The vitamin D level was 14 ng/ml.The patient has been started on 50000 IU of ergocalciferol weekly and calcium carbonate. Six months later, the patient’s labs were as follows:
Test
Value
S. Creatinine
3.7 mg/dL
S. corrected Calcium
8.6 mg/dL
Phosphorus
7.1 mg/dL
PTH
400 pg/mL
The patient had persistently progressive bony aches. A DEXA scan was performed and showed a T-score of -2.7, -2.3 and -2.6 at lumbar spine, total hip, and femur neck, respectively. A bone biopsy was performed. The bony histopathological specimens are shown in figure 1.
C- Interpret the above shown bone histopathological specimens.
C- Interpret the above shown bone histopathological specimens.
Histological characteristics of Osteitis Fibrosa; increased bone formation represented by osteoid surface, osteoclast no., resorption, and osteoclast no. with an area of BM fibrosis.
normal mineralisation in fluorescent double labels study
D- Suggest a management plan for this patient.
Treat hyperphosphatemia — Persistently high phosphate (ie, >5.5 mg/dL) should be treated before treating high PTH.
stopped Vit D (contributed in hyperPi) dietitian review intensive HD add Pi binders
Maintain normocalcemia — It is important to maintain serum calcium <9.5 mg/dL
keep calcium supplement
Treat high parathyroid hormone
in the presence of high Pi, Calcimimetics are a good option
C- hypercellularity with high ostoeid bone represent high bone turn over
D- stop VD supplement use renvela and Ca continig phosphate binder and cinacalcet to control hyperparathyroidism
C- Interpret the above shown bone histopathological specimens.
Hypercellularity with high number of osteoblasts and osteoclasts, high osteoid volume, high mineralization. Double tetracyclin stain showing separation of two lines indicating high mineralization with increase marrow fibrosis. It’s indicating that the patient is having high bone turnover – Osteitis fibrosa
D- Suggest a management plan for this patient.
For hyperphosphatemia- Stop vit D, and add phosphate binder.
To maintain normal Ca level- Keep Calcium Carbonate on board.
For hyperparathyroidism- Add cinacalcet or etelcalcetide.
Will keep monitoring bone pofile, BTMs till we normalize Ca and Ph levels. If normalized, I would consider adding anti-resorptive drugs like denosumab or bisphosphonate.
C-Interpret the above shown bone histopathological specimens.increased number and activity of osteoblasts and osteoclasts, peritrabecular marrow fibrosis
D- Suggest a management plan for this patient.STOP VITAMIN D AND GIVE PHOSPHATE BINDERS, CINACALCET
CALCIUM SUPPLAMENT
Model answers by the board: C. Interpret the above-shown bone histopathological specimens.
The bone is hypercellular (increased osteoblast and osteoclast number) and has a high osteoid volume. This is typical for patients with high turnover bone disease (osteitis fibrosa). There is marrow fibrosis. High tetracycline labelling with double and diffuse uptake in the right picture.
D. Suggest a management plan for this patient.
The patient should stop active vitamin D supplementation until serum phosphorus normalises. Cinacalcet is to be used together with calcium supplementation. Phosphate binders are to be used to control the hyperphosphatemia. Serial laboratory testing including bone formation and bone resorption markers and annual DEXA scan to follow on the response to therapy are highly indicated in this patient.
C. Increased number of osteoblasts and osteoclasts, increased osteoid production and osteoclasts activity. Tetracycline shows defective mineralization.
Conclusion :high turnover bone with osteomalacia.
D. Substitution of vitamin D, further lowering of phosphate and pth level.
Consider denosumab
C- Interpret the above shown bone histopathological specimens.
Increased Osteoblast and Osteoclast activity with thick osteoid.fluorescence for tetracycline; show abundant tetracycline
D- Suggest a management plan for this patient.
low phosphate diet- sevelamer
Add calcimimetics
The bone biopsy shows an increase in osteoid, intratrabecular fibrosis some multinucleated osteoclasts. I could not recall the double tetracycline staining pattern, but we need to control phosphorus; calcium is now normal. I will add a non-calcium phosphorous binder
Interpret the above shown bone histopathological specimens.
increase osteoblasts and osteoclasts activities
increased osteoid
intertrabecular fibrosis
areas of irregular bone
decreased mineralization
This is a case of mixed bone disease Suggest a management plan for this patient.stop vitamin D
stop calcium
add non-calcium based phosphate binders
improve dialysis adequacy
add cinacalcet
bisphosphonate may be tried
C- Interpret the above shown bone histopathological specimens.
Increase osteoclast number and activity with howship lacunae, increase osteoblast number, thick osteoid, defective mineralization, bone marrow fibrosis
Tetracycline labeling increase mineral lag time with irrigular and diffused mineralization suggest mixed osteodystrophy
D- Suggest a management plan for this patient.
Continue calcium phosphate binders give sevelamir, continue vitamin D give bone building medication like Alendronate, Donusumab
the masson techinque shows increased ostoid, increase No of osteoblasts & osteoclasts, bone marrow fibrosis, while florescent double labels show broad single label. all these changes point to mixed osteodystrophy
Suggest a management plan for this patient
1- ttt of vit D deficiency
2- non-calcium based phosphate binder
3- add of calcimimetics
C- Interpret the above shown bone histopathological specimens.Cellular bone with excessive osteoblast and osteoclast activity, acceptable calcification
==> high bone turnover
D- Suggest a management plan for this patient.Active vitamin D instead of the ergo, Phosphate binder, follow up
C-Interpret the above shown bone histopathological specimens.
Acase of hyperdynamic bone disease secondary to hyperparathyroidism from increase no if oesteoblast and oesteoclast and high oesteoid volume with bone marrow fibrosis
D- Suggest a management plan for this patient.
Intensification of hemodialysis to eleminate high po4 stop vit d add non ca contaning phosphate binders
c- incrase in the osteoid tissue,
increase osteoclasts, and the osteoblasts.
The high activity of the osteoclasts
Peri trabecular fibrosis
secondary hyperparathyroidism
d- adequate of RRT stop vit d
non ca phos. Binder
C- Interpret the above shown bone histopathological specimens.left one:shows increased osteoblast and osteoclast cell (giant multinucleated cell) number
increased osteoid (matrix) volume due to accelerated bone formation process
increased intertrabecular fibrosis
right one : label technique( tetracycline-double labelling): mineralization lag time
DEXA scan : osteopenia and osteoporosis
Treatment :
Vitamin d replacement
dietary phosphate restriction
sevelamer
after treatment of vitamin d deficiency , can start denosumab
C- Interpret the above bone biopsy .
there is increase of both number of osteoclast and osteoblast indicate increase osteoclastic activity with pre trabecular fibrosis, increase osteoid volume, near normal mineralization, also double tetracycline labelling
Conclusion : high bone turnover ROD,
EXA scan with t score going with osteoporosis at the lumbar spine and femur neck and osteopenia at hip
D- Suggest a management plan for this patient.
to Continue vitamin could start calcimimetics 30 mg od and titrate dose according to follow up results of Ca, Pi, & PTH.
better to use noncalcium-based phosphate binders e.g., sevelamer 1600 tds for target po4 less than 5.5 mg/dl with dietary phosphate restriction.
Interpret the above shown bone histopathological specimens.
tHIS bone biopsy showed increased osteoclast and osteoblast activity with normal miniralization or rather low .
increased osteoid and bone formation
Trabeculation to some extent dose not showed featuers of osteoporosis
Suggest a management plan for this patient.This patient has high turnover bone disease with ROD
we need to keep him on vit D oral supplements .reduce his phophorus level through using Phophate binder and increase the dialysis session
use Non Ca base phophate binder
His Dexa scan showed osteoporosis features with in the spine and forearm with osteopenic featuers in the hip may be will consider anabolic treatment dunosumab RANK inhibitors .
C- Interpret the above shown bone histopathological specimens. A. On the left hand, the findings on the bone biopsy:
Increased osteoclastic activity.
Increased osteoblastic activity.
Normal mineralization
Increased bone volume
Peri trabecular fibrosis
B. On the right hand, there is tetracycline-double labelling which revealed:lag in mineralization time.
These findings are consistent with high turnover bone disease or osteitis fibrosa cystica and the DEXA scan is diagnostic for osteoporosis at the lumbar spine/femur neck and osteopenia at total hip.
D- Suggest a management plan for this patient. A. High turnover bone disease:
Continue vitamin D.
Add calcimimetics such as cinacalcet 30 mg od and titrate the dose up gradually.
Regular monitoring Ca, Pi, & PTH.
Add noncalcium-based phosphate binders e.g., sevelamer 800 tds and titrate gradually to the maximum dose.
C- Interpret the above shown bone histopathological specimens. A DEXA scan showed a T-score of -2.7, -2.3 and -2.6 at lumbar spine, total hip, and femur neck, (( osteoporotic at lumber spine , total hip osteopenia and osteoporotic femur neck )biopsy show
osteoclastic activity
unmineralization failure
trabecular thick osteod
pictur of secondry hyperpara thyrodism
D- Suggest a management plan for this patient. added non calcuim -phosphorus binding
added alfacalcidol or paricalcitol according calcium level
cinacalcite 30 and titrated
C- Interpret the above-shown bone histopathological specimens.There is an increase in the osteoid tissue, the osteoclasts, and the osteoblasts. The activity of the osteoclasts is high, (and the bone resorption is high. The mineralization, to some degree, is normal. some cystic changes with fibrosis.
The picture revealed secondary hyperparathyroidism(OFC) plus osteoporosis
D- Suggest a management plan for this patient.Review the diet with a restricted PO4 intake.
Adequate dialysis
Adding a non-calcium PO4 binder, stopping calcium, and adding cinacalcet
shifting from ergocalciferol to paricalcitol after controlling hyperphosphatemia.
C- increased trabecular bone with decreased cortical bone , cortical thinning with porosity and increased osteoid tissue consistant with high turnover bone disease
D – continue calcium carbonate , reduce or stop vit D temporarily until po4 levels are controlled , start calcium based po4 binders to decrease po4 levels and supply calcium and decrease PTH until po4 levels are within normal and then continue vit D again with diet control and increased duration and frequency of HD if possible
C- Interpret the above shown bone histopathological specimensIn my opinion this is high turn over CKD-MBD mostly secondary to hyperparathyroiedism
( hyperparathyroidism in CKD leads to increased cortical porosity and to decreased cortical thickness, but with an increased trabecular volume in relation to cortical trabecularization) . D- Suggest a management plan for this patientNeeds 1st to be sure of dialysis adequacy , stop vit d , ,add phosphate binder , increase dose of dialysis , may needs to add calcimemtic
high turnover state
stop active vitamin D until phosphate normalises
add cinecalcet with ca supplements
C- Interpret the above shown bone histopathological specimens.
D- Suggest a management plan for this patient.
stopped Vit D (contributed in hyperPi)
dietitian review
intensive HD
add Pi binders
keep calcium supplement
in the presence of high Pi, Calcimimetics are a good option
C- hypercellularity with high ostoeid bone represent high bone turn over
D- stop VD supplement use renvela and Ca continig phosphate binder and cinacalcet to control hyperparathyroidism
C- Interpret the above shown bone histopathological specimens.
Hypercellularity with high number of osteoblasts and osteoclasts, high osteoid volume, high mineralization. Double tetracyclin stain showing separation of two lines indicating high mineralization with increase marrow fibrosis. It’s indicating that the patient is having high bone turnover – Osteitis fibrosa
D- Suggest a management plan for this patient.
Will keep monitoring bone pofile, BTMs till we normalize Ca and Ph levels. If normalized, I would consider adding anti-resorptive drugs like denosumab or bisphosphonate.
C-Interpret the above shown bone histopathological specimens.increased number and activity of osteoblasts and osteoclasts, peritrabecular marrow fibrosis
D- Suggest a management plan for this patient.STOP VITAMIN D AND GIVE PHOSPHATE BINDERS, CINACALCET
CALCIUM SUPPLAMENT
Model answers by the board:
C. Interpret the above-shown bone histopathological specimens.
The bone is hypercellular (increased osteoblast and osteoclast number) and has a high osteoid volume. This is typical for patients with high turnover bone disease (osteitis fibrosa). There is marrow fibrosis. High tetracycline labelling with double and diffuse uptake in the right picture.
D. Suggest a management plan for this patient.
The patient should stop active vitamin D supplementation until serum phosphorus normalises. Cinacalcet is to be used together with calcium supplementation. Phosphate binders are to be used to control the hyperphosphatemia. Serial laboratory testing including bone formation and bone resorption markers and annual DEXA scan to follow on the response to therapy are highly indicated in this patient.
C. Increased number of osteoblasts and osteoclasts, increased osteoid production and osteoclasts activity. Tetracycline shows defective mineralization.
Conclusion :high turnover bone with osteomalacia.
D. Substitution of vitamin D, further lowering of phosphate and pth level.
Consider denosumab
C- Interpret the above shown bone histopathological specimens.
D- Suggest a management plan for this patient.
C- Interpret the above shown bone histopathological specimens.
Increased Osteoblast and Osteoclast activity with thick osteoid.fluorescence for tetracycline; show abundant tetracycline
D- Suggest a management plan for this patient.
low phosphate diet- sevelamer
Add calcimimetics
The bone biopsy shows an increase in osteoid, intratrabecular fibrosis some multinucleated osteoclasts. I could not recall the double tetracycline staining pattern, but we need to control phosphorus; calcium is now normal. I will add a non-calcium phosphorous binder
Interpret the above shown bone histopathological specimens.
increase osteoblasts and osteoclasts activities
increased osteoid
intertrabecular fibrosis
areas of irregular bone
decreased mineralization
This is a case of mixed bone disease
Suggest a management plan for this patient.stop vitamin D
stop calcium
add non-calcium based phosphate binders
improve dialysis adequacy
add cinacalcet
bisphosphonate may be tried
Interpret the above shown bone histopathological specimens.
D- Suggest a management plan for this patient.
C- Interpret the above shown bone histopathological specimens.
D- Suggest a management plan for this patient.
C- Interpret the above shown bone histopathological specimens.
Increase osteoclast number and activity with howship lacunae, increase osteoblast number, thick osteoid, defective mineralization, bone marrow fibrosis
Tetracycline labeling increase mineral lag time with irrigular and diffused mineralization suggest mixed osteodystrophy
D- Suggest a management plan for this patient.
Continue calcium phosphate binders give sevelamir, continue vitamin D give bone building medication like Alendronate, Donusumab
the masson techinque shows increased ostoid, increase No of osteoblasts & osteoclasts, bone marrow fibrosis, while florescent double labels show broad single label. all these changes point to mixed osteodystrophy
Suggest a management plan for this patient
1- ttt of vit D deficiency
2- non-calcium based phosphate binder
3- add of calcimimetics
Interpret the above-shown bone histopathological specimens.
Suggest a management plan for this patient.
C- Interpret the above shown bone histopathological specimens.Cellular bone with excessive osteoblast and osteoclast activity, acceptable calcification
==> high bone turnover
D- Suggest a management plan for this patient.Active vitamin D instead of the ergo, Phosphate binder, follow up
C-Interpret the above shown bone histopathological specimens.
Acase of hyperdynamic bone disease secondary to hyperparathyroidism from increase no if oesteoblast and oesteoclast and high oesteoid volume with bone marrow fibrosis
D- Suggest a management plan for this patient.
Intensification of hemodialysis to eleminate high po4 stop vit d add non ca contaning phosphate binders
c- incrase in the osteoid tissue,
increase osteoclasts, and the osteoblasts.
The high activity of the osteoclasts
Peri trabecular fibrosis
secondary hyperparathyroidism
d- adequate of RRT stop vit d
non ca phos. Binder
C- Interpret the above shown bone histopathological specimens.left one:shows increased osteoblast and osteoclast cell (giant multinucleated cell) number
increased osteoid (matrix) volume due to accelerated bone formation process
increased intertrabecular fibrosis
right one : label technique( tetracycline-double labelling): mineralization lag time
DEXA scan : osteopenia and osteoporosis
Treatment :
Vitamin d replacement
dietary phosphate restriction
sevelamer
after treatment of vitamin d deficiency , can start denosumab
C- Interpret the above bone biopsy .
there is increase of both number of osteoclast and osteoblast indicate increase osteoclastic activity with pre trabecular fibrosis, increase osteoid volume, near normal mineralization, also double tetracycline labelling
Conclusion : high bone turnover ROD,
EXA scan with t score going with osteoporosis at the lumbar spine and femur neck and osteopenia at hip
D- Suggest a management plan for this patient.
to Continue vitamin could start calcimimetics 30 mg od and titrate dose according to follow up results of Ca, Pi, & PTH.
better to use noncalcium-based phosphate binders e.g., sevelamer 1600 tds for target po4 less than 5.5 mg/dl with dietary phosphate restriction.
Interpret the above shown bone histopathological specimens.
tHIS bone biopsy showed increased osteoclast and osteoblast activity with normal miniralization or rather low .
increased osteoid and bone formation
Trabeculation to some extent dose not showed featuers of osteoporosis
Suggest a management plan for this patient.This patient has high turnover bone disease with ROD
we need to keep him on vit D oral supplements .reduce his phophorus level through using Phophate binder and increase the dialysis session
use Non Ca base phophate binder
His Dexa scan showed osteoporosis features with in the spine and forearm with osteopenic featuers in the hip may be will consider anabolic treatment dunosumab RANK inhibitors .
C- Interpret the above shown bone histopathological specimens.
D- Suggest a management plan for this patient.
c- Interpret the above-shown bone histopathological specimens?
D- Suggest management plan for this patient ?
C- Interpret the above shown bone histopathological specimens.
A. On the left hand, the findings on the bone biopsy:
B. On the right hand, there is tetracycline-double labelling which revealed: lag in mineralization time.
D- Suggest a management plan for this patient.
A. High turnover bone disease:
B. Osteoporosis: Consider osteo-anabolic although more studies are needed
.
C. Pain management:
C- Interpret the above shown bone histopathological specimens.
A DEXA scan showed a T-score of -2.7, -2.3 and -2.6 at lumbar spine, total hip, and femur neck, (( osteoporotic at lumber spine , total hip osteopenia and osteoporotic femur neck )biopsy show
osteoclastic activity
unmineralization failure
trabecular thick osteod
pictur of secondry hyperpara thyrodism
D- Suggest a management plan for this patient. added non calcuim -phosphorus binding
added alfacalcidol or paricalcitol according calcium level
cinacalcite 30 and titrated
C- Interpret the above-shown bone histopathological specimens.There is an increase in the osteoid tissue, the osteoclasts, and the osteoblasts. The activity of the osteoclasts is high, (and the bone resorption is high. The mineralization, to some degree, is normal. some cystic changes with fibrosis.
The picture revealed secondary hyperparathyroidism(OFC) plus osteoporosis
D- Suggest a management plan for this patient.Review the diet with a restricted PO4 intake.
Adequate dialysis
Adding a non-calcium PO4 binder, stopping calcium, and adding cinacalcet
shifting from ergocalciferol to paricalcitol after controlling hyperphosphatemia.
C- increased trabecular bone with decreased cortical bone , cortical thinning with porosity and increased osteoid tissue consistant with high turnover bone disease
D – continue calcium carbonate , reduce or stop vit D temporarily until po4 levels are controlled , start calcium based po4 binders to decrease po4 levels and supply calcium and decrease PTH until po4 levels are within normal and then continue vit D again with diet control and increased duration and frequency of HD if possible
C- Interpret the above shown bone histopathological specimensIn my opinion this is high turn over CKD-MBD mostly secondary to hyperparathyroiedism
( hyperparathyroidism in CKD leads to increased cortical porosity and to decreased cortical thickness, but with an increased trabecular volume in relation to cortical trabecularization) .
D- Suggest a management plan for this patientNeeds 1st to be sure of dialysis adequacy , stop vit d , ,add phosphate binder , increase dose of dialysis , may needs to add calcimemtic