Abstract: PO0397
High Turnover Bone Disease After Successful Parathyroidectomy in a Dialysis Patient
Session Information
- Calcified Tissues in Kidney Diseases
October 22, 2020 | Location: On-Demand
Abstract Time: 10:00 AM - 12:00 PM
Category: Trainee Case Report
- 402 Bone and Mineral Metabolism: Clinical
Authors
- Ahmad, Yahya Rauf, University of Kentucky, Lexington, Kentucky, United States
- Donaldson, Katherine Michele, University of Kentucky, Lexington, Kentucky, United States
- Shea, Matthew, University of Kentucky, Lexington, Kentucky, United States
- Lima, Florence, University of Kentucky, Lexington, Kentucky, United States
- Rao, Madhumathi, University of Kentucky, Lexington, Kentucky, United States
Group or Team Name
- University of Kentucky Department of Nephrology
Introduction
We report a patient with end stage renal disease (ESRD) on hemodialysis (HD) with history of successful near-total parathyroidectomy (PTX) and normal to low parathyroid hormone (PTH) levels, found to have high-turnover/hyperparathyroid (HPT) bone disease on biopsy (bx).
Case Description
54-year-old female with ESRD on HD for 10 years presented with declining bone density and osteoporosis (left radial T-score of -2.7). She had a near-total PTX in 2014 for secondary hyperparathyroidism and bx proven severe HPT bone disease, complicated by calciphylaxis treated with wound care and sodium thiosulfate. Patient also has history of focal segmental glomerular sclerosis of her native kidneys, gastric bypass, uterine cancer requiring radiation, and psoriatic arthritis and gout requiring steroids.
Labs showed corrected calcium 9.4 mg/dL, serum phosphorus 7.9 mg/dL, 25-OH-vitamin D3 16.9 ng/mL, bone specific alkaline phosphatase 12.8 ug/L, intact PTH level 34 pg/mL (consistent with past values), PTH-(1-84)/-(7-84) ratio 1.1 (Scantibodies CA). She was started on weekly ergocalciferol. Bone bx showed persistent high-turnover/HPT bone disease with normal mineralization and low bone volume (2019, Figure 1). Relative to her prior bx, however, there was a demonstrable decrease in bone turnover and volume.
Discussion
Bone bx studies showing the evolution of bone disease after PTX in ESRD patients are limited. Development of adynamic bone disease is often presumed, but not established. In this patient, osteoporosis was related to high bone turnover, despite near-total PTX and successful reduction of serum PTH. These observations suggest that more research is needed into mechanisms other than PTH that contribute to bone turnover and loss in ESRD patients.
Figure 1: Anterior iliac crest bone biopsy: 1A – Trichrome stain 10x showing osteoclastic activity with tunneling in trabecular bone and increased osteoid volume and surface 1B – Fluorescent microscopy for tetracycline labeling 10x showing double labels and diffuse uptake in woven bone