Renal Osteodystrophy in Ramathibodi Hospital : Histomorphometry and Clinical Correlation
SIRIBHA CHANGSIRIKULCHAI, M.D.*,
VORACHAI SIRIKULCHAYANONTA, M.D.***,
NARIN KUNKITTI, M.D.****,
SOMNEUK DOMRONGKITCHAIPORN, M.D.**,
BOONSONG ONGPHIPHADHANAKUL, M.D.**,
W ASANA STITCHANTRAKUL, M.S.**,
PlY ANUCH RADIENAHAMED, M.S.**
Affiliation : * Department of Medicine, Faculty of Medicine, Srinakharinwirot University, Bangkok 10 II 0.
** Department of Medicine, Faculty of Medicine, Ramathibodi Hospital,
*** Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University. Bangkok 10400.
**** Department of Orthopedics, Faculty of Medicine, Pramongkutklao Hospital, Bangkok 10400. Thailand.
AbstractThe spectrum and clinical relevance of renal osteodystrophy in Thai dialysis patients
are unknown. A study was conducted on the prevalence and clinico-pathological correlation of
renal osteodystrophy in chronic dialysis patients who attended Ramathibodi Renal Transplant
Clinic between September 1996 and March 1998. All possible volunteers were enrolled irrespec-
tive of musculoskeletal symptoms. Fifty six dialysis patients, including 17 (30.4%) CAPO and 39
(69.6%) hemodialysis patients, participated in this study. Serum calcium, phosphate, iPTH. and
bone specific alkaline phosphatase were determined. Transiliac crest bone specimens were
measured with an average of 30 fields/specimen by a specific computer program for bone histo-
morphometry (Osteomeasure), and were also studied for dynamic by double tetracycline label.
Bone mineral density (BMD) was also determined by DEXA scan. The type of bone pathology
was based on Fournier's criteria for renal osteodystrophy. The mean±SEM for age was 45.52±
1.74 years, dialysis duration 42.26±5.54 (range 1-156) months, calcium phosphate product
52.31 ±2.77, and iPTH 307 .73±62.04 pg/ml. The following types of renal osteodystrophy were
found: adynamic bone 23 (41.1%), hyperparathyroid 16 (28.6%), mixed type II (19.6%), mild
lesion 3 (5.4% ), osteomalacia 2 (3.6% ), and osteosclerosis I ( 1.8%) cases. Two cases of aluminum
related bone disease were found. The distribution of different bone diseases was not affected by
mode of dialysis or vitamin D supplement, but it was affected by dialysis duration. High turn-
over bone diseases were associated with longer dialysis duration (63.19±8.9 vs 23±4. 73
months), higher iPTH (541.53±109.32 vs 87.77±15.76 pg/ml), and higher bone specific alkaline
phosphatase (25.43±5.04 vs 9.62±1.34 mg/ml) when compared to low turnover bone diseases,
p < 0.05. Intact PTH of greater than 200 pg/ml was a good predictor for high turnover bone
diseases (74% sensitivity and 96% specificity). BMD at torch and wards areas varied inversely with
dialysis duration (r = -0.3 and r= -0.4, respectively; p < 0.05). Chronic dialysis patients had a
greater tendency of bone loss compared to the general Thai population. There was no difference
in BMD between CAPD and hemodialysis patients or different types of bone lesions.
Conclusion : Significant bone diseases are common among Thai chronic dialysis
patients. Adynamic bone disease is the most common bone lesion followed by hyperparathyroid
and mixed type. The spectrum of bone diseases is affected mainly by dialysis duration. Intact
PTH is a good predictor of high turnover bone disease. Greater bone loss than in the general
population is common in our patients and is also accentuated by longer dialysis duration.
Keywords : Renal Osteodystrophy, High Turnover Disease, Low Turnover Bone Disease, Dialysis.
Intact PTH, Bone-specific Alkaline Phosphatase
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