Abstract: TH-PO0242
Bone Biopsy as a Diagnostic Pivot in a Patient with a Fracture Receiving Dialysis
Session Information
- Bone and Mineral Metabolism: Clinical Reports and Practice
November 06, 2025 | Location: Exhibit Hall, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Bone and Mineral Metabolism
- 502 Bone and Mineral Metabolism: Clinical
Authors
- Siu, Man Kit Michael, VA Greater Los Angeles Healthcare System, Los Angeles, California, United States
- Gardezi, Lemar Ahmad, VA Greater Los Angeles Healthcare System, Los Angeles, California, United States
- Lei, Sean, VA Greater Los Angeles Healthcare System, Los Angeles, California, United States
- Sharma, Shilpa, VA Greater Los Angeles Healthcare System, Los Angeles, California, United States
- Pereira, Renata C., University of California Los Angeles Department of Medicine, Los Angeles, California, United States
- Rhee, Connie, VA Greater Los Angeles Healthcare System, Los Angeles, California, United States
Introduction
With end-stage renal disease (ESRD), skeletal fragility may stem from both osteoporosis and renal osteodystrophy. Imaging techniques including dual-energy X-ray absorptiometry (DEXA) cannot distinguish them. Antiresorptives like denosumab - used for osteoporosis, notably risky for severe hypocalcemia in high-turnover states from secondary hyperparathyroidism (SHPT). This case highlights the value of bone biopsy in guiding therapy.
Case Description
A 77-year-old man with ESRD on hemodialysis for over 15 years (presumed diabetes, hypertension) sustained a right hip fracture after a mechanical fall. Routine post-fracture DEXA scan showed a T-score of –3.4 at the left femoral neck. Per standard protocol, he was referred for denosumab and underwent dental extraction to reduce risk of osteonecrosis of the jaw.
After tooth removal, he could not chew lanthanum, prompting a switch to sevelamer. This triggered review of his pending denosumab order and a broader CKD-MBD assessment. PTH was 500–900 pg/mL despite calcitriol and dual calcimimetic therapy. Phosphorus 4–5 mg/dL, calcium 7.5–8.0 mg/dL. Concerned about denosumab-related hypocalcemia, nephrology conferred with endocrinology, and treatment was held pending tetracycline-tagged bone biopsy.
Histomorphometry revealed high-turnover bone disease: increased osteoid surface (25.25%), cortical thinning, porosity, and diffuse tetracycline labeling - consistent with severe osteitis fibrosa (Figure 1). Although mild trabecular disconnection and cortical fragility did suggest a secondary osteoporotic component.
Discussion
This case underscores how protocol-driven management can gain momentum even in complex ESRD patients. For our patient, bone biopsy served as the diagnostic pivot, redirecting care toward PTH control and parathyroidectomy evaluation. In dialysis patients, fracture does not imply osteoporosis. Diagnostic pause can prevent harm and guide effective therapy.
Figure 1:
Fluorescent tetracycline-labeled bone biopsy - diffuse double tetracycline labels, indicating high bone turnover consistent with severe osteitis fibrosa.