Cuppari L, Carvalho A, Lobao R, Ventura R, Martini L, Vieira
JB, Draibe SA
Hormonal responses to oral phosphorus supplementation in
predialysis patients with low levels of PTH or adynamic bone
disease
Am Soc Nephrol
J Am Soc Nephrol (abstract)
(Sep) 7:1788 1996
The significance of the adynamic bone lesion remains to be defined.
Problems with fracture, hypercalcemia, calciphylaxis, and even increased
mortality have been reported. One study has demonstrated improvement in
bone formation by stimlating PTH via hypocalcemic dialysis. A concern
with that approach is whether stimulating PTH might not lead to
uncontrolled hyperparathyrodism. Nonetheless, the adynamic bone lesion
appears to be the most common form of renal osteodystrophy today, and
measures to correct are being aggressively pursued, while at the same
time we are attempting to define exactly how problematic it is. Another
recent development in the area of hyperparathyroidism is the
identification that phosphate may directly stimulate PTH.
These authors have identified low PTH values and adynamic bone disease
commonly in their pre-dialysis patients. They identified 7 patients
with PTH < 40 pg/ml and 11 patients with biopsy proven adynamic bone
disease. Mean creatinine was 2.2 mg/dl (range 1.0 to 3.5). They then
treated them with a high phosphate intake and were able to raise the PTH
from a mean of 58.5 to 83.0 (P<.05). Ionized calcium fell from 1.26 to
1.19 (p <.05) and 1,25 D levels from 43.3 to 33.3 pg/ml (p<.05).
Fifteen
of these 18 patients had increases in PTH without changes in
creatinine. Repeat bone biopsies were not done.
Comment: It is difficult to assess this information. Most patients
with
creatinine levels <3.5 have normal PTH levels. It is also a surprise to
find patients with creatinines of 1.0 listed as pre-dialysis. It is not
clear whether one should try to elevate the level at this very early
stage; most investigators are more concerned with keeping the PTH down
at this period in the patient's course. The surprisingly high incidence
of adynamic bone disease these investigators find raises questions about
the patients' general health. They assure us that only one patient was
malnourished, but one must be concerned. Although it is now well
recognized that many patients present for dialysis with adynamic bone
disease it has not previously been described so early in the course of
uremia. Further studies of this phenomenon are mandatory.
(Donald Sherrard, M.D., University of Washington)
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Am Soc Nephrol
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