Internal Medicine

0521779407-18 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 8:1

1290 Renal Osteodystrophy

Imaging

■X-rays for symptomatic bone disease or elevated PTH:

■Early disease: radiologic findings usually absent

■Advanced disease: high PTH causes subperiosteal bone resorption

(hands)

Bone Biopsy

■Performed infrequently; management guided by serum tests

differential diagnosis

■Muscle weakness: electrolyte disturbances, peripheral neuropathy,

steroid-induced myopathy

■Bone pain: osteomyelitis, osteoporosis, fractures, bone tumors

management

What to Do First

■Check serum PO4, Ca, albumin (to correct Ca level):

stage 3 (GFR 30–59 ml/min/1.73 m2) every 12 months

stage 4 (GFR 15–29 ml/min/1.73 m2) every 3 months

stage 5 (GFR <15 ml/min/1.73 m2) every month

■Check serum PTH:

stage 3 every 12 months

stage 4 every 3 months

stage 5 every 3 months

■Check 25(OH) vitamin D3 level if PTH is elevated

General Measures

■Normalize PO4 and Ca

■Monitor PTH

■Add vitamin D analogs when necessary

■Treatment for age-related and postmenopausal osteoporosis in renal

insufficiency not established:

➣Bisphosphonates not approved for use

➣Standards for estrogen replacement not described

specific therapy

■Indicated whenever PO4 and/or Ca values are chronically abnormal

■First lower PO4: target normal range:

➣Restrict dietary PO4: major sources: dairy products, meat

➣Phosphate binders to reduce gut PO4 absorption

➣Calcium carbonate or calcium acetate with each meal

➣If hypercalcemic, use sevelamer HCl or lanthanium carbonate

with each meal