 1.5 mmol/L and explored the appropriate use of calcitriol to regulate bone metabolism in hemodialysis patients. METHODS: The dialysate Ca levels of 36 patients were reduced from 1.75 to 1.5 mmol/L. They were divided into three groups according to basal intact parathyroid hormone (iPTH) level (group 1, iPTH < 150 pg/mL, n = 21; group 2, iPTH 150-300 pg/mL, n = 7; group 3, iPTH > 300 pg/mL, n = 8). Data were collected at 3-month intervals for 1 year. RESULTS: Throughout the study period, no significant difference in phosphate binders, serum Ca, phosphorus (P), or Ca x P products was observed among groups. However, iPTH, alkaline phosphatase (AP), and calcitriol dosage patterns differed among groups. In group 1, iPTH and AP increased significantly over 12 months (p = 0.01). In group 2, iPTH and AP showed no significant changes. In group 3, iPTH and AP declined significantly over 12 months (p = 0.02). Calcitriol dosage did not change in groups 1 and 2, but increased significantly in group 3 (p = 0.001). CONCLUSIONS: After converting hemodialysate Ca levels from 1.75 to 1.5 mmol/L, the initially different iPTH concentrations converged to a modestly elevated level. The use of 1.5 mmol/L hemodialysate Ca may thus be appropriate for both high- and low-turnover bone disease if phosphate binders and calcitriol are combined appropriately.
Alkaline Phosphatase ; Bone Diseases ; Calcitriol ; Calcium ; Humans ; Hypercalcemia ; Parathyroid Hormone ; Phosphorus ; Renal Dialysis ; Renal Osteodystrophy

BACKGROUND/AIMS: Whereas higher dialysate calcium (Ca) levels may pose a risk of hypercalcemia, lower levels may induce a negative Ca balance. We evaluated the effect of lowering dialysate Ca levels from 1.75 to 1.5 mmol/L and explored the appropriate use of calcitriol to regulate bone metabolism in hemodialysis patients. METHODS: The dialysate Ca levels of 36 patients were reduced from 1.75 to 1.5 mmol/L. They were divided into three groups according to basal intact parathyroid hormone (iPTH) level (group 1, iPTH < 150 pg/mL, n = 21; group 2, iPTH 150-300 pg/mL, n = 7; group 3, iPTH > 300 pg/mL, n = 8). Data were collected at 3-month intervals for 1 year. RESULTS: Throughout the study period, no significant difference in phosphate binders, serum Ca, phosphorus (P), or Ca x P products was observed among groups. However, iPTH, alkaline phosphatase (AP), and calcitriol dosage patterns differed among groups. In group 1, iPTH and AP increased significantly over 12 months (p = 0.01). In group 2, iPTH and AP showed no significant changes. In group 3, iPTH and AP declined significantly over 12 months (p = 0.02). Calcitriol dosage did not change in groups 1 and 2, but increased significantly in group 3 (p = 0.001). CONCLUSIONS: After converting hemodialysate Ca levels from 1.75 to 1.5 mmol/L, the initially different iPTH concentrations converged to a modestly elevated level. The use of 1.5 mmol/L hemodialysate Ca may thus be appropriate for both high- and low-turnover bone disease if phosphate binders and calcitriol are combined appropriately.
Alkaline Phosphatase ; Bone Diseases ; Calcitriol ; Calcium ; Humans ; Hypercalcemia ; Parathyroid Hormone ; Phosphorus ; Renal Dialysis ; Renal Osteodystrophy

Brown tumor is a histologically benign lesion that is a serious complication of renal osteodystrophy because it may result in severe deformity and discomfort. We report a case of brown tumor, which occurred in a 35-year-old woman with chronic renal failure, who had been treated with hemodialysis for 14 years. The lesion was found on the lingual side of the mandible. Standard panoramic radiograph showed generally decreased bone mineral density, loss of lamina dura, and thin cortical plates. Computed tomography (CT) revealed multilocular expansile lesions with heterogeneous attenuation in the anterior mandible, as well as generalized trabecular alteration with homogeneous sclerosis, and thinning or obliteration of cortical plates. Excision of the mandibular lesion and curettage of the affected bone were performed.
Adult ; Bone Density ; Congenital Abnormalities ; Curettage ; Female ; Humans ; Kidney Failure, Chronic ; Mandible ; Renal Dialysis ; Renal Osteodystrophy ; Sclerosis

Maxillary enlargement is a rare complication of secondary hyperparathyroidism (SHPT). A 35-year-old Korean man undergoing chronic hemodialysis presented with a painless enlargement involving the maxilla and mandible. Plain radiography and CT scan showed bony expansion at the maxilla and mandible with multiple radiolucency. Serum intact parathyroid hormone (iPTH) was >1,600 pg/mL. Tc-99m sestamibi (MIBI) parathyroid scan and neck sonogram were compatible with SHPT. He underwent limited parathyroidectomy and commenced a course of paricalcitol. Fifteen months after surgery, maxillary enlargement and bony resorptions involving both hands markedly improved. Thirty-six months after the surgery, the serum iPTH level was 109.3 pg/mL. This is the first report in Korea documenting a patient with maxillary enlargement in SHPT who was successfully treated with limited parathyroidectomy and paricalcitol.
Adult ; Ergocalciferols ; Hand ; Humans ; Hyperparathyroidism ; Hyperparathyroidism, Secondary ; Korea ; Mandible ; Maxilla ; Neck ; Parathyroid Hormone ; Parathyroidectomy ; Renal Dialysis ; Renal Osteodystrophy

BACKGROUND: More than 25 years have been passed since Korea started the hemodialysis. Initially, the technical problems of dialysis machine, a handling of azotemia, sustained anemia, as well as renal osteodystrophy were major matters we have to solve, however, recently the focused matters were changed that the removal of heavier molecular weighed uremic toxins, toxins like aluminium and silicon are very important, because these toxins are hardly removed and are very influential on the uremic signs. In this study, we planned to observe how much aluminium accumulated in chronic hemodialysis patients, and how much significant is increased aluminium blood level in patients. METHODS: We randomly selected fifty patients undergoing chronic hemodialysis to estimate the serum level of aluminium. We analyzed patients by using clinical informations, such as the time period of hemodialysis, the dialysis frequency, whether diabetes or not , according to the aluminium serum levels. The aluminium serum levels were estimated before and after the hemodialysis, which were measured by using the atomic absorption spectrophotometry. RESULTS: The serum levels of aluminium in CRF patients undergoing hemodialysis were significantly increased, as compared with normal range and much more increased levels was observed after hemodialysis 48.9+/-3.2 microgram/L than before 27.6+/-2.3 microgram/L (p<0.05) (Table 2). The aluminium level before hemodialysis of diabetic patients (40.3+/-17.6 microgram/L) showed I.57 times higher than non-diabetes (25.7+/-21.2 microgram/L), but the level after hemodialysis showed non-significant difference (Figure 1). The aluminium blood level after hemodialysis and the duration of hemodialysis were correlated positively (r=0.34, p<0.01), but this wasn't before hemodialysis (Figure 2). The serum level of aluminium tends upward following to increasing level of serum calcium, serum magnesium, as well as parathyroid hormone (Table 3). The delta aluminium(post-pre dialysis) level was significantly correlated positively (r=0.66, p<0.05) with delta Hb (post-pre dialysis) level (Figure 3). CONCLUSION: The serum level of aluminium in chronic renal failure patients undergoing hemodialysis were significantly increased and especially, more increased as soon as the hemodialysis was finished.
Anemia ; Azotemia ; Calcium ; Dialysis ; Humans ; Kidney Failure, Chronic* ; Korea ; Magnesium ; Parathyroid Hormone ; Reference Values ; Renal Dialysis* ; Renal Osteodystrophy ; Spectrophotometry, Atomic

PURPOSE: This study was performed to evaluate the aluminum level in hemodialysis patients and to find a correlation between aluminum level and bone specific alkaline phosphatase level. METHODS: Eighty five randomly selected patients with end-stage renal disease, undergoing maintenance hemodialysis treatment over 1 year were studied. Serum aluminum and bone specific alkaline phosphatase concentration were measured. Low dose desferrioxamine test (5 mg/kg) was done. RESULTS: The serum aluminum concentration before and after low dose desferrioxamine test were 4.21+/-2.13 microgram/L and 8.89+/-4.48 microgram/L (p<0.01) respectively. Bone-specific alkaline phosphates and parathyroid hormone concentration were 39.08+/-39.90 mg/dL and 98.27+/-112.92 pg/mL. The aluminum level after desferrioxamine test was correlated with duration of hemodialysis (r=0.238, p=0.03). Aluminum level was not correlated with bone specific alkaline phosphatase level. CONCLUSION: Aluminum level was lower than that of previous studies. Aluminum level was not increased in patients with low bone specific alkaline phosphatase. Thus, it seems that serum aluminum level is not a major problem in hemodialysis patients with lower turnover bone disease. However, confirm diagnosis of aluminum related bone disease in hemodialysis patients needs combined study of bone histology with a large number of cases.
Alkaline Phosphatase ; Aluminum* ; Bone Diseases ; Deferoxamine ; Diagnosis ; Humans ; Kidney Failure, Chronic ; Parathyroid Hormone ; Phosphates ; Renal Dialysis* ; Renal Osteodystrophy

Renal osteodystrophy (ROD) is an early complication in chronic kidney disease (CKD). Irreversible skeletal complications and deformities in children are already present before CKD progresses to end stage renal disease; therefore, the early detection of coexisting ROD is important in children with CKD. In the present work, we present a case of ROD in a 14-year-old female patient with chronic renal failure. The patient had already suffered bilateral femoral neck fractures before starting extracorporeal dialysis. On the 21st day after dialysis, external fixations of the femoral neck were performed.
Adolescent ; Child ; Congenital Abnormalities ; Dialysis ; Female ; Femoral Neck Fractures ; Femur Neck ; Humans ; Kidney Failure, Chronic ; Renal Dialysis ; Renal Insufficiency, Chronic ; Renal Osteodystrophy ; Renal Replacement Therapy

Renal osteodystrophy is used to describe the diverse clinical spectrum and the various histologic bone abnormalities found in patients with chronic renal failure. Although asymptomatic, histologic bone abnormalities begin early in chronic renal failure. The principal types of histologic bone abnormalities observed in patients with chronic renal failure are a high-turnover bone disease associated with secondary hyperparathyroidism and the histologic picture of osteitis fibrosa and a low-turnover bone disease included osteomalacia and adynamic or aplastic bone disease and a mixed bone disease shared histologic evidence of high- and low-turnover bone disease. Bone biopsy is an invasive procedure that remains the only approach for definitive diagnosis of aluminum-related bone disease and the type and severity of renal osteodystrophy. Positive aluminum staining is found mainly patients with low-turnover bone disease. We experienced a case of high-turnover renal osteodystrophy associated with positive aluminum staining. After successful kidney transplantation, serial bone histological studies indicate that aluminum overload resolves and high-turnover renal osteodystrophy improves more slowly. Because aluminum is retained long periods at the tissue, we should keep in mind that even low-dose use of aluminum-based phosphate binders adds to the bone load in dialysis patients and has the risk of aluminum-related bone disease.
Aluminum* ; Biopsy ; Bone Diseases ; Diagnosis ; Dialysis ; Humans ; Hyperparathyroidism, Secondary ; Kidney Failure, Chronic ; Kidney Transplantation ; Osteitis ; Osteomalacia ; Renal Osteodystrophy*

BACKGROUND/AIMS: Checking bone mineral density (BMD) is not sufficient for determining the progression of renal osteodystrophy. Measuring pyridinoline or deoxypyridinoline in urine does not give an accurate bone status, due to insufficient urine in patients with renal failure. However, another biochemical marker, beta-CTX (the carboxy-terminal telopeptide of type 1 collagen), in serum is believed to be a good indicator of the status of renal osteodystrophy. METHODS: Fifty-nine patients undergoing hemodialysis agreed to have their blood and BMD checked. Beta-CTX was measured using an electro-chemiluminescence sandwich immunoassay and BMD was counted at the lumbar spine, femoral neck, and distal humerus using a Discovery-Wi (Hologic). RESULTS: Bone-alkaline phosphatase (49.8+/-36.7 U/L), parathormone (PTH) (192.8+/-263.3 U/L), osteocalcin (33.4+/-18.2 ng/mL), and beta-CTX (2.1+/-1.2 ng/mL) were all increased, while the average BMD of the lumbar spine (0.86+/-0.17), femoral neck, (0.67+/-0.14) and distal humerus (0.67 +/- 0.17) were all decreased. The BMD of the femoral neck in females was significantly lower than in males (p=0.044). The serum phosphate and PTH concentrations in non-diabetics were significantly higher than in diabetics (p=0.001, p=0.04, respectively). The measured serum osteocalcin and beta-CTX concentrations in patients older than 40 years were much lower than in patients younger than 40 (p=0.009, p=0.01, respectively). Beta-CTX was strongly correlated with bone-alkaline phosphatase (r=0.625, p=0.00), osteocalcin (r=0.698, p=0.00), and PTH (r=0.648, p=0.00). CONCLUSIONS: Beta-CTX is another convenient, significant marker for evaluating renal osteodystrophy.
Amino Acids ; Biomarkers ; Bone Density ; Bone Resorption ; Collagen Type I ; Female ; Femur Neck ; Humans ; Humerus ; Immunoassay ; Male ; Osteocalcin ; Parathyroid Hormone ; Peptides ; Renal Dialysis ; Renal Insufficiency ; Renal Osteodystrophy ; Spine