1. According to KDIGO guideline 2017, is performing bone biopsy mandatory before starting anti-osteoporotic medications in patients with CKD? No not mandatory especially if will not change management plan, but bone biopsy consider the gold for accurate and precise diagnosis of different type of renal osteodystrophy , According to KDIGO guideline 2017 bone biopsy could be doneonly if result of biopsy and knowing the type of ROD will affect the treatment decisions. But evidence is (not graded) 2. Explain why Bone biopsy could be of a higher value especially to nephrologists. As better diagnostic utility for different type of ROD, osteoporosis, mixed types of ROD and different bone staining to diagnosis aluminum intoxication and iron deposition bone biopsy preferred as the accurate diagnostic test for CKD MBD for nephrologist 3. What are the obstacles of performing iliac-crest bone biopsies at large scale? And how do you think we can overcome them? The main obstacles are because it is invasive procedure need special skills , and more frequent training to do such invasive Tanique , low number of experienced laboratories in interpretation of bone biopsy and so if encourage to do it frequently more physicians will be trained and more laboratory will be experienced in it.
According to KDIGO guideline 2017, is performing bone biopsy mandatory before starting anti-osteoporotic medications in patients with CKD
it is not recommended to do a bone biopsy before starting anti-osteoporotic medication as it would imply denying them treatment if bone biopsy not available
Explain why Bone biopsy could be of a higher value especially to nephrologists.
ROD in CKD patient gold diagnosis is by bone biopsy
ROD is complex bone derangement in uraemic millieu.
Differentiation between Osteoporosis and ROD involves bone turnover, mineralisation and volume and bone density scan does not give enough information.
What are the obstacles of performing iliac-crest bone biopsies at large scale? And how do you think we can overcome them?
Invasive procedure- use of smaller haematological needle might help
lack of expertise
lack of lab facilities
Renal Biopsy registry and increase number of doing biopsies..
According to KDIGO guideline 2017, is performing bone biopsy mandatory before starting anti-osteoporotic medications in patients with CKD?
although is still remained the gold standard to diagnose ROD, its recommended only the knowledge of the type of ROD will affect the treatment decisions. On practical ground a bone biopsy procedure can be considered if parathyroid hormone trends are conflicting. 2.Explain why Bone biopsy could be of a higher value especially to nephrologists.
While experts of osteoporosis physicians hardly ever question the diagnostic value of BMD, nephrologists admit the limited sensitivity and specificity of either BMD assessment or circulating biochemical markers in the diagnostic process of ROD. Therefore, while therapeutic choices might be straightforward for the former specialist, concerns could arise for the latter.
The rationale of the recommendation is that the bone biopsy is no longer indicated. If the bone biopsy is not available, antiresorptive therapies could be withheld for patients with a high risk of fracture. While this could be reasonable in very early CKD G1–2 stages, in more advanced phases and without a balanced evaluation by an expert nephrologist, a risk exists when prescribing these drugs, even in patients with osteomalacia or any other type of ROD. For these conditions, they are not still validated. Indeed, the relationship between osteoporosis and ROD is intriguing and still unsettled. If we accept any stage of CKD is associated with an increased fracture rate, ROD could be a type of osteoporosis. 3.What are the obstacles of performing iliac-crest bone biopsies at large scale? And how do you think we can overcome them?
there is lack of experience with the procedure of sampling and few labs have specific ex-
pertise that guarantees proper evaluation. Indeed, there are
practical hurdles to obtaining a bone biopsy. Besides qualitative
histologic examination, also quantitative histomorphometric
measurement is recommended, which requires an intact bone
sample, with adequate amounts of cortical and cancellous bone,
unaffected by artefacts For this reason, dedicated instruments and
sufficiently skilled and experienced operators are necessary. As
for the site of sampling, given its accessibility and safety, the il-
iac crest is invariably preferred, with either a vertical or hori-
zontal approach
Thank you for your comments. Please find this suggested answer:
Bone biopsy in chronic kidney disease: still neglected and in need of revitalization
1. According to KDIGO guideline 2017, is performing bone biopsy mandatory before starting anti-osteoporotic medication in patients with CKD?
Despite still being considered the gold standard test to diagnose ROD, it is recommended only when ‘knowledge of the type of ROD will impact treatment decisions’ (level of evidence: ‘not graded’) Thus, on practical grounds, a bone biopsy procedure can be considered if parathyroid hormone trends are inconsistent, fractures or hypercalcemia are unexplained, and/or the response to therapy is unclear or associated with progressive BMD decrease. Importantly, in these guidelines, bone biopsy is no longer recommended in CKD patients with BMD values and/or clinical data indicating osteoporosis, before initiating antiresorptive therapies (like bisphosphonates or denosumab). The rationale for this recommendation is that, ‘if bone biopsy is not available’, antiresorptive therapies could be withheld to patients with high risk of fracture.
2. Explain why Bone biopsy could be of a higher value especially to nephrologists.
While expert physicians of osteoporosis hardly ever question the diagnostic value of BMD, nephrologists recognize the limited sensitivity and specificity of either BMD assessment or of circulating biochemical markers in the diagnostic process of ROD.
In advanced phases of CKD, a risk exists when prescribing anti-resorptive drugs even in patients with osteomalacia or any other type of ROD, for which conditions they are not still validated. Recent years have witnessed a total revolution in the appreciation of the biologic role played by bone in our body. Nowadays bone is regarded as a sophisticated endocrine organ (probably the largest in our body), synthesizing a number of possibly still unrecognized hormones, with multiple and underappreciated systemic clinical implications. Accordingly, ROD should be viewed as a complex endocrine disorder that warrants more precise appreciation.
The early phases of CKD with the associated adaptive or maladaptive responses of kidneys, parathyroids and bone, and characterized by the disarray of the Fibroblast Growth Factor 23 (FGF23)/Klotho/vitamin D axis.
Bone histology is the gold standard for diagnosis of ROD.
3. What are the obstacles of performing iliac-crest bone biopsies at large scale? And how do you think we can overcome them? Invasive procedure: Invasiveness is the main reason why bone biopsies are rarely performed in renal patients, despite the clinical relevance now acknowledged for bone dysfunction in CKD and the very low rate of complications. >> small haematologic needles, which are definitely less invasive and painful for the patient and certainly more practical for the physician, can be used (small haematologic needles, which are definitely less invasive and painful for the patient and certainly more practical for the physician). Lack of experience with the procedure of sampling and few labs have specific expertise that guarantees proper evaluation. Practical hurdles: Besides qualitative histologic examination, also quantitative histomorphometric measurement is recommended, which requires an intact bone sample, with adequate amounts of cortical and cancellous bone, unaffected by artefacts (e.g. breakage, fractures, compressions, cellular damage). For this reason, dedicated instruments and sufficiently skilled and experienced operators are necessary. >> Increase the referral for bone biopsies: the fewer bone biopsies are performed, the lower will be the number of skilled operators and of experienced laboratories available. >> Create a registry of bone biopsies, which, by encouraging the diffusion of the procedure and by collecting large databases, is expected to allow more sophisticated association analyses and more precise evaluation of the effects of available therapies.
According to KDIGO guideline 2017, is performing bone biopsy mandatory before starting anti-osteoporotic medications in patients with CKD?
No
It is recommended only when ‘knowledge of the type of ROD will impact treatment decisions’ .
If parathyroid hormone trends are inconsistent .
fractures or hypercalcaemia are unexplained.
And/or the response to therapy is unclear or associated with progressive BMD decrease.
Explain why Bone biopsy could be of a higher value especially to nephrologists.
while expert physicians of osteoporosis hardly ever question the diagnostic value of BMD, nephrologists recognize the limited sensitivity and specificity of either BMD assessment or of circulating biochemical markers in the diagnostic process of ROD. Therefore, while therapeutic choices might be straightforward for the former specialist, concerns could arise for the latter.
The rationale of the recommendation that the bone biopsy is no longer indicated, is that, ‘if bone biopsy is not available’, antiresorptive therapies could be withheld to patients with high risk of fracture. While this could be reasonable in very early CKD G1–2 stages, in more advanced phases and without a bal- anced evaluation by an expert nephrologist, a risk exists when prescribing these drugs even in patients with osteomalacia or any other type of ROD, for which conditions they are not still validated. Indeed, the relationship between osteoporosis and ROD is intriguing and still unsettled. If we recognize that any stage of CKD associates with an increased fracture rate, ROD could be a type of osteoporosis .
What are the obstacles of performing iliac-crest bone biopsies at large scale? And how do you think we can overcome them?
it is an invasive procedure, there is lack of experience with the procedure of sampling and few labs have specific expertise that guarantees proper evaluation. Indeed, there are practical hurdles to obtaining a bone biopsy. Besides qualitative histologic examination, also quantitative histomorphometric measurement is recommended, which requires an intact bone sample, with adequate amounts of cortical and cancellous bone, unaffected by artefacts (e.g. breakage, fractures, compressions, cellular damage).
For this reason, dedicated instruments and sufficiently skilled and experienced operators are necessary.
As for the site of sampling, given its accessibility and safety, the iliac crest is invariably preferred, with either a vertical or horizontal approach.
the bone sample diameter is crucial, since the quality of 3 mm diameter samples is significantly lower than those of 5 mm .In general, there is agreement that trephines with an internal diameter of 6–8 mm guarantee better results, and that artefacts increase below 4mm.
A recent paper published by Novel-Catin et al.this article suggests that bone biopsy samples of sufficient quality can be obtained with small haematologic needles, which are definitely less inva- sive and painful for the patient and certainly more practical for the physician. Also, since the number of fields available was higher with the vertical approach, this type of procedure should be favoured.
According to KDIGO guideline 2017, is performing bone biopsy mandatory before starting anti-osteoporotic medications in patients with CKD?
In these guidelines, bone biopsy is no longer recommended in CKD patients with BMD values and/or clinical data indicating osteoporosis, before initiating antiresorptive therapies (like bisphosphonates or denosumab). The rationale for this recommendation is that, ‘if bone biopsy is not available’, antiresorptive therapies could be withheld to patients with high risk of fracture. While this could be reasonable in very early CKD G1–2 stages, in more advanced phases and without a balanced evaluation by an expert nephrologist, a risk exists when prescribing these drugs even in patients with osteomalacia or any other type of ROD, for which conditions they are not still validated.
2- Explain why Bone biopsy could be of a higher value especially to nephrologists.
However, while expert physicians of osteoporosis hardly ever question the diagnostic value of BMD, nephrologists recognize the limited sensitivity and specificity of either BMD assessment or of circulating biochemical markers in the diagnostic process of ROD. Therefore, while therapeutic choices might be straightforward for the former specialist, concerns could arise for the latter.
3-What are the obstacles of performing iliac-crest bone biopsies at large scale?
an invasive procedure,
there is lack of experience with the procedure of sampling and
few labs have specific ex- pertise that guarantees proper evaluation.
Indeed, there are practical hurdles to obtaining a bone biopsy. Besides qualitative histologic examination, also quantitative histomorphometric measurement is recommended, which requires an intact bone sample, with adequate amounts of cortical and cancellous bone, unaffected by artefacts (e.g. breakage, fractures, compressions, cellular damage). And how do you think we can overcome them?
bone biopsy samples of sufficient quality can be obtained with small haematologic needles, which are definitely less invasive and painful for the patient and certainly more practical for the physician.
An excellent initiative, led by Pieter Evenepoel, as part of the ERA-EDTA CKD-MBD Working Group activities, is to create a European registry of bone biopsies , which, by encouraging the diffusion of the procedure and by collecting large databases, is expected to allow more sophisticated associa- tion analyses and more precise evaluation of the effects of available therapies.
According to KDIGO guideline 2017, is performing bone biopsy mandatory before starting anti-osteoporotic medications in patients with CKD? Not, except as recommended in:
Know type of ROD
Unexplained fracture or hyper Ca
no response with progressive BMD.
Abornamal PTH trend
Explain why Bone biopsy could be of a higher value, especially to nephrologists.
plan of management if there is an unclear diagnosis.
understand the cause leading to ROD, therapeutic response.
What are the obstacles to performing iliac-crest bone biopsies at a large scale? And how do you think we can overcome them?
1. According to the 2017 KDIGO guideline, is performing a bone biopsy mandatory before starting anti-osteoporotic medications in patients with CKD?
No, labs and clinical picture and Dexa are usually enough to initiate treatment with antiresorptive therapy especially in early stage CKD.
2.Explain why a bone biopsy could be of higher value, especially to nephrologists.
Bone biopsy is the gold standard to differentiate between different types of ROD.
The specificity and sensitivity of serum markers with x rays and dexa are in some cases not higher enough.
3.What are the obstacles to performing iliac crest bone biopsies on a large scale? And how do you think we can overcome them?
Obstacles are lack of experience between nephrologists and pathologists, patient acceptances and we should use relative big needle size (over 5 mm in diameter).
This can be Overcome by training and doing more biopsies because it will be like a viscous cycle if we didn’t do any biopsies at all. We can use a vertical approach with small needle 4mm or hematological needle. When using haematologic needles 3-4mm internal diameter, a vertical approach seems better, since a greater number of fields is predictably obtained. and lastly patient Education
1. According to the 2017 KDIGO guideline, is performing a bone biopsy mandatory before starting anti-osteoporotic medications in patients with CKD? No, a bone biopsy is not mandatory for starting anti-osteoporotic treatment. Lab parameters consistent with osteoporosis are enough to start these medications.
2. Explain why a bone biopsy could be of higher value, especially to nephrologists. It is often difficult to ascertain which side of ROD a patient has (ABD vs. SHPT vs. osteoporosis alone), and since treatment is different for each, a bone biopsy becomes the tool for diagnosis and management.
3. What are the obstacles to performing iliac crest bone biopsies on a large scale? And how do you think we can overcome them? Obstacles: A bone biopsy is a painful, invasive procedure. There is a lack of expertise in doing the biopsy, in addition to lacking expertise to read it. Overcome suggestions: *Train more staff (Nephrologist and Pathologists) * An awareness campaign for concerned physicians *An awareness campaign for patients *Set up a CKD-MBD-specific clinic to handle this issue. *Work on methods to properly read smaller biopsies
According to KDIGO guideline 2017, is performing bone biopsy mandatory before starting anti-osteoporotic medications in patients with CKD? In these guidelines,bone biopsy is not recommended before initiating antiresorptive
therapies (like bisphosphonates or denosumab).The explanation for this guideline is that ‘if a bone biopsy is not available,’ antiresorptive medicines may be avoided from individuals with high risk of fracture .
Explain why Bone biopsy could be of a higher value especially to nephrologists.
In the diagnostic procedure of ROD, nephrologists realize the poor sensitivity and specificity of either BMD measurement or circulating biochemical markers.. As a result, while the first specialist’s therapy options may be clear, questions may develop for the second one.
What are the obstacles of performing iliac-crest bone biopsies at large scale? And how do you think we can overcome them?
The iliac crest is always preferable, whether approached vertically or horizontally.Patient-not accepted procedure because it is invasive, extremely painful, and limited physician or histopathologist training in bone biopsy.
there is a lack of experience, and few laboratories have the specialized skills required to ensure correct evaluation.Practical barriers to obtaining a bone biopsy.
In addition to qualitative histologic assessment, quantitative histomorphometric measurement is advised, which needs an intact bone sample with enough amounts of cortical and cancellous bone that is free of artifacts (e.g., breaking, fractures, compressions, cellular damage). As a result, specialized instruments and operators with sufficient knowledge and expertise are required. we can overcome them by Continued education to improve skills through different workshops and conferences.Recognizing the importance of bone biopsy in the diagnosis of CKD-MBD. Histopathologists need additional training and safer approaches from doctors .
**According to KDIGO guideline 2017, is performing bone biopsy mandatory before starting anti-osteoporotic medications in patients with CKD?
The rate of fracture increase among ckd stage 3a-5 than general population this requires improvement of better diagnosis of ROD.
So bone biopsy recommended when there is doubt about the decision of treatment, so it is recommended when PTH level is inconsistent, fracture or hypercalcimia unexplained, response to the treatment is unclear or when BMD decrease. It is no more recommended when BMD level or the clinical data consistent with osteoporosis before initiating antiresorptive drug, as risk exist when prescribing the antiresorptive drug in patients with osteomalacia and other types of ROD
**Explain why Bone biopsy could be of a higher value especially to nephrologists.
Because of the limited sensitivity and specificity of either BMD assessment of circulating biochemical markers in the diagnoses of ROD , and the need of bone biopsy important for determining the decision of treatment
**What are the obstacles of performing iliac-crest bone biopsies at large scale? And how do you think we can overcome them?
It is invasive procedure, lack of experience with sampling, little laboratory have specific expertise that guarantees the examination of the sample quantitative histomorphmetric measures that need intact sample with adequate amount of cortical and cancellous bone and unaffected by artifacts like cellular damage, fracture, breakage and compression
So that suitable instruments and sufficient experienced an skilled operate are needed, iliac crest preferred with vertical or horizontal approach and taking triphine sample with internal diameter 6-8mm provides a better results because artifact increase with diameter below 4mm
The Kidigo 2017 guideline states that bone biopsy is not mandatory. In a discussion after the guideline’s release, the authors stated that the main reason is the lack of availability and experience. In the same guideline and opposite to the previous suggestion and because of emerging research, the role of BMD value is recommended.
The lack of experience of performers as well as pathologists’ experience, is the main reason behind the hesitancy to perform biopsies.
The main obstacle against widening the biopsy of the bone is the lack of experience both for performing as well as evaluation and integration with management plans. The increase in experience and multidsispnary clinics may be a good solution. Courses, as we are taking plus workshops, seems to have a role but with the lack of pathology support and experience the problem will not be solved in its own
According to KDIGO guideline 2017, is performing bone biopsy mandatory before starting anti-osteoporotic medications in patients with CKD?
No, it is not mandatory but by performing bone biopsy you will decied proberly about what type of ROD is patient has .
as not all patient with fragility fractuer will havwe the same bone pathology ,foir that to implement the bone biopsy among nephrologist to define the exat type of ROD and treat accordingly .
Explain why Bone biopsy could be of a higher value especially to nephrologists.
As we all know that CKD-MBD is very complex medical problems and not very clear for a lot of physition ,and it is not like any aother patiennt who has no ckd ,as in normal osteoporosis patient it is seay to interpret his DEXA scan and read his BTS and treat him directly ,but in CKD patient a lot of obstecls and a lot of data need to be interbret before take the decision of treatment ,for that bone biopsy will help the nephrologist to take the decision more clearly .
What are the obstacles of performing iliac-crest bone biopsies at large scale? And how do you think we can overcome them?
first of all it is painfull and invasive proceduer ,need trained hand
even at the level of pathologist need some expert hane to process the speciment and read the silde.
We need to give more attanetion as nephrologist for CKD-MBD ,with special clinic and performing bone biopsy will understand all range of ROD in better ways and will build our experience to deal with patients and treat them .
By doing this ,will increase the awarness among nephrologist about the imporatance of CKD-MBD and its impact on patient and health serv ices
1. According to KDIGO guideline 2017, is performing bone biopsy mandatory before starting anti-osteoporotic medications in patients with CKD?
No, KDIGO guideline 2017 does not recommend performing bone biopsy before starting anti-osteoporotic medications in patients with CKD. The rationale for this recommendation is that, if a bone biopsy is not available, antiresorptive therapies could be withheld for patients with a high risk of fracture.
2. Explain why Bone biopsy could be of a higher value especially to nephrologists.
Bone biopsy is the gold standard diagnostic test for Renal Osteodystrophy (ROD). it can provide detailed information on the structure and composition of the bone and can help diagnose ROD. The results of a bone biopsy can help nephrologists assess the risk of fractures and hypercalcemia and can help them make informed decisions about antiresorptive therapies such as bisphosphonates or denosumab.
3. What are the obstacles of performing iliac-crest bone biopsies at large scale? And how do you think we can overcome them?
The main obstacle is the invasiveness of the procedure and the lack of experience with the procedure of sampling.
To overcome these obstacles, the European Renal Osteodystrophy Initiative (ERA-EDTA CKD-MBD Working Group) has put forth an excellent initiative to create a European registry of bone biopsies.
The use of a haematologic small needle to perform the biopsies could make the procedure less invasive and more accessible for both patients and operators.
Increasing the number of skilled operators and experienced laboratories, as well as improving the knowledge and understanding of the pathomechanisms leading to ROD.
All these steps could help to revitalize the use of bone biopsies in CKD.
1-According to KDIGO guideline 2017, is performing bone biopsy mandatory before starting anti-osteoporotic medications in patients with CKD?
No the bone biopsy is not mandatory before beginning antiosteoprotic treatments in CKD patients with BMD levels with clinical evidence suggesting osteoporosis.
2-Explain why Bone biopsy could be of a higher value especially to nephrologists.
Bone biopsy is considered the gold-standard method for diagnosis of ckd mbd and Assesses separately cortical and trabecular bone Information on bone mineralization and turnover.
Clarify causes of persistent bone pain.
explain possiblity of Fragility fracture
3-What are the obstacles of performing
iliac-crest bone biopsies at large scale?
Non easily accepted manuver from patient, invasive ,so painful,not widely training physician or histopathologist oriented about the bone biopsy
And how do you think we can overcome them?
continued education to increase the skills via multiple workshops and conference.
Explanation for patients how get the benefits from doing it and value of bone biopsy in diagnosis CKD-MBD and different types
According to KDIGO guideline 2017, is performing bone biopsy mandatory before starting anti-osteoporotic medications in patients with CKD?
No
The KDIGO guidelines acknowledge the increased fracture risk associated with chronic kidney disease as compared to the general population, and takes cognizance of the fact that bone biopsy still remains the gold standard in diagnosing renal osteodystrophy
Antiresoprtive therapies are effective in treating patients with CKD who has low bone mass, and the initiation of these therapies cannot be withheld because of the abscence of a bone biopsy.
We would then do more harm, thgen any good!
Explain why Bone biopsy could be of a higher value especially to nephrologists.
For physicians treating patients with osteoporosis, the assessment of bone mass density is much easier to interpret as compared to patients with chronic kidney disease metabolic bone disease
The use bone mass density and circulating biomarkers are much more difficult to interpret in patients with chronic kidney disease, and this should warrant that more renal biopsy should be performed
Clinical indications for bone biopsy in patients with CKD stages 3-5, based on guidelines from KDIGO are as follows:
Unexplained fractures
Unexplained hypercalcemia
Unexplained hypophosphatemia
Persistent bone pain
Suspected aluminum toxicity based upon clinical symptoms or history of aluminum exposure
Inconsistency among biochemical parameters, thereby preventing definitive interpretation
Prior to parathyroidectomy if a history of aluminum exposure exists
In patients with stage 5 CKD, who has an intact PTH levels between 100-500pg/mL in association with unexplained hypercalcemia, severe bone pain, or unexplained increase in bone alkaline phosphatase activity
What are the obstacles of performing iliac-crest bone biopsies at large scale? And how do you think we can overcome them?
In South Africa we rarely do any bone biopsies in patients with CKD, unless if there is a hematological indication. The procedure is very invasive and can be very painful. We also lavk expertise to interpret the histological findings in these patients
I suggest that in South Africa, we need to:
Make the patients and fellow medical practitioners aware of the impact CKD-MBD has on this population’s outcome
Train technicians, histopathologist and nephrologist – in order to have these biopsies performed properly, in order to get accurate reports upon which the nepherologist can act
According to KDIGO guideline 2017, is performing bone biopsy mandatory before starting anti-osteoporotic medications in patients with CKD?
No, bone biopsy is not mandatory before starting anti-osteoprotic medications, as
1-There is growing evidence that anti-osteoporosis medications are effective in CKD with low BMD and a high risk of fracture with antiresorptive therapy
2- no strong evidence that these medications will induce adynamic bone disease in CKD patients Explain why Bone biopsy could be of a higher value especially to nephrologists.
Bone biopsy is the gold standard to differentiate between types of adynamic bone diseases., as it can assess T,V,M and allow assessment of microarchitecture What are the obstacles of performing iliac-crest bone biopsies at large scale? 1- Ivasiveness
2-Needs skilled and experienced operator And how do you think we can overcome them?
Use of Haematologic needles, vertical approach and establishment of bone biopsy clinics
1.According to KDIGO guideline 2017, is performing bone biopsy mandatory before starting anti-osteoporotic medications in patients with CKD?
No, a bone biopsy is not mandatory before beginning antiresorptive treatments in CKD patients with BMD levels and/or clinical evidence suggesting osteoporosis.
2- Explain why Bone biopsy could be of a higher value especially to nephrologists.
Bone biopsy is considered the gold-standard method for histological classification of ROD.
High specificity and sensibility to diagnose bone diseases, including ROD Assesses separately cortical and trabecular bone Information on bone mineralization and turnover.
explain persistent bone pain. explain Fragility fracture.
3- What are the obstacles of performing iliac-crest bone biopsies at large scale? And how do you think we can overcome them?
Invasive
painful
Does not evaluate bone density
No data on fracture risk prediction
Lack of skills.
How to overcome them?
continues education to increase the skills.
Recognizing value of bone biopsy in diagnosis CKD-MBD
According to KDIGO guideline 2017, is performing bone biopsy mandatory before starting anti-osteoporotic medications in patients with CKD?
It is not always recommended although it is the gold standard in diagnosing MBD, however, recommended in;
a) To acknowledge the type of ROD that will impact the treatment decisions (not graded). b) PTH trends are inconsistent. c) Unexplained fracture. d) Unexplained hypercalcemia. e) Response to treatment is unclear, or associated with progressive BMD.
Differentiation between bone disordered based on biopsy for either types of CKD-BMD is still unsettled, so treatment should be started based on metabolic and clinical assessment.
Explain why Bone biopsy could be of a higher value, especially to nephrologists.
It will help to understand the pathomechanism leading to ROD, and the knowledge of the metabolic bone derangement associated with CKD and the therapeutic response.
It can use as a directive plan of management if there is an unclear diagnosis.
What are the obstacles to performing iliac-crest bone biopsies at a large scale? And how do you think we can overcome them?
Invasive procedure
Lack of experience with sampling.
Few labs have the expertise for proper evaluation.
So, CKD-MBD as per KDIGO guidelines can be diagnosed based on metabolic bone profile, with laboratory results +/- bone biopsy if strongly indicated in a narrow window, evaluation of the treatment, and clinical responses
1.According to KDIGO guideline 2017, is performing bone biopsy mandatory before starting anti-osteoporotic medications in patients with CKD?
No, once you have CKD-MBD laboratory parameters and clinic picture compatible with the diagnosis of osteoporosis you can actually proceed to treatment with anti-resorptive therapy particularly in early CKD stages G1-G2.
In advanced CKD one must be careful in making this decision as treatment is not validated in this set up. Therefore, a balanced approach by a senior nephrologist may a make a difference.
2.Explain why Bone biopsy could be of a higher value especially to nephrologists.
The current tests (DEXA scan, biomarkers of bone turn over)for evaluation of CKD-MBD may not be enough in terms of sensitivity and specificity.Hence adding a bone biopsy to these plate form may influence the therapeutic approach for ROD from nephrology point of view.
3.What are the obstacles of performing iliac-crest bone biopsies at large scale? And how do you think we can overcome them?
A. Obstacles
Lack of skilled operators
Lack of experienced laboratories
Invasive nature of the procedure
B. How to overcome them?
Improve understanding of CKD-MBD and it is relation to morbidity and mortality
Recognizing the emerging value of bone biopsy in diagnosis CKD-MBD
Investment in hands on training of nephrologists /pathologists in this area
Increase awareness about bone biopsy world-wide
The use of small hematology needle may reduce the invasivness of the procedure and it is more practicle to the nephrologist
Opening a separate clinic under the name BONE-CKD clinic; through which patient education, proper diagnosis including the utilization of bone biopsy, and management of CKD-MBD can be employed
1.According to KDIGO guideline 2017, is performing bone biopsy mandatory before starting anti-osteoporotic medications in patients with CKD? No , not mandatory bone biopsy is no longer recommended in CKD patients with BMD values and/or clinical data indicating osteoporosis, before initiating antiresorptive therapies (like bisphosphonates or denosumab). 2.Explain why Bone biopsy could be of a higher value especially to nephrologists. while expert physicians of osteoporosis hardly ever question the diagnostic value of BMD, nephrologists recognize the limited sensitivity and specificity of
either BMD assessment or of circulating biochemical markers in the diagnostic process of ROD. Therefore, while therapeutic choices might be straightforward for the former specialist, concerns could arise for the latter. 3.What are the obstacles of performing iliac-crest bone biopsies at large scale? And how do you think we can overcome them?
Hypothetically, most nephrologists would agree to perform routine bone biopsies in all CKD patients, were it not for the fact that it is an invasive procedure, there is lack of experience with the procedure of sampling and few labs have specific expertise
that guarantees proper evaluation. Indeed, there are practical hurdles to obtaining a bone biopsy. Besides qualitative histologic examination, also quantitative histomorphometric measurement is recommended, which requires an intact bone
sample, with adequate amounts of cortical and cancellous bone, unaffected by artefacts (e.g. breakage, fractures, compressions, cellular damage).
We can overcome if we used vertical approach with 4mm diameter needles.
According to KDIGO guideline 2017, is performing bone biopsy mandatory before starting anti-osteoporotic medications in patients with CKD?
No, thenew recommendations state that before beginning antiresorptive treatments in CKD patients with BMD levels and/or clinical evidence suggesting osteoporosis, a bone biopsy is no longer advised.
This advice is justified by the possibility of withholding antiresorptive treatments from individuals at high risk of fracture “if the bone biopsy is not accessible.”
Explain why a bone biopsy could be of higher value, especially to nephrologists.
Nephrologists are aware of the poor sensitivity and specificity of both BMD measurement and circulating biochemical markers in the diagnosis of ROD, despite the fact that professional osteoporosis doctors almost never dispute the diagnostic significance of BMD. So, even though the first doctor might have clear treatment options, the second specialist might have doubts.
What are the obstacles to performing iliac-crest bone biopsies at a large scale? And how do you think we can overcome them?
As sampling is a new process, there is a dearth of experience with it, and few laboratories have the specialized knowledge to ensure accurate evaluation. In fact, there are practical obstacles to getting a bone biopsy. In addition to qualitative histologic analysis, quantitative histomorphometric assessment is advised. This method needs an undamaged bone sample that has sufficient quantities of cortical and cancellous bone and is free of artifacts (such as breaking, fractures, compressions, or cellular damage). Because of this, specialized equipment as well as operators with the proper training and expertise are required.
To overcome this, we need safe techniques and more training for histopathologists.
searching for less intrusive and more user-friendly. Hematologic needles may work.
1. According to KDIGO guideline 2017, is performing bone biopsy mandatory before starting anti-osteoporotic medications in patients with CKD?
No not mandatory especially if will not change management plan, but bone biopsy consider the gold for accurate and precise diagnosis of different type of renal osteodystrophy ,
According to KDIGO guideline 2017 bone biopsy could be done only if result of biopsy and knowing the type of ROD will affect the treatment decisions. But evidence is (not graded)
2. Explain why Bone biopsy could be of a higher value especially to nephrologists.
As better diagnostic utility for different type of ROD, osteoporosis, mixed types of ROD and different bone staining to diagnosis aluminum intoxication and iron deposition bone biopsy preferred as the accurate diagnostic test for CKD MBD for nephrologist
3. What are the obstacles of performing iliac-crest bone biopsies at large scale? And how do you think we can overcome them?
The main obstacles are because it is invasive procedure need special skills , and more frequent training to do such invasive Tanique , low number of experienced laboratories in interpretation of bone biopsy and so if encourage to do it frequently more physicians will be trained and more laboratory will be experienced in it.
According to KDIGO guideline 2017, is performing bone biopsy mandatory before starting anti-osteoporotic medications in patients with CKD
it is not recommended to do a bone biopsy before starting anti-osteoporotic medication as it would imply denying them treatment if bone biopsy not available
Explain why Bone biopsy could be of a higher value especially to nephrologists.
ROD in CKD patient gold diagnosis is by bone biopsy
ROD is complex bone derangement in uraemic millieu.
Differentiation between Osteoporosis and ROD involves bone turnover, mineralisation and volume and bone density scan does not give enough information.
What are the obstacles of performing iliac-crest bone biopsies at large scale? And how do you think we can overcome them?
Invasive procedure- use of smaller haematological needle might help
lack of expertise
lack of lab facilities
Renal Biopsy registry and increase number of doing biopsies..
although is still remained the gold standard to diagnose ROD, its recommended only the knowledge of the type of ROD will affect the treatment decisions. On practical ground a bone biopsy procedure can be considered if parathyroid hormone trends are conflicting.
2.Explain why Bone biopsy could be of a higher value especially to nephrologists.
While experts of osteoporosis physicians hardly ever question the diagnostic value of BMD, nephrologists admit the limited sensitivity and specificity of either BMD assessment or circulating biochemical markers in the diagnostic process of ROD. Therefore, while therapeutic choices might be straightforward for the former specialist, concerns could arise for the latter.
The rationale of the recommendation is that the bone biopsy is no longer indicated. If the bone biopsy is not available, antiresorptive therapies could be withheld for patients with a high risk of fracture. While this could be reasonable in very early CKD G1–2 stages, in more advanced phases and without a balanced evaluation by an expert nephrologist, a risk exists when prescribing these drugs, even in patients with osteomalacia or any other type of ROD. For these conditions, they are not still validated. Indeed, the relationship between osteoporosis and ROD is intriguing and still unsettled. If we accept any stage of CKD is associated with an increased fracture rate, ROD could be a type of osteoporosis.
3.What are the obstacles of performing iliac-crest bone biopsies at large scale? And how do you think we can overcome them?
there is lack of experience with the procedure of sampling and few labs have specific ex-
pertise that guarantees proper evaluation. Indeed, there are
practical hurdles to obtaining a bone biopsy. Besides qualitative
histologic examination, also quantitative histomorphometric
measurement is recommended, which requires an intact bone
sample, with adequate amounts of cortical and cancellous bone,
unaffected by artefacts For this reason, dedicated instruments and
sufficiently skilled and experienced operators are necessary. As
for the site of sampling, given its accessibility and safety, the il-
iac crest is invariably preferred, with either a vertical or hori-
zontal approach
Thank you for your comments. Please find this suggested answer:
Bone biopsy in chronic kidney disease: still neglected and in need of revitalization
1. According to KDIGO guideline 2017, is performing bone biopsy mandatory before starting anti-osteoporotic medication in patients with CKD?
Despite still being considered the gold standard test to diagnose ROD, it is recommended only when ‘knowledge of the type of ROD will impact treatment decisions’ (level of evidence: ‘not graded’) Thus, on practical grounds, a bone biopsy procedure can be considered if parathyroid hormone trends are inconsistent, fractures or hypercalcemia are unexplained, and/or the response to therapy is unclear or associated with progressive BMD decrease.
Importantly, in these guidelines, bone biopsy is no longer recommended in CKD patients with BMD values and/or clinical data indicating osteoporosis, before initiating antiresorptive therapies (like bisphosphonates or denosumab). The rationale for this recommendation is that, ‘if bone biopsy is not available’, antiresorptive therapies could be withheld to patients with high
risk of fracture.
2. Explain why Bone biopsy could be of a higher value especially to nephrologists.
While expert physicians of osteoporosis hardly ever question the diagnostic value of BMD,
nephrologists recognize the limited sensitivity and specificity of either BMD assessment or of circulating biochemical markers in the diagnostic process of ROD.
In advanced phases of CKD, a risk exists when prescribing anti-resorptive drugs even in patients with osteomalacia or any other type of ROD, for which conditions they are not still validated.
Recent years have witnessed a total revolution in the appreciation of the biologic role played by
bone in our body. Nowadays bone is regarded as a sophisticated endocrine organ (probably the largest in our body), synthesizing a number of possibly still unrecognized hormones, with
multiple and underappreciated systemic clinical implications. Accordingly, ROD should be viewed as a complex endocrine disorder that warrants more precise appreciation.
The early phases of CKD with the associated adaptive or maladaptive responses of kidneys, parathyroids and bone, and characterized by the disarray of the Fibroblast Growth Factor 23 (FGF23)/Klotho/vitamin D axis.
Bone histology is the gold standard for diagnosis of ROD.
3. What are the obstacles of performing iliac-crest bone biopsies at large scale? And how do you think we can overcome them?
Invasive procedure: Invasiveness is the main reason why bone biopsies are rarely performed in renal patients, despite the clinical relevance now acknowledged for bone dysfunction in CKD and the very low rate of complications.
>> small haematologic needles, which are definitely less invasive and painful for the patient and certainly more practical for the physician, can be used (small haematologic needles, which are definitely less invasive and painful for the patient and certainly more practical for the physician).
Lack of experience with the procedure of sampling and few labs have specific expertise that guarantees proper evaluation.
Practical hurdles: Besides qualitative histologic examination, also quantitative histomorphometric measurement is recommended, which requires an intact bone sample, with adequate amounts of cortical and cancellous bone, unaffected by artefacts (e.g. breakage, fractures, compressions, cellular damage). For this reason, dedicated instruments and sufficiently skilled and experienced operators are necessary.
>> Increase the referral for bone biopsies: the fewer bone biopsies are performed, the lower will be the number of skilled operators and of experienced laboratories available.
>> Create a registry of bone biopsies, which, by encouraging the diffusion of the procedure and by collecting large databases, is expected to allow more sophisticated association analyses and more precise evaluation of the effects of available therapies.
According to KDIGO guideline 2017, is performing bone biopsy mandatory before starting anti-osteoporotic medications in patients with CKD?
No
It is recommended only when ‘knowledge of the type of ROD will impact treatment decisions’ .
If parathyroid hormone trends are inconsistent .
fractures or hypercalcaemia are unexplained.
And/or the response to therapy is unclear or associated with progressive BMD decrease.
Explain why Bone biopsy could be of a higher value especially to nephrologists.
while expert physicians of osteoporosis hardly ever question the diagnostic value of BMD, nephrologists recognize the limited sensitivity and specificity of either BMD assessment or of circulating biochemical markers in the diagnostic process of ROD. Therefore, while therapeutic choices might be straightforward for the former specialist, concerns could arise for the latter.
The rationale of the recommendation that the bone biopsy is no longer indicated, is that, ‘if bone biopsy is not available’, antiresorptive therapies could be withheld to patients with high risk of fracture. While this could be reasonable in very early CKD G1–2 stages, in more advanced phases and without a bal- anced evaluation by an expert nephrologist, a risk exists when prescribing these drugs even in patients with osteomalacia or any other type of ROD, for which conditions they are not still validated. Indeed, the relationship between osteoporosis and ROD is intriguing and still unsettled. If we recognize that any stage of CKD associates with an increased fracture rate, ROD could be a type of osteoporosis .
What are the obstacles of performing iliac-crest bone biopsies at large scale? And how do you think we can overcome them?
it is an invasive procedure, there is lack of experience with the procedure of sampling and few labs have specific expertise that guarantees proper evaluation. Indeed, there are practical hurdles to obtaining a bone biopsy. Besides qualitative histologic examination, also quantitative histomorphometric measurement is recommended, which requires an intact bone sample, with adequate amounts of cortical and cancellous bone, unaffected by artefacts (e.g. breakage, fractures, compressions, cellular damage).
For this reason, dedicated instruments and sufficiently skilled and experienced operators are necessary.
As for the site of sampling, given its accessibility and safety, the iliac crest is invariably preferred, with either a vertical or horizontal approach.
the bone sample diameter is crucial, since the quality of 3 mm diameter samples is significantly lower than those of 5 mm .In general, there is agreement that trephines with an internal diameter of 6–8 mm guarantee better results, and that artefacts increase below 4mm.
A recent paper published by Novel-Catin et al.this article suggests that bone biopsy samples of sufficient quality can be obtained with small haematologic needles, which are definitely less inva- sive and painful for the patient and certainly more practical for the physician. Also, since the number of fields available was higher with the vertical approach, this type of procedure should be favoured.
In these guidelines, bone biopsy is no longer recommended in CKD patients with BMD values and/or clinical data indicating osteoporosis, before initiating antiresorptive therapies (like bisphosphonates or denosumab). The rationale for this recommendation is that, ‘if bone biopsy is not available’, antiresorptive therapies could be withheld to patients with high risk of fracture. While this could be reasonable in very early CKD G1–2 stages, in more advanced phases and without a balanced evaluation by an expert nephrologist, a risk exists when prescribing these drugs even in patients with osteomalacia or any other type of ROD, for which conditions they are not still validated.
2- Explain why Bone biopsy could be of a higher value especially to nephrologists.
However, while expert physicians of osteoporosis hardly ever question the diagnostic value of BMD, nephrologists recognize the limited sensitivity and specificity of either BMD assessment or of circulating biochemical markers in the diagnostic process of ROD. Therefore, while therapeutic choices might be straightforward for the former specialist, concerns could arise for the latter.
3-What are the obstacles of performing iliac-crest bone biopsies at large scale?
an invasive procedure,
there is lack of experience with the procedure of sampling and
few labs have specific ex- pertise that guarantees proper evaluation.
Indeed, there are practical hurdles to obtaining a bone biopsy. Besides qualitative histologic examination, also quantitative histomorphometric measurement is recommended, which requires an intact bone sample, with adequate amounts of cortical and cancellous bone, unaffected by artefacts (e.g. breakage, fractures, compressions, cellular damage).
And how do you think we can overcome them?
bone biopsy samples of sufficient quality can be obtained with small haematologic needles, which are definitely less invasive and painful for the patient and certainly more practical for the physician.
An excellent initiative, led by Pieter Evenepoel, as part of the ERA-EDTA CKD-MBD Working Group activities, is to create a European registry of bone biopsies , which, by encouraging the diffusion of the procedure and by collecting large databases, is expected to allow more sophisticated associa- tion analyses and more precise evaluation of the effects of available therapies.
According to KDIGO guideline 2017, is performing bone biopsy mandatory before starting anti-osteoporotic medications in patients with CKD?
Not, except as recommended in:
Explain why Bone biopsy could be of a higher value, especially to nephrologists.
What are the obstacles to performing iliac-crest bone biopsies at a large scale? And how do you think we can overcome them?
1. According to the 2017 KDIGO guideline, is performing a bone biopsy mandatory before starting anti-osteoporotic medications in patients with CKD?
No, labs and clinical picture and Dexa are usually enough to initiate treatment with antiresorptive therapy especially in early stage CKD.
2.Explain why a bone biopsy could be of higher value, especially to nephrologists.
Bone biopsy is the gold standard to differentiate between different types of ROD.
The specificity and sensitivity of serum markers with x rays and dexa are in some cases not higher enough.
3.What are the obstacles to performing iliac crest bone biopsies on a large scale? And how do you think we can overcome them?
Obstacles are lack of experience between nephrologists and pathologists, patient acceptances and we should use relative big needle size (over 5 mm in diameter).
This can be Overcome by training and doing more biopsies because it will be like a viscous cycle if we didn’t do any biopsies at all. We can use a vertical approach with small needle 4mm or hematological needle. When using haematologic needles 3-4mm internal diameter, a vertical approach seems better, since a greater number of fields is predictably obtained. and lastly patient Education
1. According to the 2017 KDIGO guideline, is performing a bone biopsy mandatory before starting anti-osteoporotic medications in patients with CKD?
No, a bone biopsy is not mandatory for starting anti-osteoporotic treatment. Lab parameters consistent with osteoporosis are enough to start these medications.
2. Explain why a bone biopsy could be of higher value, especially to nephrologists.
It is often difficult to ascertain which side of ROD a patient has (ABD vs. SHPT vs. osteoporosis alone), and since treatment is different for each, a bone biopsy becomes the tool for diagnosis and management.
3. What are the obstacles to performing iliac crest bone biopsies on a large scale? And how do you think we can overcome them?
Obstacles: A bone biopsy is a painful, invasive procedure. There is a lack of expertise in doing the biopsy, in addition to lacking expertise to read it.
Overcome suggestions:
*Train more staff (Nephrologist and Pathologists)
* An awareness campaign for concerned physicians
*An awareness campaign for patients
*Set up a CKD-MBD-specific clinic to handle this issue.
*Work on methods to properly read smaller biopsies
According to KDIGO guideline 2017, is performing bone biopsy mandatory before starting anti-osteoporotic medications in patients with CKD?
In these guidelines,bone biopsy is not recommended before initiating antiresorptive
therapies (like bisphosphonates or denosumab).The explanation for this guideline is that ‘if a bone biopsy is not available,’ antiresorptive medicines may be avoided from individuals with high risk of fracture .
Explain why Bone biopsy could be of a higher value especially to nephrologists.
In the diagnostic procedure of ROD, nephrologists realize the poor sensitivity and specificity of either BMD measurement or circulating biochemical markers.. As a result, while the first specialist’s therapy options may be clear, questions may develop for the second one.
What are the obstacles of performing iliac-crest bone biopsies at large scale? And how do you think we can overcome them?
The iliac crest is always preferable, whether approached vertically or horizontally.Patient-not accepted procedure because it is invasive, extremely painful, and limited physician or histopathologist training in bone biopsy.
there is a lack of experience, and few laboratories have the specialized skills required to ensure correct evaluation.Practical barriers to obtaining a bone biopsy.
In addition to qualitative histologic assessment, quantitative histomorphometric measurement is advised, which needs an intact bone sample with enough amounts of cortical and cancellous bone that is free of artifacts (e.g., breaking, fractures, compressions, cellular damage). As a result, specialized instruments and operators with sufficient knowledge and expertise are required.
we can overcome them by Continued education to improve skills through different workshops and conferences.Recognizing the importance of bone biopsy in the diagnosis of CKD-MBD. Histopathologists need additional training and safer approaches from doctors .
**According to KDIGO guideline 2017, is performing bone biopsy mandatory before starting anti-osteoporotic medications in patients with CKD?
The rate of fracture increase among ckd stage 3a-5 than general population this requires improvement of better diagnosis of ROD.
So bone biopsy recommended when there is doubt about the decision of treatment, so it is recommended when PTH level is inconsistent, fracture or hypercalcimia unexplained, response to the treatment is unclear or when BMD decrease. It is no more recommended when BMD level or the clinical data consistent with osteoporosis before initiating antiresorptive drug, as risk exist when prescribing the antiresorptive drug in patients with osteomalacia and other types of ROD
**Explain why Bone biopsy could be of a higher value especially to nephrologists.
Because of the limited sensitivity and specificity of either BMD assessment of circulating biochemical markers in the diagnoses of ROD , and the need of bone biopsy important for determining the decision of treatment
**What are the obstacles of performing iliac-crest bone biopsies at large scale? And how do you think we can overcome them?
It is invasive procedure, lack of experience with sampling, little laboratory have specific expertise that guarantees the examination of the sample quantitative histomorphmetric measures that need intact sample with adequate amount of cortical and cancellous bone and unaffected by artifacts like cellular damage, fracture, breakage and compression
So that suitable instruments and sufficient experienced an skilled operate are needed, iliac crest preferred with vertical or horizontal approach and taking triphine sample with internal diameter 6-8mm provides a better results because artifact increase with diameter below 4mm
The Kidigo 2017 guideline states that bone biopsy is not mandatory. In a discussion after the guideline’s release, the authors stated that the main reason is the lack of availability and experience. In the same guideline and opposite to the previous suggestion and because of emerging research, the role of BMD value is recommended.
The lack of experience of performers as well as pathologists’ experience, is the main reason behind the hesitancy to perform biopsies.
The main obstacle against widening the biopsy of the bone is the lack of experience both for performing as well as evaluation and integration with management plans. The increase in experience and multidsispnary clinics may be a good solution. Courses, as we are taking plus workshops, seems to have a role but with the lack of pathology support and experience the problem will not be solved in its own
No, it is not mandatory but by performing bone biopsy you will decied proberly about what type of ROD is patient has .
as not all patient with fragility fractuer will havwe the same bone pathology ,foir that to implement the bone biopsy among nephrologist to define the exat type of ROD and treat accordingly .
As we all know that CKD-MBD is very complex medical problems and not very clear for a lot of physition ,and it is not like any aother patiennt who has no ckd ,as in normal osteoporosis patient it is seay to interpret his DEXA scan and read his BTS and treat him directly ,but in CKD patient a lot of obstecls and a lot of data need to be interbret before take the decision of treatment ,for that bone biopsy will help the nephrologist to take the decision more clearly .
first of all it is painfull and invasive proceduer ,need trained hand
even at the level of pathologist need some expert hane to process the speciment and read the silde.
We need to give more attanetion as nephrologist for CKD-MBD ,with special clinic and performing bone biopsy will understand all range of ROD in better ways and will build our experience to deal with patients and treat them .
By doing this ,will increase the awarness among nephrologist about the imporatance of CKD-MBD and its impact on patient and health serv ices
1. According to KDIGO guideline 2017, is performing bone biopsy mandatory before starting anti-osteoporotic medications in patients with CKD?
No, KDIGO guideline 2017 does not recommend performing bone biopsy before starting anti-osteoporotic medications in patients with CKD.
The rationale for this recommendation is that, if a bone biopsy is not available, antiresorptive therapies could be withheld for patients with a high risk of fracture.
2. Explain why Bone biopsy could be of a higher value especially to nephrologists.
Bone biopsy is the gold standard diagnostic test for Renal Osteodystrophy (ROD). it can provide detailed information on the structure and composition of the bone and can help diagnose ROD.
The results of a bone biopsy can help nephrologists assess the risk of fractures and hypercalcemia and can help them make informed decisions about antiresorptive therapies such as bisphosphonates or denosumab.
3. What are the obstacles of performing iliac-crest bone biopsies at large scale? And how do you think we can overcome them?
The main obstacle is the invasiveness of the procedure and the lack of experience with the procedure of sampling.
To overcome these obstacles, the European Renal Osteodystrophy Initiative (ERA-EDTA CKD-MBD Working Group) has put forth an excellent initiative to create a European registry of bone biopsies.
The use of a haematologic small needle to perform the biopsies could make the procedure less invasive and more accessible for both patients and operators.
Increasing the number of skilled operators and experienced laboratories, as well as improving the knowledge and understanding of the pathomechanisms leading to ROD.
All these steps could help to revitalize the use of bone biopsies in CKD.
1-According to KDIGO guideline 2017, is performing bone biopsy mandatory before starting anti-osteoporotic medications in patients with CKD?
No the bone biopsy is not mandatory before beginning antiosteoprotic treatments in CKD patients with BMD levels with clinical evidence suggesting osteoporosis.
2-Explain why Bone biopsy could be of a higher value especially to nephrologists.
Bone biopsy is considered the gold-standard method for diagnosis of ckd mbd and Assesses separately cortical and trabecular bone Information on bone mineralization and turnover.
Clarify causes of persistent bone pain.
explain possiblity of Fragility fracture
3-What are the obstacles of performing
iliac-crest bone biopsies at large scale?
Non easily accepted manuver from patient, invasive ,so painful,not widely training physician or histopathologist oriented about the bone biopsy
And how do you think we can overcome them?
continued education to increase the skills via multiple workshops and conference.
Explanation for patients how get the benefits from doing it and value of bone biopsy in diagnosis CKD-MBD and different types
According to KDIGO guideline 2017, is performing bone biopsy mandatory before starting anti-osteoporotic medications in patients with CKD?
Explain why Bone biopsy could be of a higher value especially to nephrologists.
What are the obstacles of performing iliac-crest bone biopsies at large scale? And how do you think we can overcome them?
According to KDIGO guideline 2017, is performing bone biopsy mandatory before starting anti-osteoporotic medications in patients with CKD?
No, bone biopsy is not mandatory before starting anti-osteoprotic medications, as
1-There is growing evidence that anti-osteoporosis medications are effective in CKD with low BMD and a high risk of fracture with antiresorptive therapy
2- no strong evidence that these medications will induce adynamic bone disease in CKD patients
Explain why Bone biopsy could be of a higher value especially to nephrologists.
Bone biopsy is the gold standard to differentiate between types of adynamic bone diseases., as it can assess T,V,M and allow assessment of microarchitecture
What are the obstacles of performing iliac-crest bone biopsies at large scale?
1- Ivasiveness
2-Needs skilled and experienced operator
And how do you think we can overcome them?
Use of Haematologic needles, vertical approach and establishment of bone biopsy clinics
1.According to KDIGO guideline 2017, is performing bone biopsy mandatory before starting anti-osteoporotic medications in patients with CKD?
No,
a bone biopsy is not mandatory before beginning antiresorptive treatments in CKD patients with BMD levels and/or clinical evidence suggesting osteoporosis.
2- Explain why Bone biopsy could be of a higher value especially to nephrologists.
Bone biopsy is considered the gold-standard method for histological classification of ROD.
High specificity and sensibility to diagnose bone diseases, including ROD Assesses separately cortical and trabecular bone Information on bone mineralization and turnover.
explain persistent bone pain.
explain Fragility fracture.
3- What are the obstacles of performing iliac-crest bone biopsies at large scale? And how do you think we can overcome them?
How to overcome them?
According to KDIGO guideline 2017, is performing bone biopsy mandatory before starting anti-osteoporotic medications in patients with CKD?
a) To acknowledge the type of ROD that will impact the treatment decisions (not graded).
b) PTH trends are inconsistent.
c) Unexplained fracture.
d) Unexplained hypercalcemia.
e) Response to treatment is unclear, or associated with progressive BMD.
Explain why Bone biopsy could be of a higher value, especially to nephrologists.
What are the obstacles to performing iliac-crest bone biopsies at a large scale? And how do you think we can overcome them?
So, CKD-MBD as per KDIGO guidelines can be diagnosed based on metabolic bone profile, with laboratory results +/- bone biopsy if strongly indicated in a narrow window, evaluation of the treatment, and clinical responses
Nice answer Dr. KAMAL ELGORASHI
1.According to KDIGO guideline 2017, is performing bone biopsy mandatory before starting anti-osteoporotic medications in patients with CKD?
2.Explain why Bone biopsy could be of a higher value especially to nephrologists.
3.What are the obstacles of performing iliac-crest bone biopsies at large scale? And how do you think we can overcome them?
A. Obstacles
B. How to overcome them?
Great answers. Good Job Ben.
Thank you, prof.
1.According to KDIGO guideline 2017, is performing bone biopsy mandatory before starting anti-osteoporotic medications in patients with CKD? No , not mandatory bone biopsy is no longer recommended in CKD patients with BMD values and/or clinical data indicating osteoporosis, before initiating antiresorptive therapies (like bisphosphonates or denosumab).
2.Explain why Bone biopsy could be of a higher value especially to nephrologists. while expert physicians of osteoporosis hardly ever question the diagnostic value of BMD, nephrologists recognize the limited sensitivity and specificity of
either BMD assessment or of circulating biochemical markers in the diagnostic process of ROD. Therefore, while therapeutic choices might be straightforward for the former specialist, concerns could arise for the latter.
3.What are the obstacles of performing iliac-crest bone biopsies at large scale? And how do you think we can overcome them?
Hypothetically, most nephrologists would agree to perform routine bone biopsies in all CKD patients, were it not for the fact that it is an invasive procedure, there is lack of experience with the procedure of sampling and few labs have specific expertise
that guarantees proper evaluation. Indeed, there are practical hurdles to obtaining a bone biopsy. Besides qualitative histologic examination, also quantitative histomorphometric measurement is recommended, which requires an intact bone
sample, with adequate amounts of cortical and cancellous bone, unaffected by artefacts (e.g. breakage, fractures, compressions, cellular damage).
We can overcome if we used vertical approach with 4mm diameter needles.
Great answers. Good Job Ahmed.
No, the new recommendations state that before beginning antiresorptive treatments in CKD patients with BMD levels and/or clinical evidence suggesting osteoporosis, a bone biopsy is no longer advised.
This advice is justified by the possibility of withholding antiresorptive treatments from individuals at high risk of fracture “if the bone biopsy is not accessible.”
Nephrologists are aware of the poor sensitivity and specificity of both BMD measurement and circulating biochemical markers in the diagnosis of ROD, despite the fact that professional osteoporosis doctors almost never dispute the diagnostic significance of BMD. So, even though the first doctor might have clear treatment options, the second specialist might have doubts.
As sampling is a new process, there is a dearth of experience with it, and few laboratories have the specialized knowledge to ensure accurate evaluation. In fact, there are practical obstacles to getting a bone biopsy. In addition to qualitative histologic analysis, quantitative histomorphometric assessment is advised. This method needs an undamaged bone sample that has sufficient quantities of cortical and cancellous bone and is free of artifacts (such as breaking, fractures, compressions, or cellular damage). Because of this, specialized equipment as well as operators with the proper training and expertise are required.
To overcome this, we need safe techniques and more training for histopathologists.
searching for less intrusive and more user-friendly. Hematologic needles may work.
Great answers. Good Job Weam.