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Diabetic Nephropathy
Published in Jahangir Moini, Matthew Adams, Anthony LoGalbo, Complications of Diabetes Mellitus, 2022
Jahangir Moini, Matthew Adams, Anthony LoGalbo
There may be abnormalities of calcium, parathyroid hormone (PTH), phosphate, and vitamin D metabolism. Renal osteodystrophy is also possible. Reduced renal production of the active vitamin D hormone calcitriol adds to hypocalcemia. Reduced renal excretion of phosphate causes hyperphosphatemia. Secondary hyperparathyroidism is often seen, developing in kidney failure prior to abnormal calcium or phosphate concentrations manifesting. Therefore, it is important to monitor PTH in patients with moderate CKS prior to hyperphosphatemia occurring. Renal osteodystrophy is abnormal bone mineralization. It occurs because of a deficiency of calcitriol, hyperparathyroidism, excessive serum phosphate, or low to normal serum calcium. There is usually increased bone turnover because of osteitis fibrosa, a hyperparathyroid bone disease. There may be decreased bone turnover, however, caused by an adynamic disease from increased suppression of the parathyroid glands, or osteomalacia. If there is a calcitriol deficiency, this may result in osteomalacia or osteopenia.
Miscellaneous Topics
Published in Nirmal Raj Gopinathan, Clinical Orthopedic Examination of a Child, 2021
Prateek Behera, Karthick Rangasamy, Nirmal Raj Gopinathan
A detailed history must be obtained from the caregiver of a child, and the injuries that have been sustained are to be corroborated with the history. The lack of a plausible history other than inflicted trauma is the key element in making a diagnosis of child abuse.6 Sentinel injuries may be noted in approximately 25% of abused infants and may precede the diagnosis by weeks or even months from the sentinel event.6 Bruises are the most common form of injury sustained by victims of abuse. Atypical age and atypical location of the bruises are often indicative of the possibility of child abuse. Bruises are often multiple in number and location and are of different ages. Additionally, their shapes might be different too. Bites, burns, and fractures are the other injuries that, if present, should alert the orthopedic surgeon. Fractures that can be suggestive of abuse include classic metaphyseal lesions, posterior rib fractures, and fractures of the scapula, sternum, and spinous processes, especially in young children. Fractures of these regions need forces much greater than that sustained by the child due to a fall at home. The differential diagnosis includes osteopenia of prematurity and osteogenesis imperfecta, metabolic and nutritional disorders (e.g., scurvy, copper deficiency, rickets), renal osteodystrophy, and congenital insensitivity to pain, etc. Appropriate radiographic evaluation is also necessary.
Comparing Populations
Published in Gary L. Rosner, Purushottam W. Laud, Wesley O. Johnson, Bayesian Thinking in Biostatistics, 2021
Gary L. Rosner, Purushottam W. Laud, Wesley O. Johnson
Renal osteodystrophy is a bone disease that occurs when the kidneys fail to maintain proper levels of calcium and phosphorus in the blood. Monitoring patients with loss of kidney function for lower than normal bone turnover aids in managing the disease. A commercially available diagnostic assay, DiaSorin, was believed to have the potential to determine which patients have low versus normal bone turnover. A cross-section of 34 kidney patients from the bone registry at the University of Kentucky were identified as low or normal turnover by other means and then given the commercial assay to determine whether it could correctly identify them. From boxplots, a normal sampling model appears to be untenable, due to observable skewness; however, boxplots and quantile plots of the log-transformed data appear to be reasonably normal (see Figure 5.2).
Incidence of bone fractures among patients on maintenance hemodialysis
Published in Renal Failure, 2023
Abdullah Kashgary, Feryal Omar A. Attiah, Nada AbuBakr AlKhateeb, Nada H. Abdulaziz, Banan Abdullah Alsaif, Amal Fahad Aljuhani, Mohamed Abdalbary, Eman Nagy, Mostafa Abdelsalam
Osteoporosis is an imbalance between bone resorption and formation. In patients with CKD, it might be presented as low or high bone turnover disease. To select the appropriate intervention, it is crucial to comprehend the etiology of bone loss [4]. In patients with CKD, the pathogenesis of osteoporosis is complex and multi-factorial. Many factors lead to bone loss in patients with kidney disease. Renal osteodystrophy is determined by an imbalance in bone remodeling, parathyroid hormone changes, bone mineral and vitamin D abnormalities. Furthermore, the uremic milieu, medication usage, disrupted gonadal hormones, and premature aging contribute to the increased prevalence of osteoporotic fractures among patients with ESKD [5]. Moreover, patients with CKD has not only a bone quantity but also a bone quality problem [6].
Interrelationships between sarcopenia, bone turnover markers and low bone mineral density in patients on hemodialysis
Published in Renal Failure, 2023
Yilin Wang, Wenxia Ma, Jianhong Pu, Fengling Chen
Patients with CKD have a higher risk of fractures due to abnormal bone turnover, which includes high turnover (hyperparathyroid bone disease), low bone turnover or adynamic bone disease (ABD), osteomalacia and mixed uremic osteodystrophy, and is associated with high morbidity, mortality [19] and economic burden. This is the first study to evaluate the relationship between CKD-MBD and sarcopenia in patients on maintenance dialysis in China. An observational study demonstrated that patients with CKD-MBD may have a spectrum of bone disorders [1], and the loss of ALM leads to an increase in bone loss risk. As a result, dialysis patients also demonstrate bone loss and sarcopenia, which combination is termed osteosarcopenia [10]. In our study, HD patients had a higher proportion of Osteopenia and Osteoporosis than healthy controls, whether in the elderly or in the young age group. Patients on hemodialysis are at increased risk of BMD loss than the healthy controls. Among 130 HD patients, 36 were diagnosed with sarcopenia (27.7%), 44 were diagnosed with osteopenia (33.8%), 19 were diagnosed with osteoporosis (14.6%), and 23 were diagnosed with osteosarcopenia (17.7%). HD Patients are more likely to develop BMD loss. The prevalence of osteosarcopenia was 10.4% in males and 15.1% in females in a study of community-dwelling Chinese elderly individuals [20], and frailty, mortality, and fragility fractures were more prevalent among patients with osteosarcopenia [20–22]. Thus, in patients on hemodialysis, low muscle mass and bone loss should be monitored and treated to reduce adverse outcomes.
Risk factors for hypocalcemia in dialysis patients with refractory secondary hyperparathyroidism after parathyroidectomy: a meta-analysis
Published in Renal Failure, 2022
Dan Gao, Yan Lou, Yingchun Cui, Shengmao Liu, Wenpeng Cui, Guangdong Sun
ALP activity is important for appropriate bone mineralization. In addition, it is also a well-recognized biomarker of renal osteodystrophy. Notably, ALP is the term given to a group of isoenzymes mainly found in the liver and bone. It is widely distributed in the skeletal system of the human body, with serum ALP level increasing upon activation of osteoblasts. Most patients with SHPT have metabolic bone diseases with active osteoblasts. In this case, the increased serum ALP level correlated with the severity of bone disease. On the contrary, higher ALP levels in patients with hypocalcemia before surgery suggest a more active bone remodeling state in patients with hypocalcemia after PTX [33,34]. Based on the results of this meta-analysis, it is concluded that a high preoperative ALP level was a risk factor for hypocalcemia after PTX. However, the meta-analysis exhibited strong heterogeneity. The very small OR value of multivariate logistic regression results in some studies is also a significant factor that led unsatisfactory results in the final meta-analysis. Despite the great heterogeneity of the meta-analysis, all the included studies consistently suggested that a high preoperative ALP level was a risk factor for postoperative hypocalcemia, thus confirming our conclusion. This preoperative variable allows physicians to accurately identify dialysis patients who are at a greater risk of hypocalcemia after PTX, and to aggressively monitor and treat patients who possess any of these factors in the postoperative period. An example of treatment is the supplementation of calcium and active vitamin D analogs.