The patient was afebrile and in no acute distress. Her feet, ankles, and elbows had normal ranges of motion with no point tenderness, crepitus, swelling or erythema. Her lower extremities had normal pulses, intact skin and no edema. She had stable mild cardiomegaly and retinopathy. Radiographs of the feet showed osteopenia, but no other signs or hyperparathyroidism fracture.
2/82 5/83 6/84 2/85 Ca++ 9.2 ----- 9.3 9.1 (9.1-10.9 mg/dl) PO4 4.9 ----- 4.1 4.4 (2.3-4.3 mg/dl) Alk Phosphatase 98 271 328 633 (16-95 IU/I) Creatinine 3.6 5.0 5.2 6.9 (< 1.2 mg/dl)
The major bony changes which can occur as a result of chronic renal failure are osteitis fibrosa cystica, osteomalacia or rickets, osteosclerosis and osteoporosis. The clinical presentation is influenced by the patient's age at onset of renal failure, the etiology of the renal disease, dietary content (protein, phosphate and calcium) and treatment modalities. The reported predominance of each variety of bony change varies and doesn't correlate well with clinical findings or laboratory data. About 15% of patients with hyperparathyroidism (primary or secondary) have roentgen changes in the calvarium.
Diffuse increased scintigraphic skeletal:renal uptake ratio of bone agent can occur in any disease process in which there is increased bone turnover. Uptake may be heterogeneous or homogeneous, depending upon the predominate pathophysiologic mechanism. Increased turnover can result from local processes such as widespread metastases, fibrous dysplasia, Paget's disease, or myeloproliferative disorders. Examples of the later are myelofibrosis, mastocytosis, leukemia, lymphoma, aplastic anemia and Waldenstrom's macroglobulinemia. Increased bone turnover also occurs with endocrine/metabolic abnormalities such as hyperparathyroidism, hypervitaminosis D, rickets, or combinations of these as seen in renal failure. Differentiation is based on clinical data and radiographs in many cases.
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J. Anthony Parker, MD PhD, email@example.com