Calcium Oxalate Microcrystalline-Associated Arthritis in End-Stage Renal Disease

Hoffman, George C.; Schumacher, H. Ralph; Paul, H; Cherian, Varghese I.; Reed, Roberta G.; Ramsay, Allan G.; Franck, Walter A.

doi:10.7326/0003-4819-97-1-36

Cited by 110 publications

(40 citation statements)

References 19 publications

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“…The radiographs showed articular changes resembling those described in pyrophosphate arthropathy without chondrocalcinosis, as well as those seen in erosive azotemic osteoarthropathy secondary to long-term hemodialysis (21-23). Such changes were also described by Hoffman et a1 (5) in their 3 patients with secondary oxalosis and end-stage renal disease (5). Although secondary hyperparathyroidism with osteitis fibrosa was seen in patients 3 and 4 ( Table 4), and such a condition can account for most of these subchondral bone changes, calcium oxalate crystal deposits in bone can mimic many of the radiographic manifestations of osteitis fibrosa (24,25).…”

Section: Discussionmentioning

confidence: 88%

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Arthropathy and cutaneous calcinosis in hemodialysis oxalosis

Reginato

Seoane

Álvarez

et al. 1986

Arthritis & Rheumatism

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Recently, calcium oxalate crystals have been identified in the synovial fluid of patients with arthritis and end-stage renal failure. We describe 4 patients who, during the course of long-term hemodialysis, developed calcium oxalate crystal deposits in the synovium and skin. Clinical manifestations included podagra, tenosynovitis, olecranon bursitis, and acute and chronic synovitis of the large joints that were associated with chondrocalcinosis or subchondral bone erosions. Diffuse involvement of the hand, with chondrocalcinosis of the finger joints, miliary calcified deposits in the skin, and artery calcifications, was observed in 3 patients. The fourth patient had erosive arthropathy. Oxalosis secondary to end-stage renal failure in patients treated with long-term hemodialysis can present with articular man-

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Section: Discussionmentioning

confidence: 88%

“…Abundant deposits of calcium oxalate crystals occur in the kidney, myocardium, and bone. Intraarticular deposits and arthritis have been described in only a few patients (2)(3)(4)(5). Current knowledge of the clinical, radiographic, and crystallographic features of this newly recognized crystal-associated arthropathy is limited (5,6).…”

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confidence: 99%

Arthropathy and cutaneous calcinosis in hemodialysis oxalosis

Reginato

Seoane

Álvarez

et al. 1986

Arthritis & Rheumatism

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“…In some patients with chronic renal failure, crystals of calcium oxalate have been identified in kidney, blood vessels, myocardium, thyroid, synovia, cartilage, bone, and periodontium (12)(13)(14)(15)(16)(17). The formation of crystals indicates that calcium oxalate concentrations in these tissues must have exceeded the solubility limit on some occasions, but the mechanism by which this occurs is not clear.…”

Section: Introductionmentioning

confidence: 99%

Evidence that serum calcium oxalate supersaturation is a consequence of oxalate retention in patients with chronic renal failure.

Worcester¹,

Nakagawa²,

Bushinsky³

et al. 1986

J. Clin. Invest.

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Serum oxalate rises in uremia because of decreased renal clearance, and crystals ofcalcium oxalate occur in the tissues of uremic patients. Crystal formation suggests that either uremic serum is supersaturated with calcium oxalate, or local oxalate production or accumulation causes regional supersaturation. To test the first alternative, we ultrafiltered uremic serum and measured supersaturation with two different methods previously used to study supersaturation in urine. First, the relative saturation ratio (RSR), the ratio of the dissolved calcium oxalate complex to the thermodynamic calcium oxalate solubility product, was estimated for 11 uremic (before and after dialysis) and 4 normal serum samples using a computer program. Mean ultrafiltrate oxalate predialysis was 89±8 ,uM/liter (±SEM), 31±4 postdialysis, and 10±3 in normals. Mean RSR was 1.7±0.1 (predialysis), 0.7±0.1 (postdialysis), and 0.2±0.1 (normal), where values >1 denote supersaturation, <1, undersaturation. Second, the concentration product ratio (CPR), the ratio of the measured calcium oxalate concentration product before to that after incubation of the sample with calcium oxalate monohydrate crystal, was measured in seven uremic and seven normal serum ultrafiltrates. Mean oxalate was 91±11 (uremic) and 8±3 (normal). Mean CPR was 1.4±0.2 (uremic) and 0.2±0.1 (normal). Predialysis, 17 of 18 uremic ultrafiltrates were supersaturated with respect to calcium oxalate. The degree of supersaturation was correlated with ultrafiltrate oxalate (RSR, r = 0.99, n = 29, P < 0.001; CPR, r = 0.75, n = 11, P < 0.001). A value of ultrafiltrate oxalate of 50 AM/liter separated undersaturated from supersaturated samples and occurred at a creatinine of -9.0 mg/dl.

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“…Erosive arthritis associated with apatite crystal deposition was reported in a hemodialysis patient (30). The recent finding of calcium oxalate crystals in synovial effusions from some dialysis patients suggests a possible pathogenetic role for these crystals in the production of joint symptoms (31).…”

Section: Discussionmentioning

confidence: 99%

Erosive azotemic osteoarthropathy

Rubin

Fam

Rubenstein

et al. 1984

Arthritis & Rheumatism

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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

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Calcium Oxalate Microcrystalline-Associated Arthritis in End-Stage Renal Disease

Cited by 110 publications

References 19 publications

Arthropathy and cutaneous calcinosis in hemodialysis oxalosis

Arthropathy and cutaneous calcinosis in hemodialysis oxalosis

Evidence that serum calcium oxalate supersaturation is a consequence of oxalate retention in patients with chronic renal failure.

Erosive azotemic osteoarthropathy

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