|Year : 2006 | Volume
| Issue : 3 | Page : 373-382
|Renal Osteodystrophy: Review of the Disease and its Treatment
Abdullah M.W El-Kishawi1, AM El-Nahas2
1 Nephrology Department, El-Shefa Hospital, Gaza City, Palestine
2 Sheffield Kidney Institute, Northern General Hospital, Sheffield, United Kingdom
Click here for correspondence address and email
| Abstract|| |
Renal osteodystrophy (ROD), which is most evident in patients on renal replacement therapy (RRT), usually begins when the kidney function starts to deteriorate. The spectrum of skeletal abnormalities seen in ROD is classified according to the state of bone turnover. In the past two decades, the prevalence of high turnover ROD has decreased while low bone turnover has become increasingly recognized. Secondary hyperparathyroidism represents a common disorder in patients with chronic kidney disease (CKD); it develops as a result of hyperphosphatemia, hypocalcemia and impaired synthesis of renal vitamin D with reduction in serum calcitriol levels. Patients with secondary hyperparathyroidism have a range of symptoms that affect their quality of life. The aim of treatment of ROD is to reduce the incidence of uremic bone disease as well as cardiovascular morbidity and mortality caused by elevated serum levels of parathormone (PTH) and calcium X phosphorus product. Treatment measures include control of phosphorus retention and prevent hyperphosphatemia, maintaining serum calcium concentrations within the normal range and prevent excess PTH secretion.
Keywords: Renal osteodystrophy, Pathophysiology, Parathormone, Phosphate binders, Vitamin D.
|How to cite this article:|
El-Kishawi AM, El-Nahas A M. Renal Osteodystrophy: Review of the Disease and its Treatment. Saudi J Kidney Dis Transpl 2006;17:373-82
|How to cite this URL:|
El-Kishawi AM, El-Nahas A M. Renal Osteodystrophy: Review of the Disease and its Treatment. Saudi J Kidney Dis Transpl [serial online] 2006 [cited 2021 Mar 1];17:373-82. Available from: https://www.sjkdt.org/text.asp?2006/17/3/373/35770
| Introduction|| |
Renal osteodystrophy (ROD) is a collective term describing the mixture of pathophysiological conditions that afflict the skeletal system of patients with chronic kidney disease (CKD). It is most evident in patients on renal replacement therapy (RRT), but usually starts early in the course of CKD. The spectrum of skeletal abnormalities seen in ROD is classified according to the state of bone turnover: High turnover bone disease or osteitis fibrosa cystica represents the manifestation of hyperparathyroidism, characterized by increased osteoblast and osteoclast activity and peri-trabecular fibrosis. Low turnover bone disease includes:
(i) Osteomalacia, with defective mineralization of newly formed osteoid, most often caused by aluminum deposition.
(ii) Adynamic bone disease characterized by an abnormally low bone turnover including osteopenia or osteoporosis.
Combinations of these abnormalities are called mixed ROD.
Within the past two decades, the prevalence of high turnover ROD has decreased while low bone turnover has become increasingly recognized. This trend is likely to reflect changes in the treatment of ROD and dialysis techniques. 
| Secondary Hyperparathyroidism and Osteitis Fibrosa|| |
Secondary hyperparathyroidism represents a common disorder in patients with CKD. It develops as a result of hyperphosphatemia, hypocalcemia and impaired renal vitamin D synthesis with reduction in serum calcitriol levels.
Effect of Hypocalcemia
Hypocalcemia stimulates release of parathormone (PTH) directly by inactivation of the calcium sensing receptors (CaR) on parathyroid cells. The plasma PTH concentration increases within minutes of fall in serum calcium levels, and reduction of extra cellular calcium levels for weeks or months promotes the development of parathyroid gland hyperplasia, which is the prominent feature of hyperparathyroidism.
Effect of Hyperphosphatemia
Hyperphosphatemia does not become evident until the glomerular filtration rate (GFR) has decreased to between 25 and 40% of normal.
Until that stage in the course of CKD (stage 3), compensatory hyperparathyroidism results in increased phosphorus exertion and maintaining serum phosphorus levels within the normal range. Due to declining GFR, phosphorus retention leads to a decrease in serum free calcium levels, which in turn stimulates PTH secretion.  It also leads to decreased production of calcitriol by the kidney, which in turn decreases intestinal calcium absorption leading to hypocalcemia and consequently, the stimulation of PTH secretion.
Hyperphosphatemia is associated with resistance to the actions of calcitriol on the parathyroid glands, which leads to increased PTH secretion and also causes resistance to the action of PTH on bone. Also, high serum phosphate level has a direct stimulatory effect on PTH secretion, independent of changes in calcium and 1,25(OH) 2 D 3 levels.,
Effect of Vitamin D Deficiency
The kidney is a major site for calcitriol production; with CKD, calcitriol production falls. Calcitriol has several direct and indirect effects on parathyroid glands. In CKD, vitamin D receptors (VDR) in parathyroid glands are down regulated by low levels of calcitriol; this direct mechanism leads to stimulation of PTH gene expression and increases PTH secretion.
Administration of calcitriol increases vitamin D receptors in the parathyroid glands and suppresses PTH secretion. Also, low circulating calcitriol levels may facilitate parathyroid cell proliferation.  Thus, calcitriol deficiency indirectly leads to secondary hyperparathyroidism  in addition to causing skeletal resistance to the calcemic actions of PTH in CKD.
Alterations in the Parathyroid Glands in Uremia
In severe hyperparathyroidism, there is an intrinsic abnormality in the parathyroid glands characterized by development of nodular hyperplasia due to monoclonal expansion, in which VDR and CaR expression are significantly decreased. This contributes to the reduced capacity of the parathyroid glands to respond to therapy such as vitamin D supplementation as well as changes in serum calcium levels.
Consequences of Secondary Hyperparathyroidism
It is necessary to know that bone disease in patients with CKD is usually asymptomatic, and the symptoms, if any, appear late in the course of ROD.  Patients with secondary hyperparathyroidism have a range of symptoms that affect their quality of life and daily functioning. These include:
a) Musculoskeletal symptoms: Bone pain, which occurs in the low back, hips and legs and is aggravated by weigh bearing. Bone deformities are common in patients with severe hyperparathyroidism. They are due to fractures, which can lead to kypho-scoliosis or chest wall deformity.
b) Pruritus: Pruritus occurs in advanced renal failure, especially in patients on dialysis, and is possibly related to deposition of calcium and phosphorus in the skin.
c) Cardiovascular calcification: Coronary artery calcification is commoner and more severe in patients on hemodialysis than in persons without renal failure  and is probably due to excessive use of calcium-containing phosphate binders and vitamin D analogues.
Coronary artery calcifications are found in the majority of patients on RRT and can be detected by non-invasive electron-beam computed tomography (EBCT). In addition to coronary artery calcifications, calcium deposits on the heart valves, especially the mitral and aortic valves, and in the myocardium, cause arrhythmias, left ventricular dysfunction, aortic and mitral stenosis, ischemia, congestive heart failure, and death.
A relation between left ventricular hypertrophy (LVH) and PTH has been described in patients with CKD and secondary hyperparathyroidism. PTH induces hypertrophic growth of cardiomyocytes and smooth muscle cells through the activation of the cardiomyocyte protein kinase.
d) Calciphylaxis: Another serious problem of soft tissue calcification is calcific uremic arteriolopathy (CUA), also known as calciphylaxis. It is a syndrome of calcification of small arterioles and venules with severe intimal hyperplasia, often complicated by thrombosis and recanalization, which results in painful skin necrosis. It carries a high mortality rate due to secondary infection, sepsis and ischemia. Calciphylaxis is caused by high PTH levels, hyperphosphatemia and hypercalcemia induced by high calcium in the dialysate and use of calcium-containing phosphate binders. Obesity, hypo-albuminemia and diabetes increase the risk of calciphylaxis  as also warfarin usage and hypercoagulable states (protein C and protein S deficiency).  The specific management of CUA includes stoppage of oral calcium and usage of non-calcium containing binders and parathyroidectomy if PTH levels are above 600 pg/ml.
| Adynamic Bone Disease|| |
Adynamic bone disease (ABD) represents a common skeletal lesion in adult patients with CKD. It is characterized histopathologically by marked decrease in osteoblasts and osteoclasts with increase in osteoid formation.  Adynamic bone disease is also caused by over suppression of PTH levels by aggressive use of high-calcium dialysate, calcium-containing phosphate binders and vitamin D analogues. It is also frequently seen in patients treated by peritoneal dialysis and those suffering from diabetes.
Osteomalacia is characterized by a reduction in the number of osteoblasts and osteoclasts with an increase in the amount of osteoid. It is related to aluminum accumulation due to use of aluminum-containing phosphate binders. Long standing severe metabolic acidosis may also cause osteomalacia.
Diagnosis of Renal Osteodystrophy
Bone biopsy remains the gold standard for the definitive diagnosis of ROD but biochemical parameters may be helpful in establishing the diagnosis. The K/DOQI guidelines recommend to measure serum calcium, phosphorus and PTH levels when GFR is < 60ml/min/1.73m 2 (CKD stage 3 and above).
PTH levels greater than 500 pg/ml are highly indicative of osteitis fibrosa, whereas adynamic lesion is suspected when the levels are below 100 pg/ml. The serum alkaline phosphatase level may be elevated in hyperparathyroidism indicating increased osteoblastic activity. 
Treatment of Renal Osteodystrophy
The aim of treatment is to reduce the occurrence and/or severity of uremic bone disease and cardiovascular morbidity and mortality caused by elevated serum levels of PTH and calcium X phosphorus product. The US K/DOQI guidelines  and the UK Renal Association Standards  suggest strict targets and management to control these disturbances of mineral metabolism [Table - 1].
Dietary phosphorus restriction: Restricting phosphorus intake can be achieved by reducing intake of dairy products, certain vegetables, and colas. According to K/DOQI guidelines, phosphorus intake should be restricted to 800-1000 mg daily when the serum phosphorus level is > 5.5 mg/dl (1.78 mmol/L) in patients with CKD stage 5.
Phosphate binders: Many patients with CKD, and all dialysis patients, require administration of oral phosphate binders to limit the absorption of dietary phosphorus.
Aluminum-containing phosphate binders were, for many years, the phosphate binders of choice, forming insoluble and nonabsorbable aluminum phosphate precipitates in the intestinal lumen. They are still the most effective phosphate binders but due to their elimination from the body via the kidneys, patients with impaired renal function have a gradual tissue accumulation of absorbed aluminum with resultant toxicity. , The major manifestations of aluminum toxicity develop in the bone, skeletal muscle, and the CNS, leading to low-bone turnover osteomalacia and adynamic bone disease, refractory microcytic anemia, bone and muscle pain, and dementia .However, many physicians still prescribe low doses of aluminium hydroxide. The K/DOQI guidelines recommend the use of aluminium-containing phosphate binders only in patients with serum phosphorus levels >7.0 mg/dL (2.26 mmol/L), that too for short-term therapy (4 weeks) and, for one course only, and then replace by other phosphate binders.
The problems with aluminium-containing phosphate binders led to the administration of calcium salts to bind intestinal phosphorus. In addition to lowering the plasma phosphorus concentration, absorption of some of the calcium can also raise the plasma calcium concentration, providing an additional mechanism by which PTH secretion might be reduced.
Calcium carbonate has been the most widely used calcium salt. Calcium acetate is a more efficient phosphate binder than calcium carbonate, as it dissolves in both acid and alkaline environments while calcium carbonate dissolves only in acid pH and many patients with advanced renal failure have achlorhydria or, are taking H 2 -blockers or proton pump inhibitors. 
The required dose of calcium carbonate to control phosphorus level ranges from 6 gm up to 15 gm/day (40 % of which is elemental calcium). Calcium salts are most effective if taken with meals, because they bind dietary phosphorus and therefore, leave less free calcium available for absorption.
More recently, it has become clear that the use of calcium salts in patients with ESRD can lead to an increased risk of hypercalcemia and metastatic calcifications, including coronary artery calcifications, which are in turn associated with cardiovascular mortality. To avoid metastatic calcification, the K/DOQI guidelines suggest that the total dose of elemental calcium (including dietary sources) should not exceed 2000 mg/day.
Magnesium salts may be used as an alternative to calcium-containing phosphate binders in patients who develop hypercalcemia. Magnesium carbonate reduces PTH and phosphorus levels when used with magnesiumfree dialysate. 
| Non-Calcium, Non-Aluminum Phosphate Binders|| |
Because of the occurrence of hypercalcemia with the use of calcium salts, with consequent metastatic and vascular calcifications, there arose the need for non-calcium, non-aluminium phosphate binders.
Sevelamer hydrochloride is the first synthetic non-calcium, non-aluminum phosphate binder to become widely available in the USA and Europe for the treatment of hyperphosphatemia in patients with CKD.  This cross linked poly allylamine hydrochloride exchange resin binds phosphorus and release chloride  While the potency of sevelamer is low when compared with aluminum,  there are beneficial effects of this drug such as attenuation of the progression of coronary and aortic calcifications as seen with the use of calciumcontaining phosphate binders. Also, significant improvement in lipid profile in the form of reduction of total and low-density lipoprotein (LDL) cholesterol has been noted with sevelamer usage. 
Sevelamer hydrochloride causes metabolic acidosis, which can exacerbate secondary hyperparathyroidism and renal osteodystrophy. Each 800 mg tablet of sevelamer hydrochloride could theoretically lead to an acid load equivalent to 4 mEq hydrochloric acid. 
Sevelamer hydrochloride is considered as a moderate phosphate binder because its optimal phosphorus binding capacity occurs at a pH of 7, whereas the pH in the stomach and first part of the duodenum is much lower than this. Also, high doses of this drug may reduce the absorption of vitamin D from the gut. Additionally, sevelamer hydrochloride is not selective for phosphorus ion only as, it can bind other negatively charged ions such as chloride and bicarbonate. The dose range of 2.4 to 4.8 gm daily provides effective phosphorus control without hypercalcemia.
Lanthanum carbonate is the most recent noncalcium, non-aluminum phosphate binder to be developed for the treatment of hyperphosphatemia. It is a salt of a rare earth metal acting as a highly effective phosphate binder.  It is minimally absorbed from the gastrointestinal tract and is not excreted by the kidneys.  In pre-clinical studies, lanthanum carbonate has been shown to be as effective as aluminum in binding phosphorus but without the associated toxic effects. It has minimal tissue accumulation in comparison to aluminum, but long-term toxicity of bone accumulation cannot be totally ruled out.  Doses between 1350 and 2250 mg/day is effective in reducing and maintaining phosphorus levels in most of the patients; the effect is seen within three weeks of treatment. Also the incidence of hypocalcemia is lower and the calcium X phosphorus product is reduced in comparison with calcium carbonate.
Both calcium-based phosphate binders and other non-calcium, non-aluminum-containing phosphate-binding agents are effective in lowering serum phosphorus levels and may be used as the primary therapy (K/DOQI guidelines).
| Vitamin D|| |
Calcitriol is the most active metabolite of vitamin D that has direct effects on the parathyroid gland by suppressing the synthesis and secretion of PTH and limiting parathyroid cell growth. It has been administered orally and intravenously for the treatment of secondary hyperparathyroidism. It may cause hyperphosphatemia and hypercalcemia by increasing absorption of both calcium and phosphorus. Intravenous "pulse" therapy has a greater effect in reducing bone turnover by diminishing the number of active ostoblasts rather than the reduction in PTH levels. There is indirect evidence that pulse therapy with calcitriol, combined with use of calcium-containing phosphate binding agents, increase the prevalence of adynamic bone disease. 
Due to the potential of calcitriol to cause hyperphosphatemia, hypercalcemia and an increase in calcium X phosphorus product, new vitamin D analogues have recently been developed. These analogues are relatively selective for parathyroid gland with lesser effect on intestinal absorption of calcium and phosphorus. 22-oxacalcitriol is characterized by decreasing affinity for vitamin D binding protein and has a short plasma half-life resulting in rapid clearance from the circulation; this may be the mechanism for its low effect on calcium and phosphorus levels. It is also characterized by effectively decreasing PTH secretion without affecting bone turnover.,
One of the recent studies comparing the effects of calcitriol and 22-oxacalcitriol on secondary hyperparathyroidism showed that the serum calcium and phosphorus levels are similar with these two drugs and that the suppressive effects of these drugs on PTH secretion did not significantly differ.  22oxacalcitriol and calcitriol have a similar effect on hypercalcemia and elevation of calcium X phosphorus roduct when compared to calcitriol. 
Paricalcitol is characterized by adequately controlling PTH secretion with minimal hypercalcemia and hyperphosphatemia compared to calcitriol. , Also, doxercalciferol has the same effective suppression of PTH with minimal changes in serum calcium and phosphorus levels.
The American Food and Drug Administration (FDA) indicated that there is no difference in the ability of intravenous paricalcitol and calcitriol to suppress PTH, calcium and phosphorus levels in hemodialysis patients.  Of interest, a recent study has suggested that none of the new vitamin D analogues is superior to calcitriol or alfacalcidol in suppressing PTH or controlling calcium, phosphorus levels as well as the calcium X phosphorus product.
According to K/DOQI guidelines, patients with CKD who are treated with hemodialysis or peritoneal dialysis with serum PTH levels > 300 pg/ml should receive an active vitamin D sterol such as calcitriol, alfacalcidol, paricalcitol, or doxercalciferol to reduce the serum levels of PTH to a target range of 150 to 300 pg/ml [Table - 2].
| Calcimimetics|| |
Therapy with calcimimetics is a new approach for the treatment of secondary hyperparathyroidism. These agents act at the level of the CaR, which is found in the parathyroid and C thyroid glands as well as renal tubular cells.  Activation of this receptor by calcimimetics increases intracellular calcium concentration, which causes rapid reduction in PTH secretion, serum phosphorus levels, and the calcium X phosphorus product, which remain suppressed for up to three years. ,
Cinacalcet HCl (AMG-073) is a new calcimimetic that is currently approved for clinical use. Cinacalcet HCl is administrated orally at a dose ranging from 30-180 mg once daily, which must be taken at the same hour every day to avoid overdose and adverse effects.
The patient should be started with the lowest dose, which is then increased progressively every two weeks until PTH levels between 150-300 pg/ml are achieved. The serum PTH, phosphorus as well as calcium levels should be checked regularly. Transient hypocalcemia (<7.5 mg/dl) may occur which can be corrected by increasing the dialysate calcium levels or the doses of calcium-containing phosphate binders and vitamin D. ,,
Transient episodes of nausea, vomiting have occurred in patients who were treated with cinacalcet; also, upper respiratory tract infections, hypotension, diarrhea and headache have been observed with cinacalcet HCl.
| Parathyroid Intervention Therapy|| |
It is divided into surgical parathyroidectomy (PTx) and percutaneous direct injection therapy into parathyroid glands. The need for parathyroidectomy in patients with secondary hyperparathyroidism has decreased significantly in the past decade. This is due to increased utilization of medical measures that can suppress parathyroid hormone (PTH) secretion, especially intravenous vitamin D.
The main indications for (PTx) include: therapy-resistant hypercalcemia and/or hyperphosphatemia in the presence of high PTH level, pruritus that does not respond to medical or dialysis therapy, progressive extra skeletal calcification or calciphylaxis, unexplained symptomatic myopathy and renal transplant recipients with persistent hyperparathyroidism in association with hypercalcemia. The K/DOQI guidelines recommend that (PTx) should not be performed unless the PTH levels exceed 800 pg/ml.
Parathyroidectomy includes subtotal PTx or, total PTx with or without re-implantation of parathyroid tissue in the forearm. The latter is considered the procedure of choice in patients with metastatic calcification while subtotal or total PTx with re-implantation are performed to avoid hypoparathyroidism, particularly after renal transplantataion. 
Percutaneous ethanol injection therapy has been considered as an alternative procedure to surgical parathyroidectomy but unfortunately it may cause recurrent laryngeal nerve injury.
Thus, it has recently been replaced by use of intravenous calcitriol preparation for percutaneous injection into parathyroid glands. Also, percutaneous calcitriol analogue injection therapy (22 oxacalcitriol) has shown strong suppressive effect on PTH levels as well as reduction in the size of the enlarged glands. 
In conclusion, ROD remains a major clinical challenge in patients with CKD. Its pathophysiology is not fully understood and its management continues to evolve.
| Acknowledgment|| |
I thank Prof A.M El-Nahas for his very helpful comments, suggestions and criticism. Sponsor: International Society of Nephrology (ISN).
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Abdullah M.W El-Kishawi
Nephrology Department, El-Shefa Hospital, Gaza City, Palestine
[Table - 1], [Table - 2]
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