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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
ORIGINAL ARTICLE  
Year : 2019  |  Volume : 30  |  Issue : 1  |  Page : 68-82
Musculoskeletal manifestations in end-stage renal disease patients on hemodialysis and relation to parathyroid dysfunction


1 Department of Internal Medicine, Nephrology Unit, Zagazig University, Zagazig, Egypt
2 Department of Rheumatology and Rehabilitation, Zagazig University, Zagazig, Egypt

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Date of Submission15-Jan-2018
Date of Decision01-Mar-2018
Date of Acceptance05-Mar-2018
Date of Web Publication26-Feb-2019
 

   Abstract 


End-stage renal disease (ESRD) is associated with chronic kidney disease-mineral and bone disorder (CKD-MBD); including renal osteodystrophy, and biochemical changes reflecting mineral and hormonal abnormalities. CKD-MBD can lead to serious musculoskeletal manifestations with an impact on the functional status of patients. The objective is to find the frequency of the musculoskeletal manifestations in dialysis patients, to determine the impact on the functional ability of patients, and to detect the relation between parathyroid hormone (PTH) level and musculoskeletal manifestations. The sample size included 53 adult patients on hemodialysis (HD), three times weekly, divided into two groups as follows; (Group A) included 15 patients (10 males and 5 females) on HD for a year or <1 year and (Group B) included 38 patients (24 males and 14 females) on HD for >1 year. All patients were subjected to a full history and physical examination plus a comprehensive assessment of patient's disability was done with a health assessment questionnaire (HAQ)-disability index. The most common neurological manifestations are uremic polyneuropathy (43.4%) and carpal tunnel syndrome. Arthralgia is the most common musculoskeletal manifestation (83%).The most common radiological signs of SHPT is the subperiosteal resorption of the terminal phalanges (67.9%). The most common MSUS abnormalities are Achilles tendinopathy (67.9%). Osteoporosis is detected in 24.5% of patient. There are highly positive significant correlations between HAQ score and age, HD duration, serum PTH, T-score, and X-ray findings. Musculoskeletal system involvement remains a common problem which decreases the physical function of patients with ESRD.

How to cite this article:
Afifi WM, Abo Elsaoud AM, Elgawish MH, Ghorab AM. Musculoskeletal manifestations in end-stage renal disease patients on hemodialysis and relation to parathyroid dysfunction. Saudi J Kidney Dis Transpl 2019;30:68-82

How to cite this URL:
Afifi WM, Abo Elsaoud AM, Elgawish MH, Ghorab AM. Musculoskeletal manifestations in end-stage renal disease patients on hemodialysis and relation to parathyroid dysfunction. Saudi J Kidney Dis Transpl [serial online] 2019 [cited 2019 Mar 23];30:68-82. Available from: http://www.sjkdt.org/text.asp?2019/30/1/68/252935



   Introduction Top


Chronic kidney disease (CKD) is considered as a public health issue as it affects up to 8%–16% of general population worldwide.[1] In Egypt, the prevalence of end-stage renal disease (ESRD) patients on dialysis is 483 per million populations. Around 98% of these patients are on hemodialysis (HD) and 2% on peritoneal dialysis. ESRD is commonly associated with CKD-mineral and bone disorder (CKD-MBD). It is a systemic disease that includes skeletal abnormalities which are called renal osteodystrophy (ROD), soft-tissue calcification and biochemical changes reflecting mineral and hormonal abnormalities.[2] Soft-tissue calcification, also called tumoral calcinosis, is seen in patients on HD most commonly around large joints as shoulders, knees, hips, elbows, wrists, and ankles.[3] Furthermore, tendinopathy and spontaneous tendon ruptures are commonly seen in patients on HD, especially at quadriceps, patellar and Achilles tendons.[4] The overall incidence of ROD in patients on maintenance HD is 90%–100%.[5] It is classified according to the parathyroid hormone (PTH) level into high bone-turnover diseases as osteitis fibrosa cystica (OFC) and brown tumors, low bone-turnover disease as a dynamic bone disease and osteomalacia and mixed disease as osteoporosis.[6] OFC is the most common form of ROD in patients with hyperparathyroidism. The radiological finding of OFC is the subperiosteal resorption that occurs in distal phalanges and clavicles.[7] Osteoporosis is a common disease in dialysis patients that is characterized by low bone mineral density (BMD) and a high incidence of fragility fractures, especially at lumbar vertebrae, hips, forearms, and wrists.[8] BMD is measured using dual-energy X-ray absorptiometry (DEXA), especially at the lumbar spine and hips.[9] Musculoskeletal ultrasound (MSUS) is the first choice in the early diagnosis of wide-spectrum tendon pathologies that occur in dialysis patients as tendon tears and calcifycation.[10] It helps in the diagnosis of minimal joint effusion, synovial hypertrophy, and small bone erosions.[11] Plain X-ray films are also, important in showing bony features of ROD as pseudo-fractures, bone deformities, and osteopenia.[12] The musculoskeletal disorders have an impact on the functional status of dialysis patients. The health assessment questionnaire–disability index (HAQ-DI) is one of the first worldwide self-report functional disability measures.[13]


   Methods Top


This cross-sectional study was carried out at the Rheumatology and Rehabilitation Department and all participants were recruited from the Dialysis Nephrology Unit, Internal Medicine Department at Zagazig University Hospitals. All patients were divided, according to the HD duration, into two groups:

Group A included 15 patients on HD for a year or <1 year. They were 10 males and five females; their age raged between 19 and 48 years with mean ± standard deviation (SD) of 29.47 ± 10.98 years and their HD duration ranged between 3 and 12 months with mean ± SD of 9.1 ±2.25 months.

Group B included 38 patients on HD for >1 year. They were 26 males and 12 females; their age raged between 20 and 62 years with mean ± SD of 49.24 ± 10.79 and their HD duration ranged between 2 and 25 years with mean ± SD of 11.97 ± 6.02 years.

Exclusion criteria

  • History of chronic rheumatic disorders as rheumatoid arthritis
  • History of upper or lower limb amputation
  • Restricted joint motion due to skin lesions or contracture.


All patients were subjected to the following: Full history taking, full clinical examination; general, neurological (gait analysis, sensory, motor, and special provocative tests for carpal tunnel syndrome) and local musculoskeletal examination of Achilles tendon, extensor knee mechanism (quadriceps and patellar), knee joint, ankle, hip, shoulder, and lumbar spine. Assessment of patient's disability by the HAQ-DI (consisted of eight sub categories; dressing, rising, eating, walking, hygiene, reach, grip and activities, four possible responses were present for each category ranged from unable to do (3), do with much difficulty (2), do with some difficulty (1), and do without any difficulty (0).[14] Laboratory investigations for the diagnosis of secondary hyper-parathyroidism (SHPT) as serum intact PTH, alkaline phosphatase, calcium, and phosphorus levels. Imaging including plain X-ray both hands anterior-posterior (AP) view, lumbar spine lateral view, MSUS, all patients were scanned by using HITACHI-ALOKA F37 with a linear probe (10–18 MHz). The MSUS was done on the most affected tendons that were the quadriceps, patellar, and Achilles tendons. BMD was measured in all patients at lumbar spine (L2–L4) and bilateral femoral neck by DEXA.

Statistical Analysis

The collected data were presented and analyzed using computerized software statistical packages by Statistical Package for Social Science (SPSS) version 20.0 (SPSS Inc., Chicago, IL, USA). Mean ± SD with range described quantitative data while numbers with percentages described qualitative data. Chi-square test (χ2) and Fisher's exact was used to compare proportions while independent sample (t) test was used to compare means between the main groups. Value of P <0.05 was considered to be statistically significant at 95% confidence interval.


   Results Top


[Table 1] shows a highly significant difference between the two studied groups regarding age and HD duration, but there was no significant difference regarding gender. In this study, males were more commonly affected with ESRD than females.
Table 1: Demographic distribution between the two studied groups.

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Among all our 53 patients; uncertain etiology had a high percentage in all our 53 patients which was (15.1%). Hypertension (32.1%) and diabetes (15.1%) were the main ESRD causes [Table 2].
Table 2: Distribution of end-stage renal disease (ESRD) causes in the two studied groups.

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Among all our 53 patients, the most common neurological manifestation was uremic polyneuropathy detected in 23 patients (43.4%) and it was detected only in Group B. Carpal tunnel syndrome was detected in 13 patients (24.5%), followed by dialysis disequilibrium syndrome (20.7%). There were highly significant differences between the two studied groups regarding neurological manifestations, demonstrating the effect of long-term HD on the quality of the patient's life [Table 3]. Arthralgia was the most common musculo-skeletal manifestation as it was detected in 44 patients (83%) [Table 4]. The most common arthralgia was knee arthralgia (60.4%) with VAS score mean ± SD of 1.07 ± 1.62 in Group A and 6.29 ± 3.17 in Group B patients. In addition, knee osteoarthritis was detected by palpable coarse crepitation in 19 patients (35.8%) and knee arthritis with minimal effusion was detected by bulge test in 13.2% of patients. Furthermore, ankle arthralgia had a high percentage among our 53 patients (56.6%), followed by shoulder arthralgia (20.7%), lumbar spine pain (17%), and hip arthralgia (7.5%). Arthritis was common among our patients. The most common arthritis were in the ankle joint (13.2%) and knee (13.2%), followed by hip arthritis (7.5%). Lumbar spine, shoulder, and hip affection (symptoms of osteomalacia) were detected only in Group B patients with high statistically significance as they were in long-term HD patients due to Vitamin D deficiency, SHPT and hypocalcemia. These clinical manifestations were confirmed by MSUS of the patellar, quadriceps and Achilles tendons.
Table 3: Frequency of neurological disorders in the two studied group.

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Table 4: Frequency of musculoskeletal manifestations in the two studied groups.

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Among all our 53 patients, osteophytes, demonstrating knee osteoarthritis (35.8%), and mild knee effusion (13.2%). The most common quadriceps MSUS abnormal findings were the loss of echogenicity (24.5%), followed by tendon thickness (>6 mm) (13.2%) and calcified foci (3.8%). The most common Achilles MSUS abnormal findings were tendon thickness (>6 mm) (62.3%), followed by loss of echogenicity (33.9%) and calcified foci (18.9%). Furthermore, there were highly significant differences between the two studied groups regarding tendinopathy, demonstrating the effect of long-term HD on the patient's locomotor system [Table 5].
Table 5: Musculoskeletal ultrasound (MSUS) findings in the two studied groups.

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“Notice that the same patient might have osteoporosis and osteopenia in lumbar spine, femoral neck T-score and abnormal lumbar X-ray at the same time.”

WHO criteria for osteoporosis diagnosis:

- T-score ≥−1 means “normal”

- −1 <T-score >−2.5 means “osteopenia”

- T-score ≤ − 2.5 means “osteoporosis”

Lumbar X-ray lateral view showed osteoporotic vertebral compression fractures in 22.6% of patients. Among all our 53 patients, osteoporosis was detected only in Group B, in 13 patients (24.5%). Although osteopenia was detected in 30 patients (56.6%), but lumbar spine osteopenia was detected in Group B only. There was a high significant difference between the two studied groups regarding osteoporosis and osteopenia, demonstrating the effect of long-term HD on the bone strength of our patients, especially their effect on the lumbar spine [Table 6].
Table 6: Frequency of osteoporosis in the two studied groups, regarding T-score of DEXA scan.

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Signs of SHPT were detected only in Group B patients, such as subperiosteal resorption of the terminal phalanges (67.9%), broad osteoscleosis “rugger-jersey spine sign” (26.4%) and brown tumors “complicated OFC” (7.5%). There was a highly significant difference between the two studied groups regarding abnormal X-ray findings, demonstrating the effect of long-term HD on the occurrence of SHPT with poor bone quality [Table 7]. [Table 8] and [Table 9] shows a highly significant differences between the two studied groups regarding HAQ score, serum intact PTH (iPTH), alkaline phosphatase, and calcium and phosphorus levels. There was a positive significant correlation between the HAQ score and age, but there were no significant correlations between HAQ score and the other studied parameters. In Group B patients, there were highly positive significant correlations between HAQ score and abnormal hand X-ray (AP view) findings, age, HD duration, serum iPTH level, and the T-score of both femoral neck and lumbar spine. Furthermore, there were positive significant correlations between HAQ score and the serum alkaline phosphatase level and the abnormal lumbosacral X-ray (lateral view) findings. On the other hand, there was a negative significant correlation between HAQ score and the serum calcium level. Furthermore, no significant correlations were detected between HAQ score and the other studied parameters.
Table 7: Frequency of secondary hyperparathyroidism (SHPT) in the two studied groups, regarding X-ray findings and the laboratory investigation.

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Table 8: Quantitative parameters distribution in the two studied groups; regarding other laboratory investigations and health assessment questionnaire score.

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Table 9: Correlation of the HAQ scores with both qualitative and quantitative parameters in the two studied groups.

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In Group A patients, there was a negative significant correlation between serum iPTH level and the serum hemoglobin level, but there were no significant correlations between serum iPTH level and the other studied parameters. In Group B patients, there were highly positive significant correlations between serum iPTH level and the abnormal hand X-ray (AP view) findings, HD duration, HAQ score, serum calcium level, and the T-score of both femoral neck and lumbar spine. Furthermore, there were positive significant correlations between serum iPTH level and the age and the abnormal lumbosacral X-ray (lateral view) findings. Although, there were no significant correlations between serum iPTH levels and the other studied parameters [Table 10].
Table 10: Correlation between serum parathyroid hormone (iPTH) levels and both qualitative and quantitative parameters in the two studied groups.

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In Group B, there were highly positive significant correlations between the HD duration and age, HAQ score, serum iPTH, and alkaline phosphatase levels, both abnormal hand and lumbosacral X-ray findings and the T-score of both femoral neck and the lumbar spine [Table 11]. Furthermore, there was a positive significant correlation between the HD duration and serum uric acid level. Although, no significant correlations were detected between the HD duration and the other studied parameters.
Table 11: Correlation differences between the hemodialysis duration and both qualitative and quantitative parameters in Group B patients.

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   Discussion Top


In 2005, the Kidney Disease: Improving Global Outcomes organization suggested new terminology containing the wide range of clinical syndrome called “CKD-MBDs”.[15] The most common symptoms are: bone pain, arthralgia, proximal muscle weakness, tendinopathy, and spontaneous tendon rupture.[16] In dialysis patients, the whole musculoskeletal system (bone, joint, muscle, and tendon) may be affected and most of the patients show evidence for more than one kind of musculoskeletal involvement.[17]

In the present study, the frequency of ESRD patients with HD was higher in males than in females and the HD frequency increased with ageing as the sample consisted of 36 males (67.9%) and 17 females (32%); the male patients were divided into 10 males in Group A and 26 males in Group B, but the female patients were five females in group A and 12 females in Group B. Group A included only 15 patients with their mean age of 29.47 ± 10.98 years. Group B included 38 patients with their mean age of 49.24 ± 10.79 years.

This was in agreement with Ghonemy et al,[18] who reported that patients on HD at Al-sharkia governorate were 62.2% of males and 37.8% of females with mean age of 52.03 years. These results are also similar to the study performed by El-Najjar et al[13] who detected that the majority of patients were male and the mean age was 47.5 years. Furthermore, Zahran,[19] showed that the mean age of ESRD patients in the Menoufiya governorate in Egypt was 52 years. Furthermore, Yu et al[20] reported that ESRD dramatically increased with ageing in both genders.

These results were in disagreement with studies carried out at the United Kingdom by Ejerblad et al[21] who detected that the mean age of ESRD was 65.9 years. Such differences may be due the genetic or social differences between the Egyptian community and these developed countries.

In this study, hypertension is the first cause of ESRD, followed by diabetes mellitus. The main causes of ESRD was detected in our patients as follow: hypertension (32%), diabetes mellitus (15%), urinary tract infection (9.4%), renal stone (7.5%) due to dam, analgesic abuse (5.6%), primary glomerulonephritis (3.7%), congenital anomalies (3.7%), incompatible blood transfusion (3.7%), bilharzias (1.9%), familial  Mediterranean fever More Details (1.9%) and unknown causes in 15% of patients.

This was in agreement with Ghonemy et al[18] who reported that hypertension (31.8%) and diabetes (15.5%) were the main causes of ESRD at Al-Sharkia governorate. These results were also, in agreement with a study in Kuwait by El-Reshaid et al[22] who demonstrated that hypertension was the main risk factors of ESRD, especially at older patients. Furthermore, Klag et al[23] showed that hypertension was a strong risk factor of ESRD. Furthermore, Zahran,[19] showed that hypertension followed by diabetes were the main causes of ESRD in Menofiya governorate in Egypt. In this study, unknown causes constitute 15% of all causes of ESRD. Unknown causes of ESRD was estimated to be 14.4% in an Iranian study by Malekmakan et al,[24] 14% in Qatar study by Shigidi et al,[25] and 19.9% in Saudi Arabia study by Shaheen et al.[26] It was estimated to be 27% in Al-Minya governorate[27] and 20.6% in the Menofiya governorate.[19]

These results were in disagreement with a study in Greece,[38] who detected that diabetes (25.4%) was the main cause of ESRD, followed by hypertension (18.6%). Also, a study in India by Soyibo and Barton[28] detected that glomerulonephritis is the main cause of ESRD. This may be contributed to the genetic and social differences between the Egyptian community and these communities.

In this study, neurological manifestations were common and their frequency increased with the HD duration; in Group B. These results were in agreement with Lim et al,[29] that reported increased neurological symptoms on long-term HD. Among our 53 patient, the most common neurological manifestations were uremic polyneuropathy (43.4%) that was detected only in Group B patients and manifested by decreased superficial sensations of lower limb in 43.4% of patients. These results were in agreement with Rizzo et al,[30] that reported high frequency of uremic polyneuropathy in 60% of the patients.

Also, carpal tunnel syndrome was a common manifestation among our 53 patients (24.5%) with +ve Phalen's test (24.5%) and thenar muscle weakness (20.7%). These results were in agreement with Jokar and Adle,[31] that reported symptoms of carpal tunnel syndrome in 24.3% of patients. Also, Busch et al[32] reported carpal tunnel syndrome in 31.7% of patients. Moreover, our significant predictors of carpal tunnel syndrome were age, female gender and the long-term HD, such as a study by Kopeć et al.[33] These results were in disagreement with El-Najjar et al,[13] that reported carpal tunnel syndrome only in 14.9% of patients; this may be contributed to the increased number of patients (144 patients) included in their study. Also, dialysis disequilibrium syndrome was detected in 20.7% of patients. It was due to uremic increase in cerebral membrane permeability leading to entry of more toxins into the brain. These results were in agreement with Prabhakar et al[34] that reported dialysis disequilibrium syndrome (20.7%).

In our study, the frequency of musculo-skeletal symptoms increased with the HD duration and the musculoskeletal manifestations appeared in 70% of patients. These results were in agreement with Jokar and Adle,[31] in which musculoskeletal symptoms were found in up to 70% of patients. Also, Lim et al[29] detected that symptoms increased with increased HD duration.

Among all our 53 patients, arthralgia was the most common musculoskeletal manifestation as it was detected in 44 patients (83%). The most common arthralgia was knee arthralgia (60.4%), followed by ankle arthralgia (56.6%), shoulder arthralgia (20.7%), lumbar spine pain, and hip arthralgia. These results were in agreement with Duncan et al[35] who found that osteoarthritis was a common manifestation among the HD patients; in a younger age than the normal population.

These results were in disagreement with Jokar and Adle,[31] that reported arthralgia in only 21.6% of patients; this may be contributed to the shorter HD duration in this study (1 month–14 years) than our study (1–25 years). Also, El-Najjar et al,[13] disagreed with our results as arthralgia was represented in 25.3% of patients; this may be contributed to the increased number of patients (144 patients) included in that study more than our study (53 patients).

In our study, 90.6% of patients had radiological abnormalities of hand and lumbar spine. Our study demonstrated that the abnormal radiological signs of secondary hyperparathyroidism increased with the HD duration and appeared only in Group B patients. The most common signs were subperiosteal resorption of the terminal phalanges (67.9%), osteoscleosis “rugger-jersey spine sign” (26.4%) and brown tumors “complicated OFC” (7.5%). Also, osteopenia appeared in 45.3% of patients, followed by osteoporosis (22.6%).

These results were in agreement with Hruska and Teitelbaum,[36] and also, Murphey et al[37] who reported that subperiosteal bone resorption was the most common radiological findings in 66% of patients. It is also, in agreement with Hsu et al[38] who detected osteo-sclerosis in 9%–34% of patients. Also, Lim et al[29] detected osteopenia in 83% of patients that agreed with our study. Also, Lacativa et al[39] agreed with these results, reporting rugger-jersey spine sign in 27.4% of the patients and brown tumors (9.7%).

On the other hand, this result is in disagreement with a study[40] which reported sub-periosteal resorption of the terminal phalanges in 35% of patients, osteopenia (43.2%) and osteosclerosis (2.7%) of the patients; this may be contributed to the shorter HD duration in this study (1 month–14 years) than our study (1–25 years).

In our study, high PTH levels were detected in 75.4% of patients, followed by high serum alkaline phosphatase level (71.8%), hypocalcemia (49%), hyperphosphatemia (45.3%), hyperuricemia (9.4%), and anemia (50%). These results were in agreement with El-Najjar et al,[13] that reported high PTH level in 80.4% of patients, high alkaline phosphatase (75.8%), hypocalcemia (50.5%) and hyperphosphatemia (43.6%). Furthermore, Jokar and Adle[31] agreed with our study as they reported high PTH level (81%), high alkaline phosphatase (75.6%), hypocalcemia (51.4%), and hyperphosphatemia (43.2%).

These results were in disagreement with a study[41] that reported hypocalcemia (23.8%), hyperphosphatemia (55.4%), raised alkaline phosphatase (56.9%), and secondary hyperparathyroidism (82.7%); this may be contributed to the increased number of patients (462 patients) included in the study more than our study (53 patients).

In our study, like that observed by Wei et al, females it was observed that elevated iPTH was more commonly observed in women compared with men.[42]

In our study, the most common MSUS abnormalities were Achilles tendinopathy (67.9%), followed by quadriceps tendinopathy (28.3%) and patellar tendinopathy (5.7%). The most common Achilles ultrasound abnormalities were tendon thickness (>6mm) (62.3%), followed by the loss of echogenicity (33.9%) and calcified foci (18.9%). These results were in agreement in a study[38] which found that the most common finding was abnormal Achilles tendon thickness (62.7%, followed by loss of echogenicity (44.1%) and calcified foci (23.7%). These results were in disagreement with Hussein et al,[4] who reported Achilles tendon thickness in 28% of patients and calcified foci in 24% of patients.

The most common quadriceps ultrasound abnormalities were loss of echogenicity (24.5%), followed by tendon thickness (>6 mm) (13.2%) and calcified foci (3.8%). Also, mild knee effusion (13.2%) and osteophytes were detected by ultrasound in our 53 patients, demonstrating knee osteoarthritis in 19 patients (35.8%). No reported cases of spontaneous tendons rupture. These results were in agreement with two studies by Teber et al,[43] and Morein et al.[44] These results were in disagreement with Kaymaz et al,[45] who reported spontaneous tendon rupture. Also, Basic-Jukic et al,[46] disagreed with our results as spontaneous tendon ruptures were reported. This may be contributed to the sedentary life of our patients than that study.

In our study, regarding the T-score of both lumbar spine and femoral neck; osteopenia was detected in 56.6% of patients; osteopenic femoral neck T-score (50.9%) and osteopenic lumbar spine T-score (28.3%), followed by osteoporosis (24.5%) that was detected only in Group (B) patients.

These results were in disagreement with El-Najjar et al,[13] that reported osteopenia in 3.4% of patients and osteoporosis in 10.4% of patients; this may be contributed to the increased number of patients (144 patients) included in that study more than our study (53 patients). Furthermore, Polymeris et al,[4] disagreed with our study, who reported osteoporotic lumbar spine in 14.3%. This may be contributed to the shorter duration of HD (4–5 years) than our study (1–25 years).

In our study, regarding the HAQ score, there was a highly significant difference in physical function and disability using HAQ between HD patients with knee pain, hip pain, osteo-arthritis, and osteoporosis. These results were in agreement with El-Najjar et al.[13]

In our study, regarding the serum iPTH level, there were highly positive significant correlations between serum iPTH level and the serum calcium, phosphorus and alkaline phosphatase levels. This result was in agreement with Wei et al.[42] In addition, there were no significant correlations between serum iPTH levels and the age. This result was in agreement with Vhora et al.[40] Regarding the HD duration, there were highly positive significant correlations between the HD duration and HAQ score, serum iPTH and alkaline phos-phatase levels. These results were in agreement with El-Najjar et al.[13] Furthermore, our study detected the highly positive correlation between the HD duration and clinical and radiological findings, such as a study by Jonjic et al.[48]

In conclusion, musculoskeletal system involvement remains a common morbidity which decreases the physical function of patients with ESRD.

Conflict of interest:

None declared.



 
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Correspondence Address:
Walid M Afifi
Department of Internal Medicine, Nephrology Unit, Zagazig University, Zagazig
Egypt
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PMID: 30804269

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11]



 

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