Renal osteodystrophy

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Classification according to ICD-10
N25.0 Renal osteodystrophy
ICD-10 online (WHO version 2019)

Renal osteodystrophy (synonym: Renal osteopathy , English : renal osteodystrophy ) is the name for all skeletal symptoms and disorders of mineral metabolism associated with chronic kidney failure .

clinic

It is a complex bone disease that is widely seen today due to the many years of hemodialysis that has been carried out . Clinically, there are bone and joint pain, swellings and deformations , often together with a pronounced proximal muscle weakness combined with muscle atrophy and increased bone fragility. Ectopic calcium deposits in the area of ​​the shoulder joints, elbows, knees, toes and finger joints cause severe pain, which restricts movement and affects the quality of life of the affected patient. Occasionally massive vascular calcifications cause peripheral reduced blood flow and arterial occlusive disease with toe or finger necrosis . In such cases, vascular dilatation or surgical intervention may be necessary.

Pathogenesis

Renal osteodystrophy caused by the combination of a secondary hyperparathyroidism with electrolyte disturbances and a vitamin D hormone - metabolic disorder . The bone shows on the one hand changes consistent with osteomalacia , with the vitamin D associated deficiency, on the other hand passes through the increased parathyroid hormone effect a fibro-osteoclasia on.

Diagnostic procedure

Laboratory findings

In addition to the increase in creatinine and urea (renal anemia), there is a typical laboratory constellation in renal osteodystrophy:

  • Hyperphosphatemia (common, especially when the glomerular filtration rate (GFR) drops below 30%)
  • Normal or decreased calcium levels in the blood serum
  • Intact PTH in serum is significantly increased in practically all patients with advanced renal insufficiency
  • Alkaline phosphatase (or its bone-specific isoenzyme) in the serum increased depending on the extent of the increase in bone turnover in the context of secondary hyperparathyroidism.

Imaging procedures

The x-ray shows the signs of osteitis fibrosa as an expression of secondary hyperparathyroidism, subperiosteal resorptions, patchy osteosclerosis , cortical loosening, especially on the finger phalanges and on the spine. There are often changes as in primary hyperparathyroidism as well as diffuse bone deformations, for example in the pelvic area, and extraosseous calcifications, especially in vessels. Disturbed growth plates appear in children. The radiological signs of the mostly simultaneous osteomalacia are less specific, in extreme cases pseudofractures ( Looser's zones ) are diagnosed.

Differential diagnosis

In addition to aluminum- induced osteomalacia , which is practically non-existent today, there is also hemodialysis-related amyloidosis with deposits of β2-microglobulin in bones and joints. Bone cysts, pathological fractures , scapulohumeral periarthritis and a carpal tunnel syndrome dominate here . In exceptional cases, a bone biopsy - iliac crest - biopsy - allow the differentiation between the various bone diseases.

therapy

Therapeutically, attempts must be made to normalize the calcium and phosphate levels as far as possible, the parathyroid hormone levels should be set to about twice the upper limit of the norm. Since the vitamin D metabolism is disturbed in kidney failure, vitamin D must be supplied in its activated form, for example as 1α, 25 (OH) 2Vitamin D 3 . The additional bone damage caused by aluminum deposits as a result of dialysis, which was frequently encountered in the past, is only rarely observed today.

Individual evidence

  1. ↑ Renal Osteodystrophy During Hemodialysis for Chronic Renal Failure. In: Canad. Med. Ass. J. vol. 99, Oct. 5, 1968. PMC 1945291 (free full text)
  2. ↑ Kevin J. Martin, Esther A. Gonzalez: Metabolic Bone Disease in Chronic Kidney Disease . In: J Am Soc Nephrol . No. 18 , 2007, p. 875-885 ( Article ).
  3. ↑ U. Stuby, J. Zazgornik: Clinic of renal osteodystrophy In: Journal for mineral metabolism. 8 (1), 2001, pp. 7-8. (PDF; 867 kB)
  4. ↑ Susen John: Significance of determining the vitamin D3 concentration in serum in terminal kidney failure requiring dialysis. Dissertation. Martin Luther University Halle-Wittenberg, 2005. (PDF; 455 kB)
  5. ^ Metabolic Bone Disease in Chronic Renal Failure. In: The American Journal of Pathology . Vol. 78, No. 3, March 1975, PMC 1912553 (free full text)
  6. ↑ Influence of vitamin D3 therapy on renal osteodystrophy in childhood. In: Klin Wochenschr . 58, 1980, pp. 237-247. (PDF)

literature

  • WE Berdel et al. (Ed.): Diehl Classen: Internal medicine . Urban & Fischer in Elsevier, Munich 2006, ISBN 3-437-44405-0 .

Web links

Wikibooks: Pathology: Bones  - Learning and Teaching Materials