Nephrology Dialysis Transplantation, Vol 13, Issue 9 2294-2302, Copyright © 1998 by Oxford University Press
G Coen, P Ballanti, E Bonucci, S Calabria, M Centorrino, V Fassino, M Manni, D Mantella, S Mazzaferro, I Napoletano, D Sardella and F Taggi
Background: Renal osteodystrophy includes a number of
low and high turnover bone histologic patterns which require a bone biopsy
for their full identification. The role of intact PTH and several classical
and more recent bone markers in the non-invasive diagnosis of renal bone
disease in patients with CRF in HD requires further definition since
available published data are limited. Methods: In
addition to intact PTH, alkaline phosphatase (AP) and osteocalcin (BGP),
bone alkaline phosphatase isoenzyme (BALP), tartrate resistant acid
phosphatase (TRAP), C-terminal cross-linked peptide of collagen type 1
(ICTP) and deoxypyridinoline (DPD) were measured in the serum of 41
patients on haemodialysis, subjected at the same time to transiliac bone
biopsy for histomorphometric, histodynamic and aluminium histochemical
examination. Histodynamic evaluation following double tetracycline label,
was carried out in 37 patients. The patients had no evidence of active
cytolytic and cholestatic liver disease and a history of very limited
aluminium exposure. Results: The patients had
differing degrees of hyperparathyroidism, with intact PTH ranging from
normal to very elevated levels. Serum values of the markers GBGP, ICTP and
DPD, normally excreted through the kidneys, were on average very high. The
correlation coefficients of the humoral parameters vs dynamic variables,
such as BFR/BS, were high. The highest values were: intact PTH 0.798, AP
0.900, BALP 0.891, ICTP 0.807. The patients, grouped in low turnover
osteodystrophy (LTO; 9), mixed osteodystrophy (MO; 9) and prevalent
hyperparathyroidism (HP; 23), showed significant difference in the levels
of most humoral and static and dynamic parameters (ANOVA). Bone aluminium
histochemistry was negative in all cases. Discrimination of LTO patients
from the other groups by humoral parameters, at the highest value of
accuracy, showed 100% sensitivity and 93.7% specificity with a cut-off of
12.9 ng/ml for BALP; 88.9% sensitivity and 93.7% specificity with a cut-off
of 21.5 ng/ml for DPD, and 88.9% sensitivity and 90.6% specificity with a
cut-off of 79.7 pg/ml for intact PTH. The other markers had lower values. A
standardized z-score approach for evaluation of all humoral parameters was
also carried out. Using all variables, a correct classification of MO/HP
and of LTO was possible in 93.8 and 88.9% of the cases, respectively.
Predictive power was 96.8 and 80%, respectively for MO/HP and LTO. When the
only variables used were intact PTH and BALP, a correct classification of
MO/HP and LTO was possible in 90.6% and 88.9%, respectively. Predictive
value of MO/HP was 96.7% and for LTO 72.7%. Predictive values using PTH and
AP were 96.3% and 57.2%, respectively. Conclusion:
Intact PTH and several relatively new bone markers are of certain value in
the non-invasive diagnosis of renal osteodystrophy. However some of the
humoral markers carry the same quality of information and the use of intact
PTH and BALP may be adequate in the discrimination of bone histologic
patterns. In cases exempt from liver disease, PTH and AP may be used as a
less costly alternative. Bone biopsy could be chiefly limited to cases with
borderline humoral values and to all those with a suspected aluminium
overload. Key words: renal osteodystrophy; adynamic
bone disease; bone biopsy; intact PTH; bone markers; osteocalcin; tartrate
resistant acid phosphatase; deoxypiridinoline; bone alkaline phosphatase
isoenzyme; C-terminal telopeptide of collagen type I
ORIGINAL ARTICLES
Bone markers in the diagnosis of low turnover osteodystrophy in haemodialysis patients
Chair of Nephrology, Pathophysiology and Hypertension Unit, Institute of 2nd Clinica Medica, Policlinico Umberto I, Viale del Policlinico, I-00161 Rome, Italy; Department of Experimental Medicine and Pathology, La Sapienza University and 1st Superiore di Sanita', Rome, Italy; Corresponding author
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