Increased incidence of hip fractures in dialysis patients with low serum parathyroid hormone

Coco, Maria; Rush, Heather

doi:10.1053/ajkd.2000.19812

Cited by 541 publications

(439 citation statements)

References 19 publications

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“…Of concern is the tendency toward very low bone turnover evidenced by bone histology at 6 mo in our study. We and others have reported that low PTH and presumably low bone turnover are associated with increased fractures in dialysis patients (38,39). Whether low bone turnover with increased bone density in these subjects treated with bisphosphonates carries the same risks associated with adynamic bone disease in dialysis patients is unclear (21).…”

Section: Discussionmentioning

confidence: 95%

Prevention of Bone Loss in Renal Transplant Recipients

Coco¹,

Glicklich²,

Faugère

et al. 2003

Journal of the American Society of Nephrology

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232

155

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Abstract. Renal transplant recipients are at risk of developing bone abnormalities that result in bone loss and bone fractures. These are related to underlying renal osteodystrophy, hypophosphatemia, and immunosuppressive treatment regimen. Although bisphosphonates are useful in ameliorating bone mineral loss after transplantation, it is not known whether their use in renal transplant patients leads to excessive suppression of bone turnover and increased incidence of adynamic bone disease. A randomized, prospective, controlled, clinical trial was conducted using the bisphosphonate pamidronate intravenously in patients with new renal transplants. Treatment subjects (PAM) received pamidronate with vitamin D and calcium at baseline and at months 1, 2, 3, and 6. Control (CON) subjects received vitamin D and calcium only. During months 6 to 12, the subjects were observed without pamidronate treatment. Biochemical parameters of bone turnover were obtained monthly and, bone mineral density (BMD) was obtained at baseline and months 6 and 12. Bone biopsies for mineralized bone histology were obtained at baseline and at 6 mo in a subgroup of subjects who underwent scheduled living donor transplantation. PAM preserved bone mass at 6 and 12 mo as measured by bone densitometry and histomorphometry. CON had decreased vertebral BMD at 6 and 12 mo (4.8 Ϯ 0.08 and 6.1 Ϯ 0.09%, respectively). Biochemical parameters of bone turnover were similar in both groups at 6 and 12 mo. Bone histology revealed low turnover bone disease in 50% of the patients at baseline. At 6 mo, all of PAM had adynamic bone disease, whereas 50% of CON continued to have or developed decreased bone turnover. Pamidronate preserved vertebral BMD during treatment and 6 mo after cessation of treatment. Pamidronate treatment was associated with development of adynamic bone histology. Whether an improved BMD with adynamic bone histology is useful in maintaining long-term bone health in renal transplant recipients requires further study.

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Section: Discussionmentioning

confidence: 95%

Prevention of Bone Loss in Renal Transplant Recipients

Coco¹,

Glicklich²,

Faugère

et al. 2003

Journal of the American Society of Nephrology

Self Cite

232

155

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“…The implications of low bone turnover for bone structure and strength during growth are not known; however, this bone lesion is associated with increased fracture risk in adults [14] -perhaps due to impaired microfracture repair. It has been suggested that intermittent calcitriol therapy combined with calcium-containing phosphate binders may adversely affect chondrocyte activity in the epiphyseal growth plate, with a consequent reduction in linear growth.…”

Section: Histomorphometry Of Renal Osteodystrophymentioning

confidence: 99%

A structural approach to the assessment of fracture risk in children and adolescents with chronic kidney disease

Leonard

2007

Pediatr Nephrol

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Children with chronic kidney disease (CKD) have multiple risk factors for impaired accretion of trabecular and cortical bone. CKD during childhood poses an immediate fracture risk and compromises adult bone mass, resulting in significantly greater skeletal fragility throughout life. Highturnover disease initially results in thickened trabeculae, with greater bone volume. As disease progresses, resorption cavities dissect trabeculae, connectivity degrades, and bone volume decreases. Increased bone turnover also results in increased cortical porosity and decreased cortical thickness. Dual-energy X-ray absorptiometry (DXA)-based measures of bone mineral density (BMD) are derived from the total bone mass within the projected bone area (g/cm 2 ), concealing distinct disease effects in trabecular and cortical bone. In contrast, peripheral quantitative computed tomography (pQCT) estimates volumetric BMD (vBMD, g/cm 3 ), distinguishes between cortical and trabecular bone, and provides accurate estimates of cortical dimensions. Recent data have confirmed that pQCT measures of cortical vBMD and thickness provide substantially greater fracture discrimination in adult dialysis patients compared with hip or spine DXA. The following review considers the structural effects of renal osteodystrophy as it relates to fracture risk and the potential advantages and disadvantages of DXA and alternative measures of bone density, geometry, and microarchitecture, such as pQCT, micro-CT (μCT), and micro magnetic resonance imaging (μMRI) for fracture risk assessment.

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“…Esses pacientes apresentam hipercalcemia importante que suprime o PTH, o que torna o quadro facilmente diferenciado do HPT. Na verdade, pacientes com PTH diminuído possuem mais risco de fratura patológica que aqueles com HPT2 ario (81). Valores de PTH intacto no menor percentil estão associados com maior prevalência de fratura vertebral que no maior tercil.…”

Section: Contra-indicações à Paratireoidectomia E Diagnóstico Diferenunclassified

“…Valores de PTH intacto no menor percentil estão associados com maior prevalência de fratura vertebral que no maior tercil. A menor prevalência foi encontrada nos pacientes que mantinham PTH aproximadamente 1 a 3 vezes o limite superior do valor de referência (81). Assim, valores de PTH acima de 3 vezes o normal associado a níveis de fosfatase alcalina elevados são considerados preditores de HPT, enquanto a doença adinâmica do osso é mais comum em pacientes com PTH menores que 2 vezes o limite superior e com valores não elevados de fosfatase alcalina (82,83).…”

Section: Contra-indicações à Paratireoidectomia E Diagnóstico Diferenunclassified

“…Apesar da histologia óssea permanecer como padrão ouro para o diagnóstico da osteodistrofia renal, é cara e invasiva. Para alguns autores, níveis de PTH acima de 3 vezes o limite superior do método e fosfatase alcalina elevada são suficientes para excluir doença adinâmica do osso, e a maior preocupação continua sendo a intoxicação por alumínio (80,81). Assim, as indicações da realização da biópsia óssea são: importante exposição ao alumínio, exposição leve ou moderada de alumínio em pacientes diabéticos, e quando se deseja estabelecer o diagnóstico de doença adinâmi-ca do osso em pacientes com dor óssea e/ou fratura patológica, cujos níveis de PTH e fosfatase alcalina não são elevados.…”

Section: Contra-indicações à Paratireoidectomia E Diagnóstico Diferenunclassified

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Indicações de paratireoidectomia no hiperparatireoidismo secundário à insuficiência renal crônica

Lacativa¹,

Filho

Gonçalves³

et al. 2003

Arq Bras Endocrinol Metab

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Arq Bras Endocrinol Metab vol 47 nº 6 Dezembro 2003 644 RESUMOO hiperparatireoidismo é uma manifestação comum na insuficiência renal crônica (IRC), com alta morbi-mortalidade e difícil manejo clínico. As indicações clássicas da paratireoidectomia são: hipercalcemia persistente, principalmente após transplante renal, prurido intratável, fraturas patológicas, dor óssea refratária ao tratamento medicamentoso e calcificação metastática. Infelizmente, esta última não responde à paratireoidectomia e a calcificação dos vasos está relacionada ao aumento da mortalidade. Assim, novos critérios para indicação mais precoce de paratireoidectomia são necessários. Níveis séricos de PTH maiores que 10 vezes o limite da normalidade, apesar da adequada reposição de cálcio e calcitriol, produto cálcio x fósforo maior que 70(mg/dl) 2 , tumor marrom quando é urgente a regressão da massa, artrite e/ou periartrite incapacitantes e ruptura de tendões estão entre outras indicações a serem consideradas. Alguns cuidados são necessários para excluir doenças ósseas concomitantes, como amiloidose e intoxicação por alumínio. Esta revisão visa a orientar os endocrinologistas sobre as indicações e melhor momento de realizar paratireoidectomia no hiperparatireoidismo da IRC. Hyperparathyroidism is a common complication of end-stage renal insufficiency, with a high morbi-mortality and difficult medical control. Classical indications for parathyroidectomy are: persistent hypercalcemia, especially after kidney transplantation, untreatable pruritus, pathologic fractures, bone pain refractory to medical treatment, and metastatic calcifications. Unfortunately, this latter complication does not respond to parathyroidectomy, and blood vessels calcifications are associated with increased mortality. Severe osteitis fibrosa and bone deformities also never disappear. Thus, new criteria for early parathyroidectomy are needed. Serum intact PTH higher than 10 times the upper limit of normality despite adequate calcium and calcitriol supplements, calcium-phosphorus product higher than 70(mg/dL) 2 , "brown tumor" whenever a rapid regression is needed, incapacitating arthritis and/or periarthritis, and rupture of tendons are among other indications that should be considered. Care must be taken to exclude concomitant diseases such as amiloidosis and aluminum intoxication. This review intends to advise endocrinologists about the indications and timing of surgery in hyperparathyroidism due to chronic renal failure.

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Increased incidence of hip fractures in dialysis patients with low serum parathyroid hormone

Cited by 541 publications

References 19 publications

Prevention of Bone Loss in Renal Transplant Recipients

Prevention of Bone Loss in Renal Transplant Recipients

A structural approach to the assessment of fracture risk in children and adolescents with chronic kidney disease

Indicações de paratireoidectomia no hiperparatireoidismo secundário à insuficiência renal crônica

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