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Bone histomorphometry in renal osteodystrophy 

Bone histomorphometry in renal osteodystrophy
Chapter:
Bone histomorphometry in renal osteodystrophy
Author(s):

Arnold J Felsenfeld

and Armando Torres

DOI:
10.1093/med/9780199559176.003.010
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date: 25 February 2020

Treatment for disorders of high bone turnover, OF and MUO, characterized by high PTH values include active vitamin D sterols, cinacalcet, parathyroidectomy, and in a limited number of centres direct injection of the parathyroid gland. OM is much less common than before because of strict standards for dialysate water preparation and the discontinuation of aluminum-based phosphate binders. However, in some areas of the world, aluminum exposure still remains a problem. AD is now a common disorder that is seen in the absence of aluminum. It is probably associated with an increased risk of fractures and even more important, a possible acceleration of vascular calcification. AD is associated with a relative deficiency of PTH and factors contributing to its development include old age, diabetes, and an increased calcium load. Treatment of AD is limited because it is difficult to increase PTH levels in patients with AD. It is generally accepted that PTH is the primary modifier of bone turnover. However, less well appreciated is that several factors may alter the bone response to PTH. Several studies of bone histology in dialysis patients have shown that the bone response to PTH as measured by the osteoblast surface and bone formation rate, decreases after age 45 or 50 years. Older patients also eat less protein resulting in a decreased phosphate load that, in turn, reduces the stimulus for PTH secretion. There is also increasing evidence that the bone response to PTH, as determined by bone turnover in histological studies, is decreased in black CKD patients. Attempts to use non-invasive means of assessing bone turnover, such as PTH values and bone alkaline phosphatase, have lacked sensitivity at intermediate PTH values between 150 and 450pg/ml. Finally, variability in PTH assays and problems associated with the collection of PTH samples have further complicated the ability to make therapeutic decisions based on PTH measurements.

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