Scenario 1 - Part 2:
The patient underwent a bone biopsy which revealed high osteoid volume and normal lamellar architecture of bones. Approximately 80% of trabecular surfaces show aluminum deposit.
D- What is the most likely diagnosis of this case according to his bone histomorphometry?
E- How would you approach this case?
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D- What is the most likely diagnosis of this case according to his bone histomorphometry?
Aluminum overload causes defective mineralization and increased matrix
E- How would you approach this case?
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D- What is the most likely diagnosis of this case according to his bone histomorphometry?
Mineralization defect due to aluminum Toxicity.
E- How would you approach this case?
Check the plasma level of aluminum using desferoxamine test. It if the test showed high aluminum level that increased with the test, then desferral course weekly infusion for 8 weeks. Then the course could be repeated depend on the aluminum level.
D cannot inteprete it not enough knowledge on bone biopsy. mineralisation issue due to aluminiun toxicity
E check serum aluminium, review drugs and check dialysis water aluminium content
What is the most likely diagnosis of this case according to his bone histomorphometry?
mixed bone disease
How would you approach this case?
monitor serum aluminum concentration.
stop aluminum containing phosphate Binders. Deferoxamine
Deferoxamine
What is the most likely diagnosis of this case according to his bone histomorphometry?
Mixed renal osteodystrophy with mineralization defect secondary to aluminum accumulation is the most probable diagnosis.
E. How would you approach this case?
KDOQI guidelines recommended screening for aluminum toxicity with plasma aluminum concentrations at least yearly and quarterly in those receiving aluminum-containing drugs.
Rise in serum aluminum of ≥50 µg/L following desferoxamine test combined with serum PTH levels of <150 pg/Ml, can predict aluminum intoxication.(OPINION)
The gold standard for the diagnosis is bone biopsy with aluminum staining of about 25% of the bone surface.
Symptomatic patients with an aluminum concentration between 20 and 200 μg / L and whose concentration increases by 50 μg / L after desferrioxamine test should receive 5 mg / kg of desferral per week for 8 weeks.
After 8 infusions, if the serum desferrioxamine test is still positive, a new cycle of eight weeks should be prescribed until the blood aluminum level has decreased to less than 50 μg / L. (1)
What is the most likely diagnosis of this case according to his bone histomorphometry?Mixed bone disease
How would you approach this case?Look for the source of aluminum and remove it , check the water unit , aluminum-containing phosphate binder , foods or drugs.
use chelating agent like DFO
5mg /kg for 8wk till normalization of its serum level.
biopsy mostly towered A dynamic bone disease type of ROD with osteomalacia due to aluminium toxicity .
treatment stop aluminum sources and aluminum containing phosphate Binders with also Deferoxamine 5 mg/kg ever week for 8 week and follow up with screen for infection with mucuromucosis during course of treatment
Adynmic bone dis
treat aluminum toxicity
check water system and deferoxamine
What is the most likely diagnosis of this case according to his bone histomorphometry?
ROD (Osteomalacia)
How would you approach this case?
D. Adynamic bone or osteomalacia due to aluminium intoxication.
E treat water, stop aluminum containing phosphate Binders. Deferoxamine 5 mg/kg ever week for 8 week
D- What is the most likely diagnosis of this case according to his bone histomorphometry?
E- How would you approach this case?
D- What is the most likely diagnosis of this case according to his bone histomorphometry?
This is a case of Mixed ROD, with the under mineralization likely secondary to Aluminium toxicity.
E- How would you approach this case? This case of Aluminium toxicity should raise an alarm. Other patients in the unit should be screened for aluminium toxicity. If the patient is the only one having this, then the source of Aluminium can be related to his own environment (drinking water, tablets, etc). If other patients have the toxicity, then water reaching dialysis unit should be assessed for Al contamination.Otherwise, patient has to get his vitamin D replenished.
1-adynamic bone disease dt aluminium toxicuty
2-DFO test
Desfiroxamine and review warer treatment
and medications
D- What is the most likely diagnosis of this case according to his bone histomorphometry?
Mixed renal osteodystrophy with bone demineralization due to aluminum intoxication .
E- How would you approach this case?
Weekly deferoxamine is considered for a period of 8 weeks. and repeat for another 8 ws if aluminium still high Follow-up to the aluminium serum level.Stop source of aluminum in foods and medicines.
Hypocellularity; most probably due to Aluminum toxicity as described. So we need chelation treatment and avoidance of AL sources that may be unreported as part of some products.
D- What is the most likely diagnosis of this case according to his bone histomorphometry?
ROD and bone demineralization due to AL intoxication .
E- How would you approach this case?
check water treatment unit.
DFO TEST.
TTT .
DFO 5 mg/kg for 8 weeks.and repeat for another 8 ws if AL still high .
D- What is the most likely diagnosis of this case according to his bone histomorphometry?
Adynamic bone disease due to Aluminum toxicity
E- How would you approach this case?
Treatment of water used in Dialysate, stop source of aluminum in foods and medicines, use desferoxamine
D- What is the most likely diagnosis of this case according to his bone histomorphometry?
Adynamic bone disease secondary to alamunium toxity
E- How would you approach this case?
Should identify source of alamunium And treat it to stop further exposure
Treat patient with desferroxamine 5 mg/kg weekly for 8 weeks
Adquate diyalisis
D- What is the most likely diagnosis of this case according to his bone histomorphometry?I AM NOT FAMILIAR WITH BONE BIOPSY , BUT WITH THE DESCREPTION THERE IS ALNMINIUM DEPOSITION AND THERE IS REDUCED BONE MASS SO THE DIAGNOSIS ALUMINIUM INDUCED OSTEOMALACIA
E- How would you approach this case?NEEDS TO
1-LOOK FOR THE SOURCE OF ALUMINIUM AND AVOID IT
2-HIGH FLUX FREQUENT DIALYSIS
3-DESFEROXAMIN
What is the most likely diagnosis of this case according to his bone histomorphometry?
This patient is. a Bone slide showed reduced osteoblast and osteoclast activity with reduced osteoid formation, so if we took all the laboratory findings, we would conclude that
this patient either has osteomalacia or adynamic bone disease
Aluminum toxicity appears here in the bone biopsy
in this case, will check his aluminium level and treat it with desfurexmin tabs with serial follow-up to the aluminium serum level.
How would you approach this case?Will check the water dialysis centre and check all the patient medications.
Desferrioxamine 5 mg/kg weekly for eight weeks and repeat desferrioxamine test and if still positive, repeat another eight cycles until Aluminum levels become below 50 mcg/l.
Osteomalacia secondary to aluminum toxicity
Management:
1- desferroxamine 5 mg/kg weekly for eight doses, repeat the deferoxamine stimulation test one month after completion of the eightweek course. If there is an increase in deferoxamine-stimulated aluminum concentration of 50 to 299 mcg/L, give eight more weekly doses of 5 mg/kg and repeat the stimulation test after an additional month.If, after eight weeks of treatment, the deferoxamine-stimulated aluminum increases by <50 mcg/L, then no further deferoxamine is given.
2- intensive hemodialysis therapy
3- using high flux dialysis membrane
4- stop any aluminium containing drugs
D- What is the most likely diagnosis of this case according to his bone histomorphometry? osteomalacia 2ry to aluminuim toxicity
E- How would you approach this case? desferroxamine 5 mg/kg weekly for 8 weeks and repeat desferroxamine test and if still positive , repeat another 8 cycles until Aluminum levels become below 50 mcg/l .
Aluminum intoxication almost explains the mineralization defect on a background of mixed renal osteodystrophy.
What is the most likely diagnosis of this case according to his bone histomorphometry
the patient has aluminium induced osteomalacia, as aluminium staining is more than 15-20%( in our case 80%), there is accumulation of unmineralized ostoid.
How would you approach this case?
the patient has chronic aluminium toxicity,we should:-
1- identify and remoce all sources of aluminium, all medications that are not absolutely necessary and may contain even small amount of aluminium should be discountinued.
2- intensive 6 days per week dialysis, with high flux filter
3- when serum aluminium level < 200mcg/l, give low dose deferoxamine 5mg/kg
Aluminum intoxication almost explains the mineralization defect on a background of mixed renal osteodystrophy
D- What is the most likely diagnosis of this case according to his bone histomorphometry?
Trabecular surfaces show aluminum deposits suggesting Allmunium intoxication from the RO water.
E- How would you approach this case?
Inform the dialysis unit director about the Aluminum intoxication
Check the serum level of aluminum if is high give the patient desferrioxamine
Review the medication of the patient and check if he is taking antiAcids, aluminum containing binders and so on.
Weekly deferoxamine is considered for a period of 8 weeks
D- it is mostly a case of Aluminum Intoxication maybe related to water treatment in HD unit or Aluminum containing drugs
E- patient should receive desferroxamine 5 mg/kg weekly for 8 weeks and repeat desferroxamine test and if still positive , repeat another 8 cycles until Aluminum levels become below 50 mcg/l
Great job! Aluminum intoxication almost explains the mineralization defect, but on a background of mixed renal osteodystrophy
What is the most likely diagnosis of this case according to his bone histomorphometry?The most likely diagnosis is the painful form of ROD (Osteomalacia)
How would you approach this case?
Aluminum intoxication almost explains the mineralization defect but on a background of mixed renal osteodystrophy. Desferrioxamine is considered for a period of eight weeks.
the most likely diagnosis of this case according to his bone histomorphometry?
Symptomatic patients with an aluminum concentration between 20 and 200 μg / L and whose concentration increases by 50 μg / L after desferrioxamine test should receive 5 mg / kg of desferral per week for 8 weeks.
D- What is the most likely diagnosis of this case according to his bone histomorphometry?
-Putting it all together AND looking at this histology which showed in addition, reduced number of osteoblasts, osteoclasts, and decreased bone formation rate, one will think of:
E- How would you approach this case?
-Two key issues:
1.Aluminum overload:
2.Vitamin D deficiency (osteomalacia)
3.Monitoring & follow up is essential
Great! but the bone histomorphometry reveals mixed renal osteodystrophy with mineralization defect secondary to aluminum accumulation
D- What is the most likely diagnosis of this case according to his bone histomorphometry?
MOSTLIKLY DIAGNOSIS IS OSTEOMALACIA CAUSED MOSTLIKLY BY ALUMINIUM TOXICITY .
E- How would you approach this case?
1ST NEEDS TO FIND THE SOURCE OF THIS ALUMINIUM Ö THEN FREQUENT DIALYSIS AND USE OF CHELATING AGENT ( DEFEROXAMIN )
KDOQI guidelines recommended screening for aluminum toxicity with plasma aluminum concentrations at least yearly and quarterly in those receiving aluminum-containing drugs
D- What is the most likely diagnosis of this case according to his bone histomorphometry?Osteomalacia secondary to aluminum toxicity.
E- How would you approach this case?In hemodialysis patients with bone and muscular pain, weakness, iron-resistant anemia, and neurologic abnormalities, chronic aluminum poisoning should be considered, particularly if aluminum exposure (such as aluminum-containing phosphate binders) is known.
A definitive diagnosis is made by the demonstration of aluminum deposition on a bone biopsy. send for serum aluminum.
The following therapies may all be used to treat aluminum toxicity:
Identification and elimination of all aluminum sources
intensive dialysis with high-flux dialysis (six days a week)
Treatment with deferoxamine.
All symptomatic patients with unstimulated serum aluminum concentrations of 20 to 200 mcg/L should undergo deferoxamine stimulation testing to determine the optimal treatment.
Serum concentration >200 mcg/L: Patients with unstimulated serum aluminum concentrations >200 mcg/L should not undergo a deferoxamine stimulation test. Deferoxamine is not given to such patients. Deferoxamine causes severe and even fatal neurotoxicity in people with extremely high blood aluminum concentrations.
The patient shows both mixed renal osteodystrophy with the mineralization defect.