Saudi Journal of Kidney Diseases and Transplantation

LETTER TO THE EDITOR
Year
: 2016  |  Volume : 27  |  Issue : 6  |  Page : 1285--1286

Spontaneous fracture of neck of femur as presenting manifestation of chronic kidney disease in a young patient


Manjusha Yadla, Malleshwar Bottu 
 Department of Nephrology, Gandhi Medical College, Hyderabad, Telangana, India

Correspondence Address:
Manjusha Yadla
Department of Nephrology, Gandhi Medical College, Hyderabad, Telangana
India




How to cite this article:
Yadla M, Bottu M. Spontaneous fracture of neck of femur as presenting manifestation of chronic kidney disease in a young patient.Saudi J Kidney Dis Transpl 2016;27:1285-1286


How to cite this URL:
Yadla M, Bottu M. Spontaneous fracture of neck of femur as presenting manifestation of chronic kidney disease in a young patient. Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2020 Feb 21 ];27:1285-1286
Available from: http://www.sjkdt.org/text.asp?2016/27/6/1285/194695


Full Text

To the Editor,

Fractures are common in chronic kidney disease (CKD) patients on hemodialysis (HD) and peritoneal dialysis. Risk of fracture even in patients of CKD Stages 2-4 is reported to be high compared to those without CKD. Fracture of neck of femur in elderly patients already on HD is well reported. However, spontaneous fracture neck of femur as the presenting manifestation of CKD in young adults is unusual.

Herein, we present a case of a young patient with sudden onset of lower limb monoplegia due to fracture neck femur as the presenting manifestation of CKD.

A 23-year-old female engineering graduate presented to emergency room with sudden onset of inability to move the right lower limb of one-day duration. There was no history of trivial or significant trauma. She was asymptomatic till the day of presentation except for the history of blood transfusion for an episode of menorrhagia about 10 years back. There was no history suggestive of renal parenchymal disease or lower urinary tract symptoms. Her weight was 50 kg. On examination, the right lower limb was externally rotated at the hip joint and the power was 0/5. Her blood pressure was 130/90 mm Hg. Pallor was present. Systemic examination was unremarkable. Her hemoglobin was 7.2 g/dL, and total leukocyte count and platelets were within normal limits. Serum creatinine was 5.2 mg/dL. Complete urine examination showed 2+ albumin with bland sediment. Twenty-four hours urine protein was 2.4 g/day. Ultrasound of the abdomen showed the right kidney of 7 cm and left kidney of 7 cm. Serum calcium was 7.2 mg/dL. Serum phosphorus was 4.2 mg/dL and serum alkaline phosphatase was 110 IU/dL. Serum intact parathyroid hormone (iPTH) was 352 pg/mL, and level of Vitamin D was found to be <3 ng/mL. X-ray of the right hip showed fracture neck of femur [Figure 1].{Figure 1}

She was initiated on HD. After stabilization with HD and improvement of hemoglobin, the right hip hemiarthroplasty was done. She was discharged and continued on maintenance HD.

Femoral neck fractures are uncommon in young patients. They are usually associated with high-energy trauma. Spontaneous femoral neck fracture due to renal osteodystrophy is rare. Hip fractures are 4-14 times more common in patients with end-stage renal disease compared to general population. [1],[2] Risk factors for fractures in patients on HD and those with CKD Stages 2-4 are well described. Alteration in bone quality, bone quantity (turnover, mineralization, and volume), muscle strength, deranged parathyroid function, and elevation of pro-inflammatory cytokines such as tumor necrosis factor-alpha cause changes in bone remodeling. Nickolas et al reported that moderate-tosevere kidney dysfunction is highly prevalent in those with hip fracture in the age group of 50- 74 years. It was noted that the contribution of renal dysfunction is more than the traditional risk factors of age, gender, race, family history, and weight, but what is the extent of this contribution is not known. [3] In DOPPS, the incidence of fracture was reported to be 3%. The National Health and Nutrition Examination Survey reported a two-fold increase in the risk of fracture hip in those with glomerular filtration rate (GFR) <60 mL/min compared to those with GFR >60 mL/min.

Our patient is young and nonobese without any significant family history which suggests that the underlying renal dysfunction must have been the sole cause for hip fracture. Her higher parathyroid hormone levels, low Vitamin D levels, and hypocalcemia suggest severe secondary hyperparathyroidism. Our patient had severe Vitamin D deficiency.

It is reported that the prevalence of severe hypovitaminosis D is high among Indian CKD patients, [4] despite India being a tropical country. This was thought to be due to complete clothing style, malnutrition, and limited outdoor activities. The points of interest in our case are:

Occurrence of fracture neck femur as the presenting manifestation of CKD Stage 5Need to consider fracture neck of femur in a young CKD patient with sudden loss of mobility of lower limb.

Conflict of interest: None declared.

References

1Mittalhenkle A, Gillen DL, Stehman-Breen CO. Increased risk of mortality associated with hip fracture in the dialysis population. Am J Kidney Dis 2004;44:672-9.
2Coco M, Rush H. Increased incidence of hip fractures in dialysis patients with low serum parathyroid hormone. Am J Kidney Dis 2000; 36:1115-21.
3Nickolas TL, McMahon DJ, Shane E. Relationship between moderate to severe kidney disease and hip fracture in the United States. J Am Soc Nephrol 2006;17:3223-32.
4Jabbar Z, Aggarwal PK, Chandel N, et al. High prevalence of Vitamin D deficiency in North Indian adults is exacerbated in those with chronic kidney disease. Nephrology (Carlton) 2009; 14:345-9.