A 38-year-old male with ESKD was referred to the neurosurgery clinic because of muscle weakness in both upper limbs and posterior neck pain. He had been undergoing peritoneal dialysis for five years. DEXA scan showed a T-score of −2.5 in left femoral head and −2.9 in lumbar spine. MRI scan of the cervical spine showed severe kyphosis with spinal cord compression at C3-4, and C5-6 levels.
Review of his routine laboratory work-up revealed:
Test
Value
S. Creatinine
4.8 mg/dL
S. Corrected Calcium
8.3 mg/dL
S. Phosphorus
5.6 mg/dL
iPTH
67 pg/mL
A- Interpret the above laboratory investigation.
B- What is the most likely mechanism behind the patient’s bone disease?
C- Would you recommend any further investigations?
27 Comments
Muhammad Soobadar
A – high phosphate , normal calcium suppressed PTH
B adynamic bone disease
C Vitamin D, ALP , thyroid test rule out osteporosis
B- What is the most likely mechanism behind the patient’s bone disease?
Low bone turnover keeping with ABD. The principal factor underlying ABD is either over-suppression of PTH release, which may be induced by the relatively high doses of vitamin D analogs, calcium-based phosphate binders, and/or calcimimetic agents, or resistance to PTH actions on bone.
C- Would you recommend any further investigations?
A- Interpret the above laboratory investigation.Low PTH with hypocalcemia and hyperphosphatemia B- What is the most likely mechanism behind the patient’s bone disease?Low bone turnover consistency with Adynamic bone disease C- Would you recommend any further investigations?25(OH)D levels- BALP-Thyroid profile, liver function , Serum Aluminum Bone biopsy
B- What is the most likely mechanism behind the patient’s bone disease?ABD + Osteoporosis . C- Would you recommend any further investigations? Total and specific ALP Vitamin D level TRAP5P level Serum Aluminum Bone biopsy
Could you interpret the above laboratory investigation?Hypocalcemia, Hyperphosphatemia and low PTH and osteoporosis features in MRI. What is the most likely mechanism behind the patient’s bone disease?
This picture is denoted for adynamic bone disease versus low bone Turnover, with no new bone formation, and the defect is a balanced process between bone resorption and bone formation. And this will lead to fragile bone and fractures.
Would you recommend any further investigations?
Will need to check for Vit D level and BSALP as it will support or rule out my diagnosis.
This patient with PTH less than 100, normocalcimeia, and hyperphosphatemia is compatible with an adynamic bone disease. With low turnover, there is less formation of bone, eventually resulting in low bone density and osteoporosis. Other concomitant reasons should be evaluated. In cases of vitamin D deficiency, replacement therapy should be pursued. After checking for low bone turnover markers (low ALP, etc.), we can give teripartite or other anabolic agents.
A.Interpret the above laboratory investigation. Very low PTH level below the target range according to KDIGO 2017 guidelines (2-9 folds of upper normal limits). Hyperphosphatemia and hypocalcemia are also present. B. What is the most likely mechanism behind the patient’s bone disease?
The patient presented with a low PTH level that reflects low turnover bone disease. Adynamic bone disease characterised by suppressed bone formation that results in poor skeletal health and increased bone fragility as well as diminished ability to restore damaged bone.
C. Would you recommend any further investigations?
Vitamin D level assessment is very important to help better management especially with a very low level of vitamin D that needs to be replenished.Total and bone specific alkaline phosphatase (bone formation marker) help in supporting the diagnosis of bone turnover state since the low level of either of them suggest a low turnover bone disease. Thyroid profile and liver function tests should be screened as possible causes for osteoporosis.
ESRD, low normal ca, high pi, low PTH for CKD stage, osteoporosis by DEXA.
B- What is the most likely mechanism behind the patient’s bone disease?
ABD (low turnover bone disease) caused by high ca in peritoneal fluid. C- Would you recommend any further investigations?
Total and specific ALP
Vitamin D3 level
TRAP5P level
Serum Aluminum
Bone biopsy
A- Interpret the above laboratory investigation.
Patient has mild hyperphosphatemia, low normal calcium but with Very low PTH for CKD 5D ,,, adynamic bone disease, and T-score revealed osteoporosis.
B- What is the most likely mechanism behind the patient’s bone disease?
Picture is going with adynamic bone disease (ABD) due to excessive suppression of PTH, common in PD patients.
C- Would you recommend any further investigations? Yes, alk. phosphatase, Bone-specific alkaline phosphatase, 25-OH Vitamin D, lateral Abdominal X-ray, and bone biopsy the only way to confirm the diagnosis of ABD
A- Interpret the above laboratory investigation.
ESKD with low normal s. Calcium, elevated s. Phosphorous, low PTH for ckd stage 5D this is low turnover bone disease
B- What is the most likely mechanism behind the patient’s bone disease?
Low turnover bone disease(osteoporosis) caused by high calcium in peritoneal solution
C- Would you recommend any further investigations?
Total or bone specific alkaline phosphotase, 25OH vitamin D
t-score of the patient is less then -2, at the same time he has low PTH, hypocalcemia and hyperphosphatemia What is the most likely mechanism behind the patient’s bone disease? adynamic bone disease andosteoporosis Would you recommend any further investigations? vit d level
alkaline phosphatase
bone biopsy
A- Interpret the above laboratory investigation.mild hypocalcemia, hyperphosphatemia.
PTH is low regarding the target for ESRD patient
DEXA osteoporosis
B- What is the most likely mechanism behind the patient’s bone disease?low turn over disease and osteoporosis secondary to ESRD and peritoneal dialysis
C- Would you recommend any further investigations?25 OH VITAMIN D
A. Hypocalcemia mild, hyperphophatemia due to ESRD. PTH is relatively low considering his history of dialysis and labs. DEXA osteoporosis.
B. Low turnover bone disease.
C.Vitamin D level, Alkaline phosphatase bone specific, echo , lateral abdominal x rays
A- Interpret the above laboratory investigation.Hypocalcemia, hyperphosphatemia, and abnormally low iPTH, he also has osteoporosis by DEXA score. B- What is the most likely mechanism behind the patient’s bone disease?ABD
C- Would you recommend any further investigations?Vitamin D, bALP, FGF23
A- Interpret the above laboratory investigation. mild hyperphosphatemia, Very low PTH a T-score revealed osteoporosis. B- What is the most likely mechanism behind the patient’s bone disease? picture of A dynamic bone disease (ABD) due to excessive suppression of PTH a common complication in PD patients. C- Would you recommend any further investigations? Bone-specific alkaline phosphatase, 25-OH Vitamin D, lateral Abdominal X-ray,
lab. reasult revealed ;-
mild hypocalcemia
hyperphosphatemia
low targeted PTH
DEXA T-score show Osteoporosis in left femoral head and lumber spine The most likely mechanism behind the patient’s bone diseasepointed to ADYNAMIC BONE DISEASE
Recommend any further investigationsare vit. D . bone specific ALK
A- Interpret the above laboratory investigation.
mild hypocalcemia, mild hyperphosphatemia, and low PTH in an ESRD patient on peritoneal dialysis with a T-score revealed osteoporosis.
picture of adynamic bone disease
B- What is the most likely mechanism behind the patient’s bone disease?
Adynamic bone disease (ABD) resulting from low serum levels of PTH is now recognized as a common complication in PD patients. reported that ABD was found in 63.2% of PD patients and that PTH levels were less than 150 pg/mL in patients with ABD. recently shown that sclerostin, a Wnt/β-catenin pathway inhibitor that decreases osteoblast action and bone formation, seems to participate in the pathophysiology of ABD, and bone alkaline phosphatase was the sensitive serum marker of bone turnover in these patients.
Maybe the patient is on high-dose calcium or Vit-D.
post parathyroidectomy.
low Vitamin-D level.
C- Would you recommend any further investigations?Bone-specific alkaline phosphatase, 25-OH Vitamin D, lateral Abdominal X-ray, and ECHO
A – high phosphate , normal calcium suppressed PTH
B adynamic bone disease
C Vitamin D, ALP , thyroid test rule out osteporosis
A- high phos with normal ca and low PTH
osteoporosis
B-low bone turnover a dynamic bone dismc- c-bone alk. Bone biopsy vit d and mg
A- Interpret the above laboratory investigation.
B- What is the most likely mechanism behind the patient’s bone disease?
Low bone turnover keeping with ABD. The principal factor underlying ABD is either over-suppression of PTH release, which may be induced by the relatively high doses of vitamin D analogs, calcium-based phosphate binders, and/or calcimimetic agents, or resistance to PTH actions on bone.
C- Would you recommend any further investigations?
A- Interpret the above laboratory investigation.Low PTH with hypocalcemia and hyperphosphatemia
B- What is the most likely mechanism behind the patient’s bone disease?Low bone turnover consistency with Adynamic bone disease
C- Would you recommend any further investigations?25(OH)D levels- BALP-Thyroid profile, liver function , Serum Aluminum
Bone biopsy
A. Interpret the above laboratory investigation.
Hyperphosphatemia – Hypocalcemia and low PTH (2-9 folds of upper normal limits)
B- What is the most likely mechanism behind the patient’s bone disease?
low bone turnover consistency with Adynamic bone disease
C- Would you recommend any further investigations?
25(OH)D levels- BALP-Thyroid profile and liver function
A- low PTH with hypocalcemia and hypophosphatemia
B-low turn over bone disease
C-VD level and BALP
A- Interpret the above laboratory investigation.
B- What is the most likely mechanism behind the patient’s bone disease? ABD + Osteoporosis .
C- Would you recommend any further investigations? Total and specific ALP
Vitamin D level
TRAP5P level
Serum Aluminum
Bone biopsy
A- Interpret the above laboratory investigation.
ESRD with hypocalcemia and hyperphosphatemia and normal PTH.
B- What is the most likely mechanism behind the patient’s bone disease?
Low bone turnover- Adynamic bone disease
C- Would you recommend any further investigations?
Bone profie, Vitamin D level, BsALP, BMTs
Could you interpret the above laboratory investigation?Hypocalcemia, Hyperphosphatemia and low PTH and osteoporosis features in MRI.
What is the most likely mechanism behind the patient’s bone disease?
This picture is denoted for adynamic bone disease versus low bone Turnover, with no new bone formation, and the defect is a balanced process between bone resorption and bone formation. And this will lead to fragile bone and fractures.
Would you recommend any further investigations?
Will need to check for Vit D level and BSALP as it will support or rule out my diagnosis.
This patient with PTH less than 100, normocalcimeia, and hyperphosphatemia is compatible with an adynamic bone disease. With low turnover, there is less formation of bone, eventually resulting in low bone density and osteoporosis. Other concomitant reasons should be evaluated. In cases of vitamin D deficiency, replacement therapy should be pursued. After checking for low bone turnover markers (low ALP, etc.), we can give teripartite or other anabolic agents.
Here the answer of this case.
A. Interpret the above laboratory investigation.
Very low PTH level below the target range according to KDIGO 2017 guidelines (2-9 folds of upper normal limits). Hyperphosphatemia and hypocalcemia are also present.
B. What is the most likely mechanism behind the patient’s bone disease?
The patient presented with a low PTH level that reflects low turnover bone disease. Adynamic bone disease characterised by suppressed bone formation that results in poor skeletal health and increased bone fragility as well as diminished ability to restore damaged bone.
C. Would you recommend any further investigations?
Vitamin D level assessment is very important to help better management especially with a very low level of vitamin D that needs to be replenished.Total and bone specific alkaline phosphatase (bone formation marker) help in supporting the diagnosis of bone turnover state since the low level of either of them suggest a low turnover bone disease. Thyroid profile and liver function tests should be screened as possible causes for osteoporosis.
A.Interpret the above laboratory investigation.
B- What is the most likely mechanism behind the patient’s bone disease?
C- Would you recommend any further investigations?
A- Interpret the above laboratory investigation.
ESRD, low normal ca, high pi, low PTH for CKD stage, osteoporosis by DEXA.
B- What is the most likely mechanism behind the patient’s bone disease?
ABD (low turnover bone disease) caused by high ca in peritoneal fluid.
C- Would you recommend any further investigations?
Total and specific ALP
Vitamin D3 level
TRAP5P level
Serum Aluminum
Bone biopsy
Interpret the above laboratory investigation.
What is the most likely mechanism behind the patient’s bone disease?
Would you recommend any further investigations?
A- Interpret the above laboratory investigation.
B- What is the most likely mechanism behind the patient’s bone disease?
C- Would you recommend any further investigations?
A- Interpret the above laboratory investigation.
Low normal ca and slight elevation of po4 with low level of pth.
B- What is the most likely mechanism behind the patient’s bone disease?
Mostly acase of adynamic bone disease
C- Would you recommend any further investigations?
Yes
Vit d level serum alkaline phosphatase serum bone specific alkaline phosphatase dexa scan x ray on lateral view to exclude aortic calcification
A.Interpret the above laboratory investigation.
B- What is the most likely mechanism behind the patient’s bone disease?
C- Would you recommend any further investigations?
A- Interpret the above laboratory investigation.
Patient has mild hyperphosphatemia, low normal calcium but
with Very low PTH for CKD 5D ,,, adynamic bone disease, and T-score revealed osteoporosis.
B- What is the most likely mechanism behind the patient’s bone disease?
Picture is going with adynamic bone disease (ABD) due to excessive suppression of PTH, common in PD patients.
C- Would you recommend any further investigations?
Yes, alk. phosphatase, Bone-specific alkaline phosphatase,
25-OH Vitamin D, lateral Abdominal X-ray, and bone biopsy the only way to confirm the diagnosis of ABD
A- Interpret the above laboratory investigation.
ESKD with low normal s. Calcium, elevated s. Phosphorous, low PTH for ckd stage 5D this is low turnover bone disease
B- What is the most likely mechanism behind the patient’s bone disease?
Low turnover bone disease(osteoporosis) caused by high calcium in peritoneal solution
C- Would you recommend any further investigations?
Total or bone specific alkaline phosphotase, 25OH vitamin D
t-score of the patient is less then -2, at the same time he has low PTH, hypocalcemia and hyperphosphatemia
What is the most likely mechanism behind the patient’s bone disease? adynamic bone disease andosteoporosis
Would you recommend any further investigations? vit d level
alkaline phosphatase
bone biopsy
A- Interpret the above laboratory investigation.mild hypocalcemia, hyperphosphatemia.
PTH is low regarding the target for ESRD patient
DEXA osteoporosis
B- What is the most likely mechanism behind the patient’s bone disease?low turn over disease and osteoporosis secondary to ESRD and peritoneal dialysis
C- Would you recommend any further investigations?25 OH VITAMIN D
ALP AND B-ALP
TRAP5b
Bone biopsy : gold standard
A. Hypocalcemia mild, hyperphophatemia due to ESRD. PTH is relatively low considering his history of dialysis and labs. DEXA osteoporosis.
B. Low turnover bone disease.
C.Vitamin D level, Alkaline phosphatase bone specific, echo , lateral abdominal x rays
A- Interpret the above laboratory investigation.Hypocalcemia, hyperphosphatemia, and abnormally low iPTH, he also has osteoporosis by DEXA score.
B- What is the most likely mechanism behind the patient’s bone disease?ABD
C- Would you recommend any further investigations?Vitamin D, bALP, FGF23
A- Interpret the above laboratory investigation.
mild hyperphosphatemia,
Very low PTH
a T-score revealed osteoporosis.
B- What is the most likely mechanism behind the patient’s bone disease?
picture of A dynamic bone disease (ABD) due to excessive suppression of PTH a common complication in PD patients.
C- Would you recommend any further investigations?
Bone-specific alkaline phosphatase,
25-OH Vitamin D,
lateral Abdominal X-ray,
A- Interpret the above laboratory investigation.
B- What is the most likely mechanism behind the patient’s bone disease?ADYNAMIC BONE DISEASE .
C – Would you recommend any further investigations?
lab. reasult revealed ;-
mild hypocalcemia
hyperphosphatemia
low targeted PTH
DEXA T-score show Osteoporosis in left femoral head and lumber spine
The most likely mechanism behind the patient’s bone diseasepointed to ADYNAMIC BONE DISEASE
Recommend any further investigationsare vit. D . bone specific ALK
A- Interpret the above laboratory investigation.
mild hypocalcemia, mild hyperphosphatemia, and low PTH in an ESRD patient on peritoneal dialysis with a T-score revealed osteoporosis.
picture of adynamic bone disease
B- What is the most likely mechanism behind the patient’s bone disease?
Adynamic bone disease (ABD) resulting from low serum levels of PTH is now recognized as a common complication in PD patients. reported that ABD was found in 63.2% of PD patients and that PTH levels were less than 150 pg/mL in patients with ABD. recently shown that sclerostin, a Wnt/β-catenin pathway inhibitor that decreases osteoblast action and bone formation, seems to participate in the pathophysiology of ABD, and bone alkaline phosphatase was the sensitive serum marker of bone turnover in these patients.
Maybe the patient is on high-dose calcium or Vit-D.
post parathyroidectomy.
low Vitamin-D level.
C- Would you recommend any further investigations?Bone-specific alkaline phosphatase, 25-OH Vitamin D, lateral Abdominal X-ray, and ECHO