THE SPECTRUM OF RENAL OSTEODYSTROPHY IN EGYPTIAN HEMODIALYSIS PATIENTS; BONE BIOPSY STUDY

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THE SPECTRUM OF RENAL OSTEODYSTROPHY IN EGYPTIAN HEMODIALYSIS PATIENTS; BONE BIOPSY STUDY

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Co-author 1

Mahmoud Sobh sobh_92@hotmail.com Mansoura University Mansoura Nephrology and Dialysis Unit (MNDU), Internal Medicine Department, Mansoura Egypt *

Co-author 2

Nehal Elshabrawy dr.nehalelshabrawy@gmail.com Mansoura University Mansoura Nephrology and Dialysis Unit (MNDU), Internal Medicine Department, Mansoura Egypt -

Co-author 3

Rasha Shemies rashasamir@mans.edu.eg Mansoura University Mansoura Nephrology and Dialysis Unit (MNDU), Internal Medicine Department, Mansoura Egypt -

Co-author 4

Mohamed Abdalbary dr.mo7a.m@mans.edu.eg Mansoura University Mansoura Nephrology and Dialysis Unit (MNDU), Internal Medicine Department, Mansoura Egypt -

Co-author 5

Ahmed Almenshawy menshawyahmad@mans.edu.eg Mansoura University Clinical Pathology department Mansoura Egypt -

Co-author 6

Hanaa Okda hanaa_omar2003@yahoo.com Tanta University. Internal Medicine department, Faculty of Medicine Tanta Egypt -

Co-author 7

Basma Sultan basma.osman@med.seuz.edu.eg Suiz Canal University Internal Medicine department, Faculty of Medicine Ismailia Egypt -

Co-author 8

Ehab Eltoraby ehabeltoraby@yahoo.com Mansoura University Mansoura Rheumatology and Immunology Unit, Internal Medicine Department Mansoura Egypt -

Co-author 9

Amr El-Husseini amr.elhusseini.moh@uky.edu University of Kentucky Division of Nephrology & Bone and Mineral Metabolism Lexington United States -

Co-author 10

Co-author 11

Co-author 12

Co-author 13

Co-author 14

Co-author 15

Introduction

Renal osteodystrophy (ROD) exhibits varying characteristics among different populations. Variable genetic and environmental factors and prescription patterns may explain these differences. Egyptian ROD is not sufficiently studied. Although bone biopsy is the gold standard tool, no single study has reported the actual ROD spectrum based on bone biopsy in Egypt or Africa.

Methods

The ISN-sistership program enabled us to create an Egyptian bone biopsy consortium that provided a nationwide specialized CKD-MBD service. Bone biopsies were planned based on clinical indications as bone pain, osteoporosis, or fractures that are not explained by non-invasive tools. In addition to basic clinical data, novel bone turnover biomarkers were done. Bone biopsies were analyzed under the supervision of experts from the University of Kentucky, USA.

Results

Over 2 years, 14 patients consented to bone biopsy; all on HD. Adynamic bone disease (ABD) was the most common type of ROD in our cohort (50%). Unexpectedly, various degrees of +ve aluminum (AL) staining were present in 13 patients (93%) as shown in Table 1, despite the nonuse of AL-based phosphate binders.

Figure 1: Image from one of our cases with positive aluminum stains as dark delineation at the osteoid-bone interface

To define a significant amount of AL toxicity, (AL+ve) group, 30% of the trabecular bone-osteoid interface stained with aluminum special stains was used as a cut-off point. AL+ve group included 8 patients (57%). Other biopsy findings are noted in Table 1 and Figures 2 and 3.

Prevalence of biopsy variables showing number (%) of patients within each category. A: 2 biopsies had no cortical tissue. B: 1 biopsy missed any comment about trabecular thickness. C: 5 biopsies had only single label, they were represented in the previous table as “low” as we were sure the patients had received the tetracycline in the appropriate timing.

Figure 2: Radar plot for the cumulative pattern for bone biopsy variables

AL-induced suppression of bone cells was evident by low turnover biomarkers in patients with significant AL accumulation. Moreover, FGF-23 levels were significantly elevated in the AL+ group with a median of 2626 pg./mL compared to 1096 pg./mL in the AL- group (p-value = 0.041), as shown in Figure 4.

Conclusion

To conclude, AL bone disease is not extinct yet. 93% of the biopsied patients for clinical indications had variable degrees of positive aluminum staining, and 57% had significant aluminum accumulation. AL bone disease should be kept in its place in our differential diagnosis list of renal osteodystrophy.

Kewords