Calcium supplement and alfacalcidol were stopped. The patient was started on sevelamer 1600 mg.with meals TID Two months later, lab showed:
Test
Value
S. Creatinine
5 mg/dl
S. corrected Calcium
10.1 mg/dL
S. Phosphorus
7.3 mg/dL
iPTH
320 pg/mL
D- Are you happy with this response? and why?
E- Would you recommend bone biopsy for this patient? Explain your answer.
F- Discuss the indications and complications of bone biopsy in patients with CKD-MBD.
29 Comments
Amna Kununa
D- Are you happy with this response? and why?
Yes, bone profile going in a right direction
E- Would you recommend bone biopsy for this patient? Explain your answer.
iPTH is within the range as per KDIGO (2-9), for now, I wouldn’t proceed to bone biopsy unless the bone symptoms persist.
F- Discuss the indications and complications of bone biopsy in patients with CKD-MBD. KDIGO 2017 guidelines: bone biopsy is indicated if knowledge of the type of renal osteodystrophy will affect treatment decisions.
indications:
Patients with unexplained bone pain or fractures (ie, with minimal or no trauma).
Patients with unexplained, refractory hypercalcemia to rule out the presence of multiple myeloma or granulomatous diseases.
Patients with suspicion of osteomalacia, based upon a history of aluminum exposure or other risk factors (eg, vitamin D deficiency, hypocalcemia, hypophosphatemia, metabolic acidosis).
Patients who have an atypical response to standard therapies for elevated PTH to rule out atypical or unexpected bone pathology. For example, in a patient who develops fractures after treatment, we would consider a bone biopsy to clarify whether ABD or OM is present.
Patients with ESKD who are planning to undergo parathyroidectomy because of bone-related symptoms (eg, bone pain and/or fractures) but who have an indeterminate PTH level (ie, <800 pg/mL). The reason for the biopsy is to confirm the presence of PTH-mediated, high-turnover bone disease (provided that a confirmed diagnosis would alter treatment decisions).
Patients with bone pain and persistent serum intact PTH levels <100 pg/mL despite the withdrawal of calcitriol or other vitamin D analogs to confirm the diagnosis of ABD.
Patients in whom an inconsistency in biochemical parameters precludes a definitive interpretation (eg, levels of serum intact PTH are high, but BSAP levels are low).
Complications:
Transiliac bone biopsy is generally well tolerated, with minimal pain and discomfort. It is associated with very little morbidity and no mortality.
Pain
Hematoma
Wound infection
Transient neuropathy
Skin incision site infection
OM
Hip fracture
Exostosis
Allergic reactions, gastrointestinal disturbances, and photosensitivity secondary to tetracycline intake
D:yes ca and phosphorus is decreasing
E:no it is invasive and we still have chance to correct his phosphorus
F:indication persistent bone pain or unexplained fracture inspite of adequate management
complication :bleeding – infection-fracture inadequate sample
D- Are you happy with this response? and why?yes, the calcium and phosphate has decreased.
E- Would you recommend bone biopsy for this patient? Explain your answer.the bone biopsy is recommended to find out the type of bone disease. F- Discuss the indications and complications of bone biopsy in patients with CKD-MBD.indications
hypercalcemia
fractures
persistent bone pain Suspicion of aluminum and/or iron intoxication; complications Inadequate samples, Fractures, bleeding and pain
D. Are you happy with this response? and why? The hypercalcemia and hyperphosphatemia are moving in the right direction. The increased PTH level is still within the recommended KDIGO 2017 range(2-9 folds of upper limits of normal). E. Would you recommend bone biopsy for this patient? Explain your answer. This patient has PTH level within target range according to KDIGO 2017 guidelines. Bone biopsy might be helpful to determine the type of bone disorders that leads to his persistent bone pain. F. Discuss the indications and complications of bone biopsy in patients with CKD-MBD.
The 2009 KDIGO guidlines reported that the Indications for bone biopsy include the following:
4. Discrepancy between serum biomarkers and clinical presentation;
5. Suspicion of aluminum and/or iron intoxication;
6. Before using anti-osteoporotic drugs, such as bisphosphonates and denosumab.
The updated 2017 KDIGO guidelines recommends that 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 anterior iliac crest bone biopsy has been proved to be safe and associated with minor complications. The most common complications are pain, bleeding, hematoma, infection, and superficial nerve injury.
Are you happy with this response? and why?
No , still high p and ca Would you recommend bone biopsy for this patient? Explain your answer.
Yes , to differentiate between high and low bone turnover
F- Discuss the indications and complications of bone biopsy in patients with CKD-MBD.
indication
failure of treatment
unexplained fractures
PTH inconsistent with other biochemical data
D.no the patient need phosphate binders
E. We need to differentiate if the fracture in this case are due to low turnover bone disease or high turnover bone disease
F. Unexplained fracture, unexplained high calcium level, persistent bones pain, unexpected increase in AP , iPTH between 100 and 500 in ESRD + above problems
Complications like pain and fracture and small or low quality simple size
E- Would you recommend bone biopsy for this patient? Explain your answer. Yes,
to differentiate between ABD SHPT or other diseases F- Discuss the indications and complications of bone biopsy in patients with CKD-MBD. Indications
· PTH value inconsistent with other biochemical profile
· Unexplained fracture
· treatment failure Complications
· Pain, Inadequate samples, Fractures
E- Would you recommend bone biopsy for this patient? Explain your answer.
Yes
F- Discuss the indications and complications of bone biopsy in patients with CKD-MBD.
INDICATIONS:
Unexplained fractures
Unexplained hypercalcemia
Unexplained hypophosphatemia
Persistent bone pain
Suspected aluminum toxicity
Previous therapy with bisphosphonates
Inconsistency among biochemical parameters
Severe progressive vascular calcification
Intact plasma parathyroid hormone (PTH) levels between 100 and 500 pg/mL (in CKD stage 5) in association with unexplained hypercalcemia, severe bone pain, or unexplained increase in bone alkaline phosphatase activity
D- Are you happy with this response? and why?
No, because still patient high po4 upper normal ca with slight elevation of pth.
E- Would you recommend bone biopsy for this patient? Explain your answer.
Yes ,I will recommend bone biopsy to patient to detect accurate diagnosis
F- Discuss the indications and complications of bone biopsy in patients with CKD-MBD.
bone biospy is the gold stardard test for diagnisis of CKD-MBD, 2017 guidelines state that it should be considered in
before parathyroidectomy, before treatment of osteoporosis,multiple fragility fractures, sever bone pain
, progressive vasculr calcification
complications
Bleeding, infection, fractures, pain post biopsy
D- Are you happy with this response? and why? No, patient still has hypercalcemia, no change in his PTH, and has sever hyperphosphatemia, there is no decrease in his CVD risk, sevelamer had no effect. need to assess compliance
E- Would you recommend bone biopsy for this patient? Explain your answer. Yes I would recommend bone biopsy. despite stopping Ca and vitD, patient still has the same level of Ca. with the present PTH, one cannot be sure if this patient has ABD SHPT or other diseases
F- Discuss the indications and complications of bone biopsy in patients with CKD-MBD.
Indications
· PTH value inconsistent with other biochemical profile
· Unexplained fracture
· Unexplained treatment failure Complications
· Pain
· Inadequate samples
· Fractures
D- Are you happy with this response? and why? no, the patient still has hyperphosphatemia, calcium level still on the higher level. still patient has high risk for vascular calcification.
Would you recommend bone biopsy for this patient? Explain your answer. the patient has a fragility fracture, may have osteoporosis, the diagnosis of osteoporosis by DEXA scan in CKD patients is difficult, as aortic calcification will interfer with measurement of bmd of vertebral bodiess
Discuss the indications and complications of bone biopsy in patients with CKD-MBD. bone biospy is the gold stardard test for diagnisis of CKD-MBD, 2017 guidelines state that it should be done when diagnosis will impact treatment, e.g
1- before parathyroidectomy
2- before treatment of osteoporosis
3-multiple fragility fractures
4-sever bone pain
5- progressive vasculr calcification
D- Are you happy with this response? and why?
No, because after 2 months of sevelamer, the patient still has a high phosphate and PTH
E- Would you recommend bone biopsy for this patient? Explain your answer. Yes, the patient has hypercalcemia after stopping calcium and repeated fracture,Bone biopsy is the golden standard to diagnose ROD
F- Discuss the indications and complications of bone biopsy in patients with CKD-MBD. indications Patients with CKD G3a-G5D Patients with CKD G3a-G5D with biochemical abnormalities of CKD-MBD and low bone mineral density (BMD) and/or fragility fractures
complicationsThe main complications of bone biopsy include infection, bleeding, nerve damage, and pain. the procedure can be expensive and may not be available in all the centres.
The only positive aspect is the slight increase in PTH which means that the cellularity is good, far from dynamic risk. But still, we need to lower the phosphorus. Sevelamer can be up to 4000 mg TID; lanthanum is an alternative.
Boe biopsy is a good option because of the fracture; it will help us decide on future treatment.
Bone biopsy, although it seems invasive, I think it is not more invasive than the operations that will be needed because of insufficient evaluation. so I am with bone biyopy. the main problem is the lack of experience of both us and the pathologists (bone pathologists not available in all centers). Complications can be fracture during the procedure, infection (but preventive measures are done)
D- Are you happy with this response? and why?
No , calcium and Pi still high .
E- Would you recommend bone biopsy for this patient? Explain your answer.I agree to arrange for bone biopsy because
repeated fractures , hypercalcemia , hyperphosphatemia and high PTH .
F- Discuss the indications and complications of bone biopsy in patients with CKD-MBD.
indications
Unexplained fractures
Unexplained hypercalcemia
Unexplained hypophosphatemia
Persistent bone pain
I. Complications
Invasive/painful
Inadequate sampling/failed procedure
Artifacts e.g., breakage, fracture, compressions, and cellular damage
No, as calcium high, phosphorous still high, with increasing PTH
E- Would you recommend bone biopsy for this patient? Explain your answer.
Yes, as the patient has hypercalcimia despite stopping calcium, repeated fracture, hyperphosphatemia
F- Discuss the indications and complications of bone biopsy in patients with CKD-MBD.
Indication :PTH level is inconsistant, fracture or hypercalcemia unexplained, response to the treatment unclear and decreasing BMD
Complications : pain, fracture, infection in addition to it is expensive, lack of experienced lab, artifact (cellular damage, fracture, compression, breakage)
D- Are you happy with this response? and why?
Of course No , calcium and Phousphorous still high .
E- Would you recommend bone biopsy for this patient? Explain your answer.
Yes i will recomend bone biopsy for him
He has repeated fractures , hypercalcemia , hyperphosphatemia and high PTH .
F- Discuss the indications and complications of bone biopsy in patients with CKD-MBD.
Indications for bone biopsy in patients with CKD stages 3-5, based KDIGO
Unexplained fractures Unexplained hypercalcemia Unexplained hypophosphatemia Persistent bone pain Suspected aluminum toxicity Previous therapy with bisphosphonates It is advisable to perform a bone biopsy if knowing of the type of the renal osteodystrophy will impact treatment decisions.
Expected that there will be complication in every intervention , which can be avoided or reduced with good hands ( Bruising and discomfort at the biopsy site. Bone fracture. Prolonged bleeding from the biopsy site. Infection near the biopsy site or in the bone.
Are you happy with this response? And why?
No, as this patient has not achieved the targeted level despite the treatment.
We need to check patient adherence first then if so, we may need to do a bone biopsy as this patient seems to have a mixed picture of ABD and High turnover bone disease.
Would you recommend a bone biopsy for this patient? Explain your answer.Yes, we may need to consider bone biopsy as it looks like he has mixed ROS
Discuss the indications and complications of bone biopsy in patients with CKD-MBD.indications:
hypercalcemia
no response to specific treatment
unexplained fractuer
D- Are you happy with this response? and why? No , still calcium and P high . E- Would you recommend bone biopsy for this patient? Explain your answer. Yes , better to do biopsy for this patient with repeated fractures and PTH borderline . F- Discuss the indications and complications of bone biopsy in patients with CKD-MBD. Clinical indications for bone biopsy in patients with CKD ;
stages 3-5, based on guidelines from Kidney Disease Improving Global Outcomes (KDIGO) and the Kidney Disease Outcomes Quality Initiative (KDOQI), are as follows: Unexplained fractures Unexplained hypercalcemia Unexplained hypophosphatemia Persistent bone pain Suspected aluminum toxicity based upon clinical symptoms or history of aluminum exposure Previous therapy with bisphosphonates Inconsistency among biochemical parameters, thereby preventing definitive interpretation Severe progressive vascular calcification Prior to parathyroidectomy if a history of aluminum exposure exists or if the biochemical determination is inconsistent with advanced secondary or tertiary hyperparathyroidism Intact plasma parathyroid hormone (PTH) levels between 100 and 500 pg/mL (in CKD stage 5) in association with unexplained hypercalcemia, severe bone pain, or unexplained increase in bone alkaline phosphatase activity The 2017 update to the KDIGO guidelines stated that it is reasonable to perform a bone biopsy if knowledge of the type of renal osteodystrophy will impact treatment decisions.
No, patient didn’t achieve much, still hypercalcemic and hyperphosphatemic despite the above measures.
We need to assess the complaints to the medications as these medicines are costly, many in numbers, big in size, may not be palatable and our patients may be in state of nausea, vomiting due to uremic environment. These factors have to be considered at first place because they will the future management.
E- Would you recommend bone biopsy for this patient? Explain your answer.
May be, as its look like this patient may have ABD or even both ABD and high turn-over may coexist. Failure to respond to adequate treatment after an excellent adherence with the drugs may be another reason to consider a bone biopsy.
F- Discuss the indications and complications of bone biopsy in patients with CKD-MBD.I. Indications:
Inconsistent iPTH values
Unexplained fracture
Unexplained hypercalcemia
No obvious or clear respond to a given treatment.
Progressive decrease in BMD
II. Complications
Invasive/painful
Inadequate sampling/failed procedure
Bone fracture due to poor technique
Artifacts e.g., breakage, fracture, compressions, and cellular damage
D- Are you happy with this response? and why?This result is unsatisfactory as there is still hyperphosphatemia , hypercalcemia E- Would you recommend bone biopsy for this patient? Explain your answer.
The patient is not compliant to drugs and diet . I recommend strict adherence to treatment plan
if no improvement despite full compliance , bone biopsy is mandatory to define bone pathology and to confirm the diagnosis
F- Discuss the indications and complications of bone biopsy in patients with CKD-MBD.
In Kdigo 2017 guidelines , 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 (Not Graded).
Indications:
Bone biopsy is an important procedure that provides helpful information on bone microarchitecture, turnover and, ultimately, on the type of ROD
Persistent bone pain
Unexplained hypercalcemia and/or hypophosphatemia
Assesses separately cortical and trabecular bone
Information on bone mineralization and turnover
Fragility fracture
Discrepancy between serum biomarkers and clinical presentation
Suspicion of aluminum and/or iron intoxication
Before using anti-osteoporotic drugs, such as bisphosphonates and denosumab.
Osteomalacia Aluminum bone disease
Prior to parathyroidectomy
Transplant bone disease
Disadvantage:
Invasive, painful, cost
Few specialized centres on this technique
No data on fracture risk prediction
A general lack of expertise in performing or analyzing bone biopsy
Are you happy with this response? and why?this result is unsatisfactory as there is still hyperphosphatemia
Would you recommend bone biopsy for this patient? Explain your answer.i think the patient is not compliant to drugs and diet
i recommend strict adherence to treatment plan, if no response despite full compliance consider bone biopsy to define bone pathology
Discuss the indications and complications of bone biopsy in patients with CKD-MBD.
(1) 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 (evidence not graded)(2) 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 (evidence 2D).(3) During the first 12 months after kidney transplant, in patients in with an estimated glomerular filtration rate greater than approximately 30 mL/min/1.73 m2 and a low BMD, it is reasonable to consider a bone biopsy to guide treatment (evidence not graded).
The main reasons for the infrequent use of bone biopsy, other than the lack of widespread expertise in performing or interpreting bone biopsy results and the high costs, are the invasiveness and potential pain associated with the procedure.
Are you happy with this response? and why?No, there my other cause of hyperparathyroidism, persistent hypercalcemia, and hyperphosphatemia Would you recommend a bone biopsy for this patient? Explain your answer.Yes;
To confirm the exact diagnosis.
To determine the patient phenotype.
Discuss the indications and complications of bone biopsy in patients with CKD-MBD. Clinical indications for bone biopsy in patients with CKD stages 3-5, based on guidelines from (KDIGO),and (KDOQI), are as follows:
Unexplained fractures
Unexplained hypercalcemia
Unexplained hypophosphatemia
Persistent bone pain
Suspected aluminum toxicity based on clinical symptoms or history of aluminum exposure
Previous therapy with bisphosphonates
Inconsistency among biochemical parameters, thereby preventing definitive interpretation
Severe progressive vascular calcification
Before parathyroidectomy if a history of aluminum exposure exists or if the biochemical determination is inconsistent with advanced secondary or tertiary
Intact plasma parathyroid hormone (PTH) levels between 100 and 500 pg/mL (in CKD stage 5) in association with unexplained hypercalcemia, severe bone pain, or unexplained increase in bone alkaline phosphatase activity
Contraindication to bone biopsy
Those who have a coagulopathy or are on anticoagulant therapy
the response of treatment unsatisfied calcium still high normal still hyperphosphatemia progressive increase of pth >>> sPTH>>>3ry pth This pattern of ( ROD ) high turn over bone disease
plan of treatment
added cinacalcet
and increase dose of non-calcuim phosphorus binding
follow up ca pi ,alk vit.D pth
i think no need renal biopsy
If no response parathyroidectomy
D – no , calcium levels are still in upper normal values with persistant hyperphosphatemia which increase CV mortality in this patient
E – i think bone biopsy has no rule in this patient and diet plan should be done according to po4 pyramid concept and extended daily or even nocturnal HD should be considered with repeat of labs after that before considering bone biopsy as an invasive intervention
D- Are you happy with this response? and why?No, still the patient has hyperphosphatemia and high normal calcium.
E- Would you recommend a bone biopsy for this patient? Explain your answer.The patient has normal PTH, while his serum PO4 and calcium are still high.
I will review the diet and restrict the PO4 intake.
I will keep the calcium dialysate at 1.25 and follow the calcium level.
optimize the dialysis session. and recommend short, frequent dialysis sessions if the PO4 persists at high levels.
send for BSAP, 25-OH Vitamin D, FGF-23
If the patient is still symptomatic, I will proceed with a bone biopsy.
F- Discuss the indications and complications of bone biopsy in patients with CKD-MBD.Indications:
The KDIGO 2017 clinical practice guideline update on diagnosis, evaluation, prevention, and treatment of CKD-MBD states that “in patients with CKD stages 3a–5D, it is reasonable to perform a bone biopsy if knowledge of the type of ROD will impact treatment decisions (not graded)”.
More specifically, a bone biopsy should be considered in patients presenting with inconsistent PTH trends, unexplained fractures, refractory hypercalcemia, suspicion of osteomalacia, an atypical response to standard therapies for elevated PTH, or a progressive decrease in BMD despite standard therapy.
The goal of a bone biopsy would be to (a) rule out atypical or unexplained bone pathology; (b) determine if the patient has a high or low turnover disease, which may alter treatment choices (e.g., initiate or discontinue calcimimetics, vitamin D [analogs]); or (c) identify a mineralization defect that would imply specific treatment options.
complication: Bruising and discomfort at the biopsy site. Bone fracture. Prolonged bleeding from the biopsy site infection near the biopsy site or in the bone.
D- Are you happy with this response? and why?
Yes, bone profile going in a right direction
E- Would you recommend bone biopsy for this patient? Explain your answer.
iPTH is within the range as per KDIGO (2-9), for now, I wouldn’t proceed to bone biopsy unless the bone symptoms persist.
F- Discuss the indications and complications of bone biopsy in patients with CKD-MBD.
KDIGO 2017 guidelines: bone biopsy is indicated if knowledge of the type of renal osteodystrophy will affect treatment decisions.
indications:
Complications:
Transiliac bone biopsy is generally well tolerated, with minimal pain and discomfort. It is associated with very little morbidity and no mortality.
D- Are you happy with this response? and why?
yes, hypercalcemia and hyperphosphatemia improved.
PTH whithin expected for ESRD patient.
E- Would you recommend bone biopsy for this patient? Explain your answer.
yes, if the patient is still complaining of severe bone pain.
F- Discuss the indications and complications of bone biopsy in patients with CKD-MBD.
Indications:
Complications:
D:yes ca and phosphorus is decreasing
E:no it is invasive and we still have chance to correct his phosphorus
F:indication persistent bone pain or unexplained fracture inspite of adequate management
complication :bleeding – infection-fracture inadequate sample
D calcium and phosphate heading down. PTH within range.
E to explain bone pain
F indication
unexplained bone pain
hypercalcaemia
fracture
bone markers not fitting with clinical picture
Complication – infection, bleeding, pain, nerve damage
D- Are you happy with this response? and why?yes, the calcium and phosphate has decreased.
E- Would you recommend bone biopsy for this patient? Explain your answer.the bone biopsy is recommended to find out the type of bone disease.
F- Discuss the indications and complications of bone biopsy in patients with CKD-MBD.indications
hypercalcemia
fractures
persistent bone pain
Suspicion of aluminum and/or iron intoxication;
complications
Inadequate samples, Fractures, bleeding and pain
D. Are you happy with this response? and why?
The hypercalcemia and hyperphosphatemia are moving in the right direction. The increased PTH level is still within the recommended KDIGO 2017 range(2-9 folds of upper limits of normal).
E. Would you recommend bone biopsy for this patient? Explain your answer.
This patient has PTH level within target range according to KDIGO 2017 guidelines. Bone biopsy might be helpful to determine the type of bone disorders that leads to his persistent bone pain.
F. Discuss the indications and complications of bone biopsy in patients with CKD-MBD.
The 2009 KDIGO guidlines reported that the Indications for bone biopsy include the following:
1. Persistent bone pain;
2. Unexplained hypercalcemia and/or hypophosphatemia;
3. Fragility fracture;
4. Discrepancy between serum biomarkers and clinical presentation;
5. Suspicion of aluminum and/or iron intoxication;
6. Before using anti-osteoporotic drugs, such as bisphosphonates and denosumab.
The updated 2017 KDIGO guidelines recommends that 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 anterior iliac crest bone biopsy has been proved to be safe and associated with minor complications. The most common complications are pain, bleeding, hematoma, infection, and superficial nerve injury.
Are you happy with this response? and why?
No , still high p and ca
Would you recommend bone biopsy for this patient? Explain your answer.
Yes , to differentiate between high and low bone turnover
F- Discuss the indications and complications of bone biopsy in patients with CKD-MBD.
indication
failure of treatment
unexplained fractures
PTH inconsistent with other biochemical data
complication
fracture
pain
bleeding
hematoma
D.no the patient need phosphate binders
E. We need to differentiate if the fracture in this case are due to low turnover bone disease or high turnover bone disease
F. Unexplained fracture, unexplained high calcium level, persistent bones pain, unexpected increase in AP , iPTH between 100 and 500 in ESRD + above problems
Complications like pain and fracture and small or low quality simple size
d- no
c- yes biopsy indicate
f- fracture and not response to stop calcium and one alpha
complication — pain and inaduqet sample + fracture
D- Are you happy with this response? and why?
No,
E- Would you recommend bone biopsy for this patient? Explain your answer.
Yes,
to differentiate between ABD SHPT or other diseases
F- Discuss the indications and complications of bone biopsy in patients with CKD-MBD.
Indications
· PTH value inconsistent with other biochemical profile
· Unexplained fracture
· treatment failure
Complications
· Pain, Inadequate samples, Fractures
D- Are you happy with this response? and why?
E- Would you recommend bone biopsy for this patient? Explain your answer.
F- Discuss the indications and complications of bone biopsy in patients with CKD-MBD.
INDICATIONS:
CONTRA-INDICATIONS:
COMPLICATIONS OF BONE BIOPSY:
D- Are you happy with this response? and why?
No, because still patient high po4 upper normal ca with slight elevation of pth.
E- Would you recommend bone biopsy for this patient? Explain your answer.
Yes ,I will recommend bone biopsy to patient to detect accurate diagnosis
F- Discuss the indications and complications of bone biopsy in patients with CKD-MBD.
bone biospy is the gold stardard test for diagnisis of CKD-MBD, 2017 guidelines state that it should be considered in
before parathyroidectomy, before treatment of osteoporosis,multiple fragility fractures, sever bone pain
, progressive vasculr calcification
complications
Bleeding, infection, fractures, pain post biopsy
D- Are you happy with this response? and why?
No, patient still has hypercalcemia, no change in his PTH, and has sever hyperphosphatemia, there is no decrease in his CVD risk, sevelamer had no effect. need to assess compliance
E- Would you recommend bone biopsy for this patient? Explain your answer.
Yes I would recommend bone biopsy. despite stopping Ca and vitD, patient still has the same level of Ca. with the present PTH, one cannot be sure if this patient has ABD SHPT or other diseases
F- Discuss the indications and complications of bone biopsy in patients with CKD-MBD.
Indications
· PTH value inconsistent with other biochemical profile
· Unexplained fracture
· Unexplained treatment failure
Complications
· Pain
· Inadequate samples
· Fractures
D- Are you happy with this response? and why? no, the patient still has hyperphosphatemia, calcium level still on the higher level. still patient has high risk for vascular calcification.
Would you recommend bone biopsy for this patient? Explain your answer. the patient has a fragility fracture, may have osteoporosis, the diagnosis of osteoporosis by DEXA scan in CKD patients is difficult, as aortic calcification will interfer with measurement of bmd of vertebral bodiess
Discuss the indications and complications of bone biopsy in patients with CKD-MBD. bone biospy is the gold stardard test for diagnisis of CKD-MBD, 2017 guidelines state that it should be done when diagnosis will impact treatment, e.g
1- before parathyroidectomy
2- before treatment of osteoporosis
3-multiple fragility fractures
4-sever bone pain
5- progressive vasculr calcification
complications
1- invasiveess
2-high cost
D- Are you happy with this response? and why?
No, because after 2 months of sevelamer, the patient still has a high phosphate and PTH
E- Would you recommend bone biopsy for this patient? Explain your answer.
Yes, the patient has hypercalcemia after stopping calcium and repeated fracture,Bone biopsy is the golden standard to diagnose ROD
F- Discuss the indications and complications of bone biopsy in patients with CKD-MBD.
indications
Patients with CKD G3a-G5D
Patients with CKD G3a-G5D with biochemical abnormalities of CKD-MBD and low bone mineral density (BMD) and/or fragility fractures
complicationsThe main complications of bone biopsy include infection, bleeding, nerve damage, and pain. the procedure can be expensive and may not be available in all the centres.
The only positive aspect is the slight increase in PTH which means that the cellularity is good, far from dynamic risk. But still, we need to lower the phosphorus. Sevelamer can be up to 4000 mg TID; lanthanum is an alternative.
Boe biopsy is a good option because of the fracture; it will help us decide on future treatment.
Bone biopsy, although it seems invasive, I think it is not more invasive than the operations that will be needed because of insufficient evaluation. so I am with bone biyopy. the main problem is the lack of experience of both us and the pathologists (bone pathologists not available in all centers). Complications can be fracture during the procedure, infection (but preventive measures are done)
D- Are you happy with this response? and why?
No , calcium and Pi still high .
E- Would you recommend bone biopsy for this patient? Explain your answer.I agree to arrange for bone biopsy because
repeated fractures , hypercalcemia , hyperphosphatemia and high PTH .
F- Discuss the indications and complications of bone biopsy in patients with CKD-MBD.
indications
I. Complications
D- Are you happy with this response? and why?
No, as calcium high, phosphorous still high, with increasing PTH
E- Would you recommend bone biopsy for this patient? Explain your answer.
Yes, as the patient has hypercalcimia despite stopping calcium, repeated fracture, hyperphosphatemia
F- Discuss the indications and complications of bone biopsy in patients with CKD-MBD.
Indication :PTH level is inconsistant, fracture or hypercalcemia unexplained, response to the treatment unclear and decreasing BMD
Complications : pain, fracture, infection in addition to it is expensive, lack of experienced lab, artifact (cellular damage, fracture, compression, breakage)
D- Are you happy with this response? and why?
Of course No , calcium and Phousphorous still high .
E- Would you recommend bone biopsy for this patient? Explain your answer.
Yes i will recomend bone biopsy for him
He has repeated fractures , hypercalcemia , hyperphosphatemia and high PTH .
F- Discuss the indications and complications of bone biopsy in patients with CKD-MBD.
Indications for bone biopsy in patients with CKD stages 3-5, based KDIGO
Unexplained fractures Unexplained hypercalcemia Unexplained hypophosphatemia Persistent bone pain Suspected aluminum toxicity Previous therapy with bisphosphonates It is advisable to perform a bone biopsy if knowing of the type of the renal osteodystrophy will impact treatment decisions.
Expected that there will be complication in every intervention , which can be avoided or reduced with good hands ( Bruising and discomfort at the biopsy site. Bone fracture. Prolonged bleeding from the biopsy site. Infection near the biopsy site or in the bone.
Are you happy with this response? And why?
No, as this patient has not achieved the targeted level despite the treatment.
We need to check patient adherence first then if so, we may need to do a bone biopsy as this patient seems to have a mixed picture of ABD and High turnover bone disease.
Would you recommend a bone biopsy for this patient? Explain your answer.Yes, we may need to consider bone biopsy as it looks like he has mixed ROS
Discuss the indications and complications of bone biopsy in patients with CKD-MBD.indications:
hypercalcemia
no response to specific treatment
unexplained fractuer
D- Are you happy with this response? and why? No , still calcium and P high .
E- Would you recommend bone biopsy for this patient? Explain your answer. Yes , better to do biopsy for this patient with repeated fractures and PTH borderline .
F- Discuss the indications and complications of bone biopsy in patients with CKD-MBD. Clinical indications for bone biopsy in patients with CKD ;
stages 3-5, based on guidelines from Kidney Disease Improving Global Outcomes (KDIGO) and the Kidney Disease Outcomes Quality Initiative (KDOQI), are as follows: Unexplained fractures Unexplained hypercalcemia Unexplained hypophosphatemia Persistent bone pain Suspected aluminum toxicity based upon clinical symptoms or history of aluminum exposure Previous therapy with bisphosphonates Inconsistency among biochemical parameters, thereby preventing definitive interpretation Severe progressive vascular calcification Prior to parathyroidectomy if a history of aluminum exposure exists or if the biochemical determination is inconsistent with advanced secondary or tertiary hyperparathyroidism Intact plasma parathyroid hormone (PTH) levels between 100 and 500 pg/mL (in CKD stage 5) in association with unexplained hypercalcemia, severe bone pain, or unexplained increase in bone alkaline phosphatase activity The 2017 update to the KDIGO guidelines stated that it is reasonable to perform a bone biopsy if knowledge of the type of renal osteodystrophy will impact treatment decisions.
D- Are you happy with this response? and why?
E- Would you recommend bone biopsy for this patient? Explain your answer.
F- Discuss the indications and complications of bone biopsy in patients with CKD-MBD.I. Indications:
II. Complications
D- Are you happy with this response? and why?This result is unsatisfactory as there is still hyperphosphatemia , hypercalcemia
E- Would you recommend bone biopsy for this patient? Explain your answer.
F- Discuss the indications and complications of bone biopsy in patients with CKD-MBD.
Indications:
Disadvantage:
Complications:
Are you happy with this response? and why?this result is unsatisfactory as there is still hyperphosphatemia
Would you recommend bone biopsy for this patient? Explain your answer.i think the patient is not compliant to drugs and diet
i recommend strict adherence to treatment plan, if no response despite full compliance consider bone biopsy to define bone pathology
Discuss the indications and complications of bone biopsy in patients with CKD-MBD.
(1) 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 (evidence not graded)(2) 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 (evidence 2D).(3) During the first 12 months after kidney transplant, in patients in with an estimated glomerular filtration rate greater than approximately 30 mL/min/1.73 m2 and a low BMD, it is reasonable to consider a bone biopsy to guide treatment (evidence not graded).
The main reasons for the infrequent use of bone biopsy, other than the lack of widespread expertise in performing or interpreting bone biopsy results and the high costs, are the invasiveness and potential pain associated with the procedure.
Are you happy with this response? and why?No, there my other cause of hyperparathyroidism, persistent hypercalcemia, and hyperphosphatemia
Would you recommend a bone biopsy for this patient? Explain your answer.Yes;
Discuss the indications and complications of bone biopsy in patients with CKD-MBD. Clinical indications for bone biopsy in patients with CKD stages 3-5, based on guidelines from (KDIGO), and (KDOQI), are as follows:
Contraindication to bone biopsy
the response of treatment unsatisfied
calcium still high normal
still hyperphosphatemia
progressive increase of pth >>> sPTH>>>3ry pth
This pattern of ( ROD ) high turn over bone disease
plan of treatment
added cinacalcet
and increase dose of non-calcuim phosphorus binding
follow up ca pi ,alk vit.D pth
i think no need renal biopsy
If no response parathyroidectomy
D – no , calcium levels are still in upper normal values with persistant hyperphosphatemia which increase CV mortality in this patient
E – i think bone biopsy has no rule in this patient and diet plan should be done according to po4 pyramid concept and extended daily or even nocturnal HD should be considered with repeat of labs after that before considering bone biopsy as an invasive intervention
D- Are you happy with this response? and why?No, still the patient has hyperphosphatemia and high normal calcium.
E- Would you recommend a bone biopsy for this patient? Explain your answer.The patient has normal PTH, while his serum PO4 and calcium are still high.
I will review the diet and restrict the PO4 intake.
I will keep the calcium dialysate at 1.25 and follow the calcium level.
optimize the dialysis session. and recommend short, frequent dialysis sessions if the PO4 persists at high levels.
send for BSAP, 25-OH Vitamin D, FGF-23
If the patient is still symptomatic, I will proceed with a bone biopsy.
F- Discuss the indications and complications of bone biopsy in patients with CKD-MBD.Indications:
The KDIGO 2017 clinical practice guideline update on diagnosis, evaluation, prevention, and treatment of CKD-MBD states that “in patients with CKD stages 3a–5D, it is reasonable to perform a bone biopsy if knowledge of the type of ROD will impact treatment decisions (not graded)”.
More specifically, a bone biopsy should be considered in patients presenting with inconsistent PTH trends, unexplained fractures, refractory hypercalcemia, suspicion of osteomalacia, an atypical response to standard therapies for elevated PTH, or a progressive decrease in BMD despite standard therapy.
The goal of a bone biopsy would be to (a) rule out atypical or unexplained bone pathology; (b) determine if the patient has a high or low turnover disease, which may alter treatment choices (e.g., initiate or discontinue calcimimetics, vitamin D [analogs]); or (c) identify a mineralization defect that would imply specific treatment options.
complication:
Bruising and discomfort at the biopsy site. Bone fracture. Prolonged bleeding from the biopsy site infection near the biopsy site or in the bone.