Scenario 2 - Part 2:

The patient underwent a bone biopsy, which is represented in Figure A. A decision has been taken to add Teriparatide therapy 20 mcg /day to the patient’s previous treatment. One year later, the patient follow-up laboratory investigations are as follow:

 

Test

Value

S. Creatinine

3.2 mg/dL

S. corrected Calcium 

8.1 mg/dL

Phosphorus

5.7 mg/dL

PTH

21 pg/mL

Alk-phosphatase/total 

110 U/L (30-130)

 

A repeat bone biopsy is shown in figure B

E) Interpret the above shown bone histopathological specimen.

F) Appraise the rationale of using teriparatide in this case in view of the current guidelines.

29 Comments

  • Radwa Ellisy


    this is hypocellular bone without fibrosis, scanty osteoid, decreased matrix
    Teriparatide is a recombinant parathormone (1-34) that directly stimulate osteoblast and osteoclasts. approved by FDA for osteoporosis, till not approved for ABD

  • Amna Kununa


    E) Interpret the above shown bone histopathological specimen.
    Hypocellularity and low bone volume

    F) Appraise the rationale of using teriparatide in this case in view of the current guidelines.
    Teriparatide (PTH 1-34) directly stimulates the number of osteoblasts and osteoclasts, which may result in increased bone turnover in patients with ABD. Teriparatide have been approved by the US Food and Drug Administration for the treatment of postmenopausal osteoporosis, have not yet been approved for the treatment of ABD. 

  • Asma Aljaberi


    E) Interpret the above shown bone histopathological specimen.Hypocellularity and low volume of osteoid indicating that he has ABD

    F) Appraise the rationale of using teriparatide in this case in view of the current guidelines.As the patient has ABD, Teriparatide is approved for treatment of this condition. Teriparatide activates osteoblasts leading to increase bone density and strength. It also causes transient hypercalcemia due to the effect on bone.

  • Mohamed Abdulahi Hassan


    Interpret the above shown bone histopathological specimen.ABD shows scanty osteoid, bone hypocellularity
    Appraise the rationale of using teriparatide in this case in view of the current guidelines.teriparatide reverses the osteoporosis by stimulating new bone formation. and increases bone mass

  • Khaldon Rashed Ahmed Moqbil


    A-dynamic bone dis with hypo cullular b improve cellular

    Teriparatide will improve bone density and reduce bone fracture

  • Muhammad Soobadar


    E-ABD
    F- Recombinant PTH used in case of osteoporosis with some evidence in Dialysis patient

  • Ahmed Altalawy


    E. Interpret the above shown bone histopathological specimen.
    The bone is hypocellular and the bone volume is low, the osteoid seams are scanty.
    F. Appraise the rationale of using teriparatide in this case in view of the current guidelines.
    Teriparatide (Forteo) is a recombinant human PTH (1–34), which stimulates osteoblast function. In addition, teriparatide has been reported to augment bone mineral density, bone mass, and strength

  • Hagar Ali


    E)hypocellular ABD
    F)Teriparatide (Forteo) is a recombinant human PTH (1–34), which stimulates osteoblast function. In addition, teriparatide has been reported to augment bone mineral density, bone mass, and strength. 

  • KAMAL ELGORASHI


    Histopathology of figure A
    Reduce osteocyte size and defective mineralization.
    Histopathology of figure B
    Better bone mineralization and bone volume and cellularity.
    Teriparatide

    • Reduce the risk of fracture.
    • Improved bone vertebral and femoral neck bone density.
    • Associated with stable GFR compared to another untreated in the cohort.

  • MOHAMMED HAJI HASSAN


    E) Interpret the above shown bone histopathological specimen.

    A-Reduced number of cellular activity and osteoid consistent with adynamic bone disease
    B- improvement of the bone minaralization and cellularity

    F) Appraise the rationale of using teriparatide in this case in view of the current guidelines.
    Teriparatide is the recombinant (1–34) N-terminal region of human parathyroid hormone (PTH1−34) and its administration is indicated for patients with severe osteoporosis and post-menopausal women.
    Teriparatide improves both bone mineralization and bone density which is useful for this case.

  • Rania Mahmoud


    E) Interpret the above shown bone histopathological specimen.The hypocellularity is marked in figure B with a low number of osteoplasts. This is consistent with ABD
    F) Appraise the rationale of using teriparatide in this case in view of the current guidelines.

    • Improve bone mineral density and decrease risk of fracture
    • Improve the quality of bone and stimulate osteoblast activity 
  • Mahmud ISLAM


    The hypocellularity is marked in figure B with a low number of osteoplasts. This is consistent with ABD. Anabolic or bone formation stimulating agents like Teriparatide is indicated in such case.

  • Alaa Abdel Nasser


    bone histopathological specimen shows low bone volume,overmineralized old bone, paucity of cells,no osteoid ,(low bone turn over).

    Appraise the rationale of using teriparatide in this case in view of the current guidelines.improve bone mineral density and decrease risk of fracture

  • Rihab Elidrisi


    Interpret the above-shown bone histopathological specimen.hypo cellular bone biopsy which looks like ABD

    Appraise the rationale of using teriparatide in this case in view of the current guidelines.

    Teriparatide will improve the quality of bone and stimulate osteoblast activity and increase bone density and miniralization

  • Asmaa Salih KHUDHUR


    E) Interpret the above shown bone histopathological specimen.
    Slide A 
    Hypocellularity
    Low mineralization 
    Low volume 
    Slide B
    Osteoblasts and osteoclasts present
    Normal mineralization 
    Normal volume 
    No bone marrow fibrosis 

    F)Appraise the rationale of using teriparatide in this case in view of the current guidelines.
    Teriparatide (Forteo) is a recombinant human PTH (1–34), which stimulates osteoblast function. In addition, teriparatide has been reported to augment bone mineral density, bone mass, and strength. 

  • Rabab ALaa Eldin keshk Rabab


    E)Interpret the above shown bone histopathological specimen.
    Hypocelular bone matrix so is adynamic bone disease
    F) Appraise the rationale of using teriparatide in this case in view of the current guidelinesTeriparatide is a recombinant PTH which stimulates osteoblast function. In addition, teriparatide has been reported to augment bone mineral density, bone mass, and strength.

  • Nour Al Natout


    E. Morphology of hypocellular bone : Adynamic bone disease
    F. Teriparatide increased BMD especially in vertebral body. The studies that can be based on are Mitsopoulos et al: 9 HD with 48 Week of therapy with teriparatide : Improvement in BMD (femoral neck 2,7% and lumbar 4,9%)
    Cejka et al : 7 patient with ADB with 6 Month –> improvement in BMD in lumbar spine
    Sumida et al: 22 patients on HD with 56.5µg dose once weekly for 1 year: improvement in BMD score at lumbar spine by 3%. No change in BMD at femoral neck and distal radius.

  • Israa Hammoodi


    E) Interpret the above shown bone histopathological specimen.
    There is decrease in the osteoblast cell with decrease bone volume and normal mineralization suggest ADB

    F) Appraise the rationale of using teriparatide in this case in view of the current guidelines

    Teriparatide is a recombinant PTH that increase osteoblast activity and improve bone density and remodeling

  • Abdulrahman Almutawakel


    A- BONE BIOPSY .. HYPOCELLULAR , LOW BONE VOLUME … ABD
    B- MY OPINION IT WAS AGOOD DESECION TO GIVE TERIPARATIDE

  • Emad mohamed mokbel Salem


    F) Appraise the rationale of using teriparatide in this case in view of the current guidelines.can be used in this patient

  • Mahmoud Sobh


    Model answers by the board:
    E. Interpret the above shown bone histopathological specimen.
    The bone is hypocellular and the bone volume is low, the osteoid seams are scanty. This is typical for patients with ABD. There is no bone marrow fibrosis. 
    F. Appraise the rationale of using teriparatide in this case in view of the current guidelines.
    Teriparatide (Forteo) is a recombinant human PTH (1–34), which stimulates osteoblast function. In addition, teriparatide has been reported to augment bone mineral density, bone mass, and strength. Therefore, FDA U has approved teriparatide use for the treatment of osteoporosis with high risk of fracture. Moreover, an additional study demonstrated that PTH analog (abaloparatide) therapy improves bone mineral density in hemodialyzed patients with adynamic bone disease.

  • Mahmoud Elsheikh


    Interpret the above shown bone histopathological specimen.
    IN SLIDE A: low mineralization, low osteoblast cells, low volume
    slide B: improvement in bone mineraliztion, increase osteoblast cells.
    Appraise the rationale of using teriparatide in this case in view of the current guidelines.
    -Teriparatide is a recombinant form of PTH , give good results in low PTH as in our case.
    Mitsopoulos et.al showed improvement in BMD in 9 HD patients after 48 weeks of therapy (femoral neck 2.7% & lumbar spine 4.9%), Cejka et al. showed improvement in BMD at lumbar spine (3.0%) in 7 HD patients after 6 months of treatment with teriparatide. However, no improvments in BMD at the femoral neck, and no changes in bone-turn over markers or CAC score, Sumida et al. showed improvment in BMD at lumbar spine in 22 HD patients over 48 weeks. No changes at the femoral neck or the distal radius. Teriparatide was discontinued in 50% due to transient hypotension

  • Riaan Flooks


    Interpretation:

    1. Slide 1:
    2. Low bone volume associated with reduced mineralisation
    3. Very little osteoblasts noted
    4. Slide 2:
    5. Improved bone volumne, mineralisation and cellularity

    Teriparatide:

    • Useful in patients with Low PTH
  • HASSAN ALYAMMAHI


    E) Interpret the above shown bone histopathological specimen.
    Slide A: unmineralized osteoid tissue, low number of osteoblast and osteoclast. Slide B:  increased number of bone cells with better bone mineralization
    F) Appraise the rationale of using teriparatide in this case in view of the current guidelines.
    The amino acids 1-34 of teriparatide, a recombinant version of PTH, bind to the PTH type 1 receptor, stimulating osteoblast activity.After 48 weeks of therapy, Mitsopoulos et al. found that BMD had improved in 9 HD patients (femoral neck 2.7% and lumbar spine 4.9%).After 6 months of teriparatide treatment, Cejka et al. found 3.0% improvement in BMD at the lumbar spine in 7 HD patients. However, no improvments in BMD at the femoral neck, and no changes in bone-turn over markers or CAC scoreSumida et al. showed improvment in BMD at lumbar spine in 22 HD patients over 48 weeks. No changes at the femoral neck or the distal radius. 50% of those taking teriparatide stopped because of temporary hypotension

  • Weam El Nazer


    E) Interpret the above shown bone histopathological specimen.A- unmineralized osteoid tissue, low number of osteoblast and osteoclast.
    b- increase the number of bone cells with the improvement of bone mineralization

    F) Appraise the rationale of using teriparatide in this case in view of the current guidelines.
    In patients with CKD G3a–G5D with biochemical abnormalities of CKD-MBD and low BMD and/or fragility fractures, we suggest that treatment choices take into account the magnitude and reversibility of the biochemical abnormalities and the progression of CKD, with consideration of a bone biopsy 
     patients with ESRD and ABD showed increases in lumbar BMD after treatment with teriparatide. Recombinant PTH might have osteoanabolic effects in this subset of patients.(1)
    Sumida et al.: 22 patients on dialysis; 56.5 μg dose :–High rate of discontinuation (50%) due to transient hypotension.
    –Improvement of BMD at lumbar spine by 3.3% and 3.0% at weeks 24 and 48, respectively.
    –No change in the BMD at femoral neck and distal radius. 

    1- Cejka, D., Kodras, K., Bader, T., & Haas, M. (2010). Treatment of hemodialysis-associated adynamic bone disease with teriparatide (PTH1–34): a pilot study. Kidney and Blood Pressure Research33(3), 221-226.‏

  • Ashraf Ahmed Mahmoud


    D Interpret the above shown bone histopathological specimen.

    IN SLIDE A

    low mineralization
    low osteoblast cells .
    low volume

    slide B

    • improvement in bone mineraliztion .
    • increase osteoblast cells.

    F) Appraise the rationale of using teriparatide in this case in view of the current guidelines.
    Teriparatide is a recombinant form of PTH 
    give good results in low PTH as in our case.

  • Ben Lomatayo


    -E) Interpret the above shown bone histopathological specimen.-A Before teriparatide

    • T = Low bone turn over .i.e decrease number of osteoblast & osteoclast
    • M = undermineralization
    • V = Low bone volume

    -B After teriparatide

    • T = Improvement in bone cellularity, now we can appreciate osteoblasts & osetoclasts
    • M = Normal mineralization
    • V = Normal bone volume

    F) Appraise the rationale of using teriparatide in this case in view of the current guidelines.

    • Teriparatide is a recombinant form of PTH consisting of amino acids 1-34 that bind to PTH type1 receptor sitmulating osteoblast activity
    • Mitsopoulos et.al showed improvement in BMD in 9 HD patients after 48 weeks of therapy (femoral neck 2.7% & lumbar spine 4.9%)
    • Cejka et al. showed improvement in BMD at lumbar spine (3.0%) in 7 HD patients after 6 months of treatment with teriparatide. However, no improvments in BMD at the femoral neck, and no changes in bone-turn over markers or CAC score
    • Sumida et al. showed improvment in BMD at lumbar spine in 22 HD patients over 48 weeks. No changes at the femoral neck or the distal radius. Teriparatide was discontinued in 50% due to transient hypotension
  • Elsayed Ghorab


    sorry
    >> poor experience in reading histopathological of bone disease
    we need lecture from our prof dr amr alhusseini
    how to reading radiology bone
    and histopathology

  • Ibrahim Omar


    E) Interpret the above shown bone histopathological specimen.

    • improvement in matrix mineralization in slide B
    • improvement in bone architecture in slide B
    • increase in the number of osteoblast cells in slide B

    F) Appraise the rationale of using teriparatide in this case in view of the current guidelines.

    • it is highly indicated in this current situation

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