Scenario 1 - Part 1:

A 72-year-old male with ESKD, who is maintained on HD for five years, complains of worsening bone pains through the past few months. The patient’s laboratory investigations are shown in table 1:

Test

Value

iPTH

199 pg/ml

corrected s. calcium

7.8 mg/dl

S.po4

5.3 mg/dl

alkaline phosphatase

187 U/L

25 (OH)vitamin D

15 ng/ml

 

DEXA scan was performed as a part of the patient’s work-up as follows:

DEXA

T score

Z score

Lumbar spine

-2.1

-2

Femur neck

-0.8

-0.1

femur (total)

-1.6

-1

forearm

-2.8

-2.1

 

A- Interpret the above laboratory investigations.

B- Interpret the results of the bone density scan.

C- Would you perform a bone biopsy for this patient?

37 Comments

  • Amna Kununa


    A- Interpret the above laboratory investigations.Hypocalcemia in the context of vitamin D deficiency with hyperphosphatemia. iPTH is within the target as per KDIGO guidelines.

    B- Interpret the results of the bone density scan.osteoporosis in the forearm, while low bone mass (osteopenia) in the spine and femur

    C- Would you perform a bone biopsy for this patient?Yes, iliac crest bone biopsy after double tetracycline labeling may be useful, particularly for distinguishing osteoporosis from osteomalacia or in the setting of advanced chronic kidney disease (stage 4+)

  • Asma Aljaberi


    A- Interpret the above laboratory investigations.
    Given severe bone pain history and considering the biochemical lab results, the patient most likely has osteomalacia due to hypocalcemia secondary to vitamin D deficiency caused by ESRD.

    B- Interpret the results of the bone density scan.
    The patient has Osteoporosis based on the T score of the forearm and the Z score of the age-matched patients. The Z-scores of the spine and forearm are worse than the age-matched population.

    C- Would you perform a bone biopsy for this patient?
    I would treat first with calcium, cholecalciferol, and calcitriol. I would watch out for the Phosphate level, and if it started to increase, I would add sevelamer. If the vitamin D and calcium corr levels were corrected, but the patient continues to have severe bone pain, I would go for a bone biopsy.

  • Muhammad Soobadar


    A- lab- spht , vitamin D deficiency
    B bone density osteoporosis forearm and osteopenia at lumbar and femoral site
    C I would treat vitamin deficiency and if pain no better consider bone biopsy.

  • Mohamed Abdulahi Hassan


    A- Interpret the above laboratory investigations.hypocalcemia, and hyperphosphatemia
    pth with in upper normal limit and hypovitaminosis D
    B- Interpret the results of the bone density scan.
    T-score of forearms is indicative of osteoporosis and femur as osteopenia.
    C- Would you perform a bone biopsy for this patient?yes, biopsy is recommended.

  • Rasha Samir


    A.    Interpret the above laboratory investigations.
    The patient presented with mild hypocalcemia and hyperphosphatemia. His PTH level is within target according to the latest KDIGO recommendations (2-9 folds of upper normal limits), so it does not explain his severe bone pain. Vitamin D deficiency may be the cause of his complaint.
    B.    Interpret the results of the bone density scan.
    The T score of the forearm refers to osteoporosis. While that of the lumbar spine and femur is considered as osteopenia. The old age and end stage kidney disease along with vitamin D deficiency are risk factors for osteopenia and osteoporosis.
    C.    Would you perform a bone biopsy for this patient?
    These laboratory investigations don’t explain the cause of his severe bone pain. So, bone biopsy helps to diagnose the bony abnormalities and guide toward the appropriate treatment.

  • Asmaa Salih KHUDHUR


    Interpret the above laboratory investigations.PTH and ALP is within the normal rang in HD patient
    hypocalcemia, p upper normal level
    vit D3 deficiency
    Interpret the results of the bone density scan.The T score of forearm indicate osteoporosis while lumbar and femur total osteopenia
    Would you perform a bone biopsy for this patient?Not at this stage, I need medical correction of vitamin D deficiency and then follow up

  • ahmed bhnassi


    PTH with lower normal level of reference for CKD5 HD (150 -600) pg/ml
    hypocalcemia
    slightly high ALp
    high po4
    Low vit D indicate deficiency
    BMD: indicate mixed osteopenia and fore arm osteoporosis
    Wait for biopsy at this stage first to correct hypocalcemia, vit d deficiency with oral supplementation and sun exposure and hyperphosphatmia

  • Khaldon Rashed Ahmed Moqbil


    A-⬆️alkaline phosphatase
    high phos,hypocalcemia and vit deficient in
    B- osteopenia
    c- no biopsy

  • Mahmoud Elsheikh


    A- interpret the above laboratory investigations.

    • high alkaline phosphatase
    • high PO4
    • hypocalcemia
    • deficient in vit D

    B- Interpret the results of the bone density scan.
     Bone scan shows Osteopenia (by t-score)
    C-  Would you perform a bone biopsy for this patient?
    No, I would treat deficient vitamin d first then re-evaluate.

  • Nour Al Natout


    A.hypocalcemia, mild hyperphophatemia with increased PTH , vitamin D deficiency.
    B.osteopenia in lumbar and femur neck
    Osteoporosis forearm.
    C. Bone biopsy will help me to differentiate between adynamic bone disease and osteomalacia in this patient and may be a mixed picture of both but i will firstly correct the vitamin D deficiency and then reassessment.

  • Riaan Flooks


    A- Interpret the above laboratory investigations.

    • Results shows Hypocalcemia associated with Hyperphosphatemia and Vitamin D deficiency
    • Also has an elevated ALP

    B- Interpret the results of the bone density scan.

    • Forearm indicative of osteoporosis
    • Femur scores indicative of osteopenia

    C- Would you perform a bone biopsy for this patient?

    • Firstly, I would address the issue of the Hypocalcemia and Hypovitamintosis D
    • The ALP and PTH is inconclusive of any specific bone disease, and if the previously mentioned interventions does not normalise the biochemical parameters – then I will consider doing a bone biopsy
  • HASSAN ALYAMMAHI


    A- Interpret the above laboratory investigations.
     
    Patient has high alkaline phosphatase, and high PO4. He has hypocalcemia, and is deficient in vit D

    B- Interpret the results of the bone density scan.
     
    Bone scan shows Osteopenia (by t-score)

    C-  Would you perform a bone biopsy for this patient?
     
    No, there are some correctable elements in this patient. I would replace vitamin, and give Ca based phosphate binder and will reassess in 2 months

  • Emad mohamed mokbel Salem


    CKD 5D
    Hypovitaminosis D ,hypocalcemia، SHPT
    2-Dxa scan
    Osteoporosis of forearm and osteopenia of lumbar spine

    3- yes this patient need bone biopsy for adjustment of treatment

  • Rania Mahmoud


    A- Interpret the above laboratory investigations.This patient has hypocalcemia , hyperphosphatemia and low VIT D
    PTH within normal level in hemodialysis patient.
    B- Interpret the results of the bone density scan.The T score of the forearm refers to osteoporosis
    The T score of lumbar spine refers to osteopeniaThe T score of femur refers to osteopeniaC- Would you perform a bone biopsy for this patient?I would not perform a bone biopsy at this time because this patient has vitamin D deficiency.

    • I’ll start with vitamin D and calcium supplements with regular follow up .
    • QCT may be considered in the future with a repeat DEXA scan, 
    • Further data about cortical and trabecular bone, as well as their quality and strength.
    • If no improvement after all of these . Bone biopsy could be considered
  • Ashraf Ahmed Mahmoud


    A- Interpret the above laboratory investigations
    – hypocalcemia , hyperphosphatemia and low VIT D
    PTH within target level in hemodialysis pts.

    B-Interpret the results of the bone density scan
    osteopenia and osteoporosis.

    C- Would you perform a bone biopsy for this patient?
    BONE BIOPSY is recommended

  • Israa Hammoodi


    A- Interpret the above laboratory investigations.

    The patient has increased PTH, hypocalcimia, low vitamin D store, normal alkaline phosphotase, increase phosphorus
    B- Interpret the results of the bone density scan.

    Osteopenia in lumber spine and forearm
    C- Would you perform a bone biopsy for this patient?

    No, treatment with calcium and vitamin D then reevaluation

  • Rabab ALaa Eldin keshk Rabab


    A- Interpret the above laboratory investigations.
    Secondary hyperparathyroidism with hypocalcimia and upper normal po4 vit d deficiency elevated alkaline phosphatase

    B- Interpret the results of the bone density scan.
    Oesteoprosis in forearm Osteopenia in femur neck and spine

    C- Would you perform a bone biopsy for this patient?
    No first i will try correction if hypocalcimia and hypovitaminosis d

  • Rihab Elidrisi


     Interpret the above laboratory investigations.This patient has hypocalcemia with relatively high PTH and highish ALP along with high normal phosphorus levels o, according to this finding. This patient is having a mixing type of ROD ( high and low bone turnover)

     Interpret the results of the bone density scan.DEXA scan showed osteopenia ( low bone mass ) in the lumbar .femuer neck and femur total with T scores of _2.1,-0.8,-1.6, respectively. In comparison, the Z score compares the patient’s MBD to an aged-matched population, which showed -2.0 and -2.1 for the lumbar spine and forearm, which is atypical for the peer age group.

     Would you perform a bone biopsy for this patient?
    i think bone biopsy in such patient will be beneficial and informative to distinguish which type of ROD this patient has specially that the bone biomarkers and PTH is showing mixed picture

  • Alaa Abdel Nasser


    Lab results show hypocalcemia, mild hyperphosphatemia, with PTH (secondary hyperparathyroidism),slightly elevated alkaline phosphatase and low vitamin d level.
    DEXA scan shows osteopenia ( and osteoporosis in the forearm )

    I recommend treatment of vitamin d deficiency first and improve hypocalcemia
    and if there is no improvement in symptoms, bone biopsy could be considered

  • Mahmud ISLAM


    This patient has mild hypocalcemia and elevated PTH but is within the target for this stage of CKD. Phosphorus is also normal and within the target. Vitamin D deficiency is present. Its supply may not affect the PTH that much, so we can give normal vitamin D rather than calcitriol. If already of calcitriol, I will modify the dose according to the trend of PTH. Leaving this patient mildly hypocalcemic and even lowering the dialysate calcium with monitoring the PTH level is acceptable to evaluate/avoid adynamic bone disease.

    The DEXA correlates with osteoporosis in the forearm, which is the most common place, and osteopenia in the femur and spine. The risk of fracture is present, so we need to give antiresorptive treatment. This may help resolve hypocalcemia, as far as I remember.

    If I have the capability, I will do a bone biopsy because the PTH is not well correlated to specific bone pathology that I can diagnose without histologic evaluation.

  • Ahmed Altalawy


    A- Interpret the above laboratory investigations. ESRD on Regular HD , normal P , low calcium and Vit D , PTH can be consider on low normal side as patient on HD since 5 years.
    B- Interpret the results of the bone density scan. consistent with osteopenia
    C- Would you perform a bone biopsy for this patient? Better to do bone biopsy to confirm if there is osteporosis or adynamic bone disease .

    • Rasha Samir


      Right! but his PTH level is within target according to the latest KDIGO recommendations (2-9 folds of upper normal limits).
      Moreover, The T score of the forearm refers to osteoporosis. While that of the lumbar spine and femur is considered as osteopenia

  • MOHAMMED HAJI HASSAN


    A- Interpret the above laboratory investigations.
    LABS: Hypocalcemia-Hyperphosphatemia-low Vitamin-High levels of PTH and ALP.

    B- Interpret the results of the bone density scan.
    DEXA: lumbar spine and femur show Osteopenia while the forearm shows Osteoporosis.
    C- Would you perform a bone biopsy for this patient?
    Yes, Bone biopsy is the gold standard diagnostic test. it can provide detailed information on the structure and composition of the bone and can help diagnose ROD.

  • Mark Nagy Zaki Amin Mark


    A- lab results show hypocalcemia with vit D deficiency and normal values of PTH , po4 and alkaline phosphatase
    B – femur neck …normal
    lumbar spine and femur (total)…..osteopenia
    forearm…..osteoporosis
    C- according to KDIGO guidelines in CKD MBD 2017 , this patient with Vit D deficiency and osteoporosis as evidenced by DEXA scan should receive anti resorptive therapy as denosumab or bisphosphonates before performing bone biopsy

  • Ahmed Wagih


    A- Interpret the above laboratory investigations
    labs showed hypocalecemia, hyperphosphatemia, vit D deficiency, and hyperparathyroidism more than2 folds upper normal limits, all these labs are going with 2ry hyperparathyroidism. MIildly elevated alkaline phosphatase can not make diagnosis of high bone turnover straight forward

    Interpret the results of the bone density scan
    as patient age is 72 yrs old, so we will focus on T-score which shows osteoporosis at the foream and osteopenia at lumbar spine and at femur

    Would you perform a bone biopsy for this patient
    this patient needs renal biopsy as the level of PTH and alk. phosphatase can not differentiate the type of renal osteodystrophy, so renal biopsy can diagnosed turnover status and mineralization before starting antiosteoporotics

  • Ben Lomatayo


    A- Interpret the above laboratory investigations.

    • Both PTH and tALP are beginning to rise
    • Hypocalcemia, and PO4 at the higher normal
    • Vitamin D deficiency
    • These are findings keeping with the description of CKD-MBD and could suggest mixed uremic osteodystrophy.

    B- Interpret the results of the bone density scan.

    1. Lumbar spine: T score = Osteopenia + Z score = Atypical BMD for peer group
    2. Femur neck: T score = Normal BMD + Z score = Typical BMD for peer group
    3. Femer total: T score = Osteopenia + Z score = Typical BMD for peer group
    4. Forearm: T score = Osteoporosis + Z score = Atypical BMD for peer group

    C- Would you perform a bone biopsy for this patient?

    • At the moment I wouldn’t go for bone biopsy, this patient had a clear clinical and laboratory evidence of vitamin D deficiency. I will go for treatment of vitamin deficiency first and closely monitor him. QCT may be considered in future together with repetition of the DEXA scan to give us the progress, response to treatment, more data about cortical, trabecular bone, their quality and strength. We may need all these before making a decision about bone biopsy.
  • KAMAL ELGORASHI


    Interpret the above laboratory investigations

    • secondary hyperparathyroidism with hypocalcemia, hyperphosphatemia, severe vitD deficiency, and elevated ALP.

    Interpret the results of the bone density scan.

    • Bone osteopenia

    Would you perform a bone biopsy on this patient?

    • According to KDIGO guidelines and recommendations, no need for bone biopsy, so plan treatment based on the laboratory and imaging results and assess treatment response.
    • Bone biopsy apart from invasiveness procedure, it may show an overlapping pathology that may not, clearly give a spot diagnosis
    • Rasha Samir


      The T score of the forearm refers to osteoporosis, While that of the lumbar spine and femur is considered as osteopenia. Yet, Bone biopsy may help the diagnosis making in such a case and guide toward the appropriate treatment.

  • Elsayed Ghorab


    A- Interpret the above laboratory investigations.the lab investigation revealed
    hypocalcemia
    hypovit. D
    PTH start to elevated 2ry to low vit.D and hypocalcemia
    alkaline phosphatase within normal
    this picture of bone marker in adynamic bone disease

    B- Interpret the results of the bone density scan.bone density scan
    T-score show osteopenia
    C- Would you perform a bone biopsy for this patient?start conservative treatment
    control hypocalcemia and deficiency vit.D
    added calcium supplement and vit D
    and follow up if no response
    interferes bone biopsy to confirm diagnosis

  • Abdulrahman Almutawakel


    A- Interpret the above laboratory investigations
    -PATIENT HAS HYPERPARA WITH HYPOCALCEMIA AND HYPERPHOSPHATEMIA WITH LOW VIT D ,
    B-Interpret the results of the bone density scan
    DEXA SCAN SHOWING PICTURE OF OSTEOPENIA WHICH USUALY ASYMPTOMATIC

    C- Would you perform a bone biopsy for this patient?
    AS PATIENT COMPLAINING OF INCREASING BONE PAIN SO MAY I WILL RECOMENEED FOR HIM BONE BIOPSY IF NO RESPONCE FOR TREATMENT WITH CALCIUM SUPPLEMENTATION AND VIT CORRECTION

  • Weam El Nazer


    A- Interpret the above laboratory investigations.normal PO4, low Ca, normal PTH, normal alkaline phosphatase, and low 25-OH Vit-D.
    an earlier stage of BMD associated with ESRD secondary to low CA and Vit-D. If not corrected, it will progress to secondary hyperparathyroidism.

    B- Interpret the results of the bone density scan.T-score revealed low bone mass (osteopenia). most likely related to low vitamin D.
    C- Would you perform a bone biopsy for this patient?There is no need for a bone biopsy as the symptoms and clinical manifestations could be explained by low vitamin D and hypocalcemia.
    I will recommend adding active vitamin D and calcium carbonate and following up on the lab and symptoms.

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