Scenario 2 - Part 2:
Sevelamer was discontinued and the patient was started on calcium, phosphate, and Vit D supplementations for three months. However, the patient’s clinical symptoms did not improve and was seen limping throughout the last two weeks. A bone biopsy was done considering the worsening of his condition. His lab showed the following:
|
Test |
Value |
|
S. Creatinine |
4.3 mg/dL |
|
Corrected s. Calcium |
8.5 mg/dL |
|
S. Phosphorus |
3.3 mg/dL |
|
25 (OH) Vit D |
20 ng/mL |
|
iPTH |
632 pg/mL |
|
Total alkaline phosphatase |
520 U/L |
E. Discuss the role of bone biopsy in this patient.
F. What is the expected bone histopathological abnormality in the patient?
The bone histology is shown in figure 2:
G. Interpret the above histopathological changes.
H. What is your suggested management plan?
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E. Discuss the role of bone biopsy in this patient.
Indication of bone bx in this scenario patients have an atypical response to standard therapies for elevated PTH, to rule out atypical or unexpected bone pathology.
F. What is the expected bone histopathological abnormality in the patient? high turn-over
H. What is your suggested management plan?
E. Discuss the role of bone biopsy in this patient.Bone biopsy is the gold standart to specify type of CKD-MBD
F. What is the expected bone histopathological abnormality in the patient?Mixed of osteoclast and osteoblasts.
G. Interpret the above histopathological changes.High bone turnover osteitis fibrosa vs Osteomalasia
H. What is your suggested management plan?Continue current treatment. Once the Ca corr and Ph levels improved further, I would add etalcalcitide.
E. Discuss the role of bone biopsy in this patient.Bone biopsy is the gold standard for diagnosis of ROD
F. What is the expected bone histopathological abnormality in the patient?High bone turnover
G. Interpret the above histopathological changes. High bone turnover with abundance of osteoclasts and unmineralized bone.
H. What is your suggested management plan?continue the above medications and add cinacalcet, if symptoms are not resolved parathyroidectomy is advised
Discuss the role of bone biopsy in this patient.bone biopsy is gold standard for renal osteodystrophy
the expected bone histopathological abnormality osteoclastosis and osteoblastosis, and unmineralization of the bone
continue vit d , alfacacidol and add cinacalcet
It allows to measure both static and dynamic parameters of bone remodeling and is the only method able to evaluate mineralization and allows analysis of both cortical and trabecular bone.
It is expected high turn over with osteomalcia
Interpret the above histopathological changes.increased osteoclast(multinucleated giant cells), osteoblasts, cavities and unmineralized matrix (osteoid)
Mixed pattern (OFC and osteomalacia)
continue vitamin d and alfacalcidol
start cinacalcet
The bone biyopsy is needed to differentiate among bone mineralization abnormalities to sacilitate suitable option, whether there is high, low or mixed turnover.
There are 2-3 osteoclasts on the left and one on the right (big cells ), osteoblasts seem to be less at the margins, blue is calcified bone (red is new formig )
seems to be high turnover , so biphophonate may help
E. Discuss the role of bone biopsy in this patient.
F. What is the expected bone histopathological abnormality in the patient?High turnover bone disease with osteoporosis
G. Interpret the above histopathological changes.Increased osteoclast numbers and some fibrosis are hallmarks of high-turnover bone disease.
A lack of mineralization and an increase in the number of osteoid bones that have not yet been mineralized.
H. What is your suggested management plan?Continue with vit d and calcium supplement and add cinacalcet if symptoms persist and no improvement we considered surgical parathyroidectomy
Bone biopsy
Bone histopathology
Management plan
E. Discuss the role of bone biopsy in this patient. bone biopsy is indicated in this patient due to persistent symptoms inspite of appropriate medical treatment .
F. What is the expected bone histopathological abnormality in the patient?High turnover bone disease With/without Osteomalacia .
G. Interpret the above histopathological changes. High bone turnover with abundance of osteoclasts and undermineralization .
H. What is your suggested management plan? continue with vit d and calcium supplement and add cinacalcet if symptoms persist and no improvement we considered surgical parathyroidectomy
E – bone biopsy is indicated in this patient due to persistant symptoms inspite of appropriate medical ttt
F – high turnover bone disease with osteoporosis
G – resorption of cortical bones with vacuolizations in cancellous bones
D – cincalcet and if not improved consider parathyroidectomy
E)important in case of symptoms worsening
F)high bone turn over
H)continue on the same regimen
E. Bone biopsy important to determine high or low turnover bone, mineralization, aluminum toxicity
F. Mixed type of osteodystrophy
G. Increase osteoblast and osteocyte with cystic lesion and decrease mineralization
H. Continue on vitamin D and calcium
Take x ray of the hip and spine to look for fractures
E. The bone biopsy is done because of worsening of bone symptoms despite vitamin D substitution for 3 months, and because the PTH value is also high enough together with AP what can cause a high turnover bone disease.
F. High turnover bone disease With/without Osteomalacia
G. we can see on one side new osteoid formation with many osteoblasts and on other side osteoclasts with bone resorption on other side. so it is a picture of mixed bone osteodystrophy. because of increased osteoid activity on one side and increased osteoclastic activity on the other side.
H. I will increase Vitamin D Dosage to maximum for further 3 months (There is furthermore vitamin D insufficency), i will increase calcium in dialysate, i will start cinacalet and if the patient did not got better or got worse in 3 month i will refer him to PTx.
the bone biopsy shows apicture of mixed osteodystrophy, on the right side osteomalaciapresents as there is a lot of osteoid which is undermineralized, on the left side there are osteoblast, continue medical treatment
Discuss the role of bone biopsy in this patient.high bone turnover
bone specific ALP
What is the expected bone histopathological abnormality in the patient?
HPT WITH HIGH BONE TURNOVER
What is your suggested management plan?
Increase alphacalcidol, cinacalcet
Bone profile
At last SURGERY
E. Discuss the role of bone biopsy in this patient.
Bone biopsy is the gold standard for diagnosing Renal osteodystrophy.
F.What is the expected bone histopathological abnormality in the patient?
High turnover bone disease characterized by boney trabeculea which were irregular in shape
Overproduction of osteoid cells like osteoblasts and osteoclasts , increase fibrosis and collagen accumulation.under mineralization with osteomalacia.
G.Interpret the above histopathological changes.
Overproduction of osteoblasts and osteoclasts
Fibrosis and over production of collagen .
H. What is your suggested management plan?
Ca and vitamin D supplements
Parathyroidectomy.
PATIENT HAS HIGH BONE TURNOVER CONFIRMED BY BIOPSY , NEEDS TO CONTINUE ON CALCIUM , VITAMIN D ,CINACALCET TO BE ADDED , CONSIDER SURGICAL INTERVENTION IF NO IMPROVEMENT
E
Bone biopsy is mandated in veiw of the worsening of the condition
F
High bone turnover
G
High bone turnover with abundance of osteoclasts and undermineralization
H
patient needs incremental doses Cinacalcit to control his SHPT, if failed, he would need parathyroidectomy
E- role of bone biopsy worsening symptoms of patient , persistence of high level of pth and alkaline phosphatase.
F- the expected findings high bone turn over as thining of Cortex of bone secondary to hyperparathyroidism
G- interpretation on bone biopsy is high bone turn over increase oesteoclast activity and decrease in cortex.
H- management plane continue with vit d and calcium supplement and add cinacalcite if symptoms persist and no improvement we considered surgical parathyroidectomy
E. Discuss the role of bone biopsy in this patient.
pt. still high alkp and HPTH
IN HIGH TURN OVER CONDITION
bone biopsy to study the volume or density of bone
F. What is the expected bone histopathological abnormality in the patient?
increase bone volum and thinning of cortex
E. Discuss the role of bone biopsy in this patient.i think high PTH with high ALP mostly suggestive high bone turnover and no need for bone biopsy we can order bone specific ALP
F. What is the expected bone histopathological abnormality in the patient?HYPERPARATHYROIDISM WITH HIGH BONE TURNOVER
H. What is your suggested management plan?WE CAN INCREASE DOSE OF ALFACALCIDOL AND ADD CINACALCET
FU BONE PROFILE AND PTH
IF NO IMPROVEMENT REFERE FOR SURGERY
E. Discuss the role of bone biopsy in this patient.
F. What is the expected bone histopathological abnormality in the patient?
G. Interpret the above histopathological changes.
H. What is your suggested management plan?
E. Discuss the role of bone biopsy in this patient.The decision for a bone biopsy was taken because of the symptoms, but the symptoms were explained by the lab finding.
In patients with CKD G3a–G5D, it is reasonable to perform a bone biopsy if knowledge of the type of renal osteodystrophy will impact treatment decisions.
The bone biopsy will not change the decision about treatment.
F. What is the expected bone histopathological abnormality in the patient?
G. Interpret the above histopathological changes.
Increased osteoclast numbers and some fibrosis are hallmarks of high-turnover bone disease.
a lack of mineralization and an increase in the number of osteoid bones that have not yet been mineralized.
According to these characteristics, it is likely that a case of secondary hyperparathyroidism exists.
H. What is your suggested management plan?Continue vitamin D supplementation, add cinacalcet
F/U bone profile and symptoms
If there is no improvement, consider parathyroid surgery.
A.Discuss the role of bone biopsy in this patient.*Biopsy may be important but in this particular case I wouldn’t recommend it because
F. What is the expected bone histopathological abnormality in the patient?
G. Interpret the above histopathological changes
H. What is your suggested management plan?
E. Discuss the role of bone biopsy in this patient.
F. What is the expected bone histopathological abnormality in the patient?
G. Interpret the above histopathological changes.
H. What is your suggested management plan?