Renal Osteodystrophy (ROD)
Renal Osteodystrophy (ROD)
Renal osteodystrophy (ROD) is a bone disorder that occurs in patients with chronic kidney disease (CKD) as part of the broader systemic condition called chronic kidney disease-mineral and bone disorder (CKD-MBD). It involves alterations in bone turnover, mineralization, volume, linear growth, or strength due to disturbances in mineral and hormone metabolism caused by impaired kidney function1.
Pathogenesis
- Mineral metabolism abnormalities: CKD leads to phosphate retention and hypocalcemia due to reduced kidney excretion of phosphate and decreased activation of vitamin D (calcitriol).
- Secondary hyperparathyroidism: Hypocalcemia and hyperphosphatemia stimulate parathyroid hormone (PTH) secretion, increasing bone resorption and turnover (osteitis fibrosa).
- Vitamin D deficiency: Reduced calcitriol synthesis impairs calcium absorption and bone mineralization.
- Fibroblast growth factor 23 (FGF23): Elevated in CKD, it further suppresses calcitriol production.
- Bone turnover imbalance: Can manifest as high turnover (osteitis fibrosa), low turnover (adynamic bone disease), osteomalacia (defective mineralization), or mixed forms1.
Types of Renal Osteodystrophy
- Osteitis fibrosa: High bone turnover with increased osteoclastic activity due to elevated PTH.
- Adynamic bone disease: Low bone turnover with decreased osteoblast and osteoclast activity, often due to over-suppression of PTH.
- Osteomalacia: Defective bone mineralization, sometimes linked to aluminum toxicity or vitamin D deficiency.
- Mixed uremic osteodystrophy: Features of both high turnover and defective mineralization.
- Mild or normal turnover: Slight increase in turnover with normal mineralization1.
Clinical Features
- Bone pain and muscle weakness
- Bone deformities and fractures
- Pruritus (itching) due to secondary hyperparathyroidism
- Increased fracture risk and skeletal fragility
- Associated vascular and soft tissue calcifications contributing to cardiovascular morbidity and mortality15.
Diagnosis
- Laboratory tests: Elevated serum phosphate, PTH, alkaline phosphatase, low calcium and vitamin D levels.
- Imaging: Bone X-rays, bone densitometry, and sometimes bone biopsy.
- Bone biopsy: Gold standard to assess bone turnover, mineralization, and volume using the TMV (Turnover, Mineralization, Volume) classification system18.
Treatment
- Phosphate control: Dietary restriction and phosphate binders (preferably non-aluminum based).
- Vitamin D supplementation: Active vitamin D analogs to correct deficiency and suppress PTH.
- Management of secondary hyperparathyroidism: Calcimimetics, parathyroidectomy in refractory cases.
- Avoid over-suppression: To prevent adynamic bone disease.
- Kidney transplantation: The only definitive cure for ROD167.
Summary Table
| Aspect | Details |
|---|---|
| Definition | Bone disorder in CKD characterized by abnormalities in bone turnover, mineralization, volume |
| Pathogenesis | Phosphate retention, hypocalcemia, vitamin D deficiency, secondary hyperparathyroidism |
| Types | Osteitis fibrosa, adynamic bone disease, osteomalacia, mixed, mild turnover |
| Symptoms | Bone pain, fractures, deformities, pruritus, muscle weakness |
| Diagnosis | Lab tests (PTH, phosphate, calcium), imaging, bone biopsy (TMV classification) |
| Treatment | Phosphate control, vitamin D, calcimimetics, parathyroidectomy, kidney transplant |
| Complications | Fractures, skeletal deformities, cardiovascular calcification, increased mortality |
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Key References
- Kidney International Reports: Renal Osteodystrophy and CKD-MBD
https://doi.org/10.1038/s41581-019-0115-5 - Wikipedia: Renal Osteodystrophy
https://en.wikipedia.org/wiki/Renal_osteodystrophy - Cleveland Clinic: Renal Osteodystrophy
https://my.clevelandclinic.org/health/diseases/24006-renal-osteodystrophy - KDIGO Conference Report on Renal Osteodystrophy
https://kdigo.org/wp-content/uploads/2017/01/Renal-Osteodystrophy-Conference-Report.pdf - Open Access Journal: Renal Osteodystrophy Treatment and Cause
https://doi.org/10.37532/oain.2022.5(4).40-43 - DaVita: Renal Osteodystrophy and Bone Disease
http://www.davita.com/treatment-services/dialysis/on-dialysis/renal-osteodystrophy-bone-disease-and-kidney-failure
Renal osteodystrophy is a complex bone disorder stemming from chronic kidney disease that disrupts mineral and hormone balance, leading to bone fragility and systemic complications. Early diagnosis and tailored management are essential to improve patient outcomes.
