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Bone Disease and Calcium Abnormalities in Elderly Patients with CKD

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Bone Disease and Calcium Abnormalities in Elderly Patients with CKD Chapter 14: Bone Disease and Calcium Abnormalities in Elderly Patients With CKD Harmeet Singh Division of Nephrology, Brody School of Medicine, Greenville, North Carolina An 81-yr-old African-American woman with end- issue problematic to define. Osteoporosis in CKD is stage kidney disease (ESKD) who has been on he- only a part of the constellation of metabolic bone modialysis for 10 yr seeks a consultation with you. problems. Therefore, its diagnosis and manage- Her primary physician obtained a dual-energy x- ment may differ from general population. Bones ray absorptiometry (DEXA) scan and asked her to are more severely affected in CKD than that from discuss the results with her nephrologist for further normal aging. In a patient with renal osteodystro- management. She is diagnosed with osteoporosis phy, there is the potential for low BMD to coexist based on her T-scores of Ϫ5.1 (AP spine), Ϫ4.1 (left with an enormous range of functional abnormali- femoral neck), and Ϫ5.4 (left total hip). Her last ties. These range from high turnover bone lesions in dialysis laboratory results show serum calcium is patients with uncontrolled hyperparathyroidism to 10.7 mg/dl, intact parathyroid hormone (PTH) is severely reduced bone remodeling activity in pa- 207 pg/ml, phosphorus is 5.7 mg/dl, and alkaline tients with adynamic bone disease. This is in con- phosphatase (ALP) is 122 IU/L. She receives pari- trast to the non-CKD patient with osteoporosis calcitol 5 mg intravenously on hemodialysis three where bone remodeling is not severely affected. times per week. Chronic kidney disease (CKD)-related bone dis- ease is known as renal or uremic osteodystrophy. It IMPACT ON QUALITY OF LIFE is associated with derangements in bone and min- eral metabolism that leads to abnormal regulation Patients with CKD-MBD and osteoporosis are as- of calcium, phosphorous, vitamin D, and PTH. It sociated with increased risk of fractures and are at a encompasses a spectrum of conditions that are clas- high risk of cardiovascular disease.2 The overall in- sified based on bone biopsy findings including os- cidence of hip fractures among dialysis patients is teitis fibrosa (high turnover disease), mixed uremic about four-fold higher than that expected for gen- osteodystrophy, osteomalacia (low turnover dis- eral population. The risk is increased in both men ease), and adynamic bone disease. KDIGO (kidney and women.3 Fractures may limit ambulation, lead- disease: improving global outcomes) has proposed ing to loss of independence and chronic pain, to define CKD-related bone and mineral metabolic thereby decreasing quality of life. Mortality risk in abnormalities in the context of a systemic disorder dialysis patients with hip fracture is twice that of called CKD–mineral and bone disorder (CKD- patients without hip fracture.4 Women who are 65 MBD).1 yr of age and older and have moderate renal dys- Osteoporosis is a condition characterized by low function (eGFR Ͻ 60 ml/min per 1.73 m2) are also bone mass leading to reduced bone strength and an at an increased risk of hip fractures.5 In addition to increased risk of fractures. Hip, spine, and wrist are the traditional risk factors, several risk factors for most commonly affected. The WHO definition of low BMD have been identified in the CKD popula- osteoporosis is based on bone mineral density tion such as renal osteodystrophy, ethnicity, trans- (BMD) measurements. The NIH consensus state- plant status, and duration of dialysis.6 ment refers to osteoporosis as a skeletal disorder characterized by compromised bone strength pre- disposing to increased risk of fracture. Correspondence: Harmeet Singh, Division of Nephrology, Brody School of Medicine, 2355 W. Arlington Boulevard, Greenville, NC Osteoporosis and renal osteodystrophy may co- 27834. E-mail: [email protected] exist in elderly patients with CKD, which makes the Copyright ᮊ 2009 by the American Society of Nephrology American Society of Nephrology Geriatric Nephrology Curriculum 1 EVALUATION diagnostic test for determining the type of bone disease asso- ciated with CKD is iliac crest bone biopsy with double tetracy- Assessment of bone strength in an elderly patient with CKD is cline labeling and bone histomorphometric analysis. Bone his- complex. The initial evaluation of CKD-related bone and min- tology shows information about turnover, mineralization, and eral disorders should include serum biomarkers and noninva- volume and may be helpful in guiding therapy. Bone biopsy is sive imaging. Bone histomorphometric analysis might be not performed routinely in clinical practice because it is inva- needed in some cases. Bone strength is represented by two sive, available in limited centers, and requires special expertise main features: bone density and bone quality. Bone density can and an experienced pathologist for interpretation. However, it be measured using several different radiologic techniques, but should be considered in patients with Stage 5 CKD who have bone quality is difficult to assess because it depends on archi- (1) fractures with minimal or no trauma (pathologic frac- tecture, turnover, and mineralization. Correlation of BMD tures); (2) intact plasma PTH levels between 100 and 500 with bone histology is poor. pg/ml (11.0 to 55.0 pmol/L; in CKD Stage 5) with coexisting conditions such as unexplained hypercalcemia, severe bone Serum Biomarkers pain, or unexplained increases in bone alkaline phosphatase Surrogate markers of bone metabolism such as serum intact activity; and (3) suspected aluminum bone disease, based on PTH, calcium (preferably ionized), phosphorus, alkaline clinical symptoms or history of aluminum exposure.2 Bone phosphatases, and bicarbonate levels should be obtained ini- biopsy should be strongly considered before starting bisphos- tially. High intact PTH levels may correlate with high turnover phonate therapy in patients with Stage 5 CKD. bone disease. The optimal target level for intact PTH in CKD is not known. TREATMENT Noninvasive Imaging Several imaging tools are available to assess bone health includ- Whether the standard agents used for osteoporosis in general ing DEXA scan, quantitative computed tomography (qCT), population can be applied to patients with CKD is unclear. The and heel ultrasound. The value of BMD in evaluation of CKD- management of osteoporosis includes addressing modifiable related bone disease is not well established. risk factors and using pharmacologic agents. DEXA scan is most commonly used to assess bone mass. It (1) Smoking cessation is strongly recommended. Excess al- can only detect overall density but not quality of the bone. cohol consumption should be avoided. According to WHO definition, a T-score of Ϫ2.5 is defined as (2) Exercise: Moderate weight-bearing physical activity has osteoporosis. The extension of this definition to groups other been associated with improvement in bone density and reduc- than postmenopausal Caucasian women is controversial. Be- tion in risk of hip fractures. However, in older women, the cause of vascular and extraskeletal calcifications in CKD, the benefit is modest. interpretation may be affected by artifacts. However, it is com- (3) Calcium and vitamin D requirements: Vitamin D defi- monly used because of low cost, accuracy, and wide availabil- ciency is common in older adults especially during winter. It ity. The distal radius may be the preferred site in CKD pa- may be related to reduced synthesis, inadequate intake, dietary tients.7 KDOQI recommends use of DEXA to measure BMD in restrictions, and inactive lifestyle in dialysis patients. 25(OH- patients with fractures and in those with known risk factors for )Vitamin D deficiency is associated with increased iPTH levels, osteoporosis. reduced BMD, and increased rate of hip fractures. The extra- renal effects of vitamin D are also receiving increasing atten- Quantitative CT tion. Low 25(OH)vitamin D levels may be associated with in- Information regarding use of qCT in assessing BMD in pa- creased risk of cardiovascular events in patients with peritoneal tients with CKD is limited. It has the advantage of distinguish- dialysis (PD)9 and higher risk of myocardial infarction in ing outer dense cortical bone from inner spongy trabecular men.10 The optimal serum 25(OH)vitamin D concentration bone. Hyperparathyroidism leads to sclerotic thickening of needed to maintain bone health has not been established. Cal- trabecular bone with increased BMD but stimulates resorption cium and vitamin D supplementation has been reported to in cortical bone with significant reductions in BMD. Thinning result in small improvement in hip bone density. It did not of the cortical bone results in increased risk of fractures. A significantly reduce hip fractures but increased the risk of kid- small study has reported association of radius cortical param- ney stones.11 In CKD Stages 3 and 4, KDOQI recommends eters with fractures in hemodialysis patients. qCT is more ex- maintaining 25(OH)vitamin D levels above 30 ng/ml by sup- pensive than DEXA and results in greater exposure to radia- plementation with ergocalciferol. In CKD Stages 3 to 5, total tion.8 elemental calcium intake including dietary and calcium based binders should not exceed 2000 mg/d. The National Osteopo- Bone Biopsy rosis Foundation recommends a daily calcium intake of 1200 It remains the gold standard for diagnosis of renal osteodys- mg and vitamin D intake of 800 to 1000 IU/d for adults 50 and trophy and assessment of bone architecture. The most accurate older. 2 Geriatric Nephrology Curriculum American Society of Nephrology (4) Role of bisphosphonates: Bisphosphonates are effective hypercalcemia and increased uric acid levels.16 Safety data in dial- in treating osteoporosis, but their use in CKD Stages 4 and 5 is ysis patients or severe renal insufficiency are not available. controversial. No data are available that proves that bisphos- The above case shows difficult real-life situations faced by phonates reduce risk of fractures in dialysis patients with os- clinicians where no guidelines are available to recommend de- teoporosis.
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