Special report: controversies in bone and mineral metabolism in chronic kidney diseaseDiagnosis, assessment, and treatment of bone turnover abnormalities in renal osteodystrophy
Section snippets
Bone biopsy
The precise nature of abnormalities of bone turnover can be reliably determined with the use of bone biopsy, which remains the gold standard for diagnosis. Bone biopsy is the parameter to which all serum biochemistry and other noninvasive assessments of bone turnover in CKD must be compared.2 A major disadvantage is the invasive nature of the procedure, the analysis of a single site and type of bone, as well as its overall complexity and cost. While the general statement that bone biopsy is the
Epidemiology of renal osteodystrophy
The prevalence of the different types of bone turnover observed in renal osteodystrophy appears to have changed within the past 2 decades. The predominance of hyperparathyroid bone disease (high-turnover disease) has diminished as more adynamic renal osteodystrophy (low-bone- turnover disease) has appeared, especially in the dialysis population.5, 6, 7 The changing profile of the different types of bone turnover has likely occurred because of changes in the therapy of renal osteodystrophy,
Parathyroid hormone
While bone histology is the gold standard for accurate assessment of bone turnover, the search for biochemical markers has been ongoing for a number of years. Measurement of parathyroid hormone (PTH) has been widely used since PTH is a major regulator of bone turnover and skeletal cellular activity.7, 9, 10, 11 Over the past 1 to 2 decades, the principal biochemical marker for diagnosis and classification and for monitoring the therapy of bone turnover has been measurements of PTH by a 2-site
Role of dexa
DEXA is a widely used technique to measure bone mineral density; however, its role in the assessment and therapy of renal osteodystrophy is not well established.20 In general, there is no role for the use of DEXA in the assessment of bone turnover. Its role is limited to providing information on overall bone mineral content/density, but not how that mineral is arranged. In the setting of kidney disease, measurements of bone mineral content do not give any indication of abnormalities in the
Vascular calcification and its relation to bone turnover
The relationship between vascular calcification and bone turnover is an active area of research. Existing data demonstrate an association between these parameters, but many details remain to be determined. This topic is explored in detail by the vascular calcification group and will not be considered further here.
Renal osteodystrophy in children
Renal osteodystrophy in children appears to differ from that seen in adults in that bony deformities and abnormal linear bone growth and abnormal growth velocity are significant problems. Associated abnormalities such as acidosis, vitamin D deficiency, protein-calorie malnutrition, and abnormal insulin-like growth factor (IGF-1) and growth hormone systems may play a role.22 These factors may be operative through the course of CKD from CKD stages 2 to 5. The correction of acidosis as well as
Role of newer dialysis techniques
Much of what we currently know about renal osteodystrophy in patients on dialysis applies to patients on hemodialysis 3 times a week or to patients who receive chronic ambulatory peritoneal dialysis. How newer dialysis techniques may impact bone and mineral metabolism is unknown. Long dialysis 6 days a week, eg, nocturnal dialysis, is often associated with phosphate depletion, and phosphate supplementation is required. Progressive decreases in bone mineral content occur in these patients, the
Vitamin D analogs
While the identification and therapy of renal osteodystrophy continues to evolve, new therapies are being brought to bear on this problem. Over the last several years, there has been an introduction of 4 vitamin D analogs designed to manipulate the activity of the parathyroid glands while minimizing the toxicities that may result from increased intestinal absorption of calcium and phosphorus produced by the native hormone, calcitriol. 19-nor-1,25-(OH)2D2), or paricalcitol, an analog based upon
Summary
Renal osteodystrophy, in which abnormalities of bone turnover predominate, continues to be a complication of CKD and is associated with morbidity and poor quality of life. There is a need to assess the current status and distribution of the types of renal osteodystrophy and to define appropriate therapeutic targets. Bone biopsy remains the gold standard in the diagnosis of the precise type of pathologic changes of bone turnover. There is also a need to standardize bone histology and biopsy
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