metabolic bone diseases - mahidol university · metabolic bone disease ... most commonly these...
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Metabolic bone disease
รศ. น.พ. ววัิฒน์ วจนะวศิษิฐ
ภาควิชาออร์โธปิดกิส์
คณะแพทยศาสตร์โรงพยาบาลรามาธิบดี
มหาวิทยาลัยมหดิล
Mineral Homeostasis
• Controlling intra- and extra-cellular levels of ions : Calcium, Phosphorus
others: pH, Na, K, Mg, Cl, HCO3, SO4
• Hormone : PTH; 1,25(OH)2D; FGF23 calcitonin, prolactin, glucocorticoid, GH, insulin, IGF & several cytokines • Target tissues : Bone, Intestine, Kidney
Mineral Homeostasis
• Controlling intra- and extra-cellular levels of ions : Calcium, Phosphorus,
others: pH, Na, K, Mg, Cl, HCO3, SO4
• Hormone : PTH; 1,25(OH)2D; FGF23 calcitonin, prolactin, glucocorticoid, GH, insulin, IGF & several cytokines • Target tissues : Bone, Intestine, Kidney
Magnesium
The players
Ca, P, Mg
Ca, P
PTH
FGF23
1,25(OH)2D
25(OH)D
Ca P
Regulation of ions
Ca, P
PTH
FGF23
1,25(OH)2D
25(OH)D
Ca P
Ca, P
PTH
FGF23
1,25(OH)2D
25(OH)D
Ca P
What is Metabolic Bone Disease?
Most commonly these metabolic bone disorders are caused by abnormalities of minerals such as calcium, phosphorus, magnesium or vitamin D leading to dramatic clinical disorders that are commonly reversible once the underlying defect has been treated.
These disorders are to be differentiated from a larger group of genetic bone disorders where there is a defect in a specific signaling system or cell type that causes the bone disorder.
4 most common causes of MBD in Thailand
1. Renal tubular acidosis type I, distal RTA 2. Systemic fluorosis 3. Thalassemia 4. Osteoporosis
Differential diagnosis
1. 1o HPT 2. Rickets/Osteomalacia 3. Renal Osteodystrophy 4. Osteoporosis 5. Bone Metastasis and Myeloma
Differential diagnosis
Loss of mineralization: osteomalacia/rickets Low bone mass: osteoporosis, OI High bone mass: osteopetrosis High bone turnover: Paget, HPT, Thyrotoxicosis Low bone turnover: adynamic bone,
hypophosphatasia
Primary hyperparathyroidism
• von Recklinghausen • Osteitis fibrosa cystica
Rickets/Osteomalacia
• Hyperosteoidosis
Rickets/Osteomalacia
1. Nutritional 2. Gastrointestinal-biliary 3. Renal tubular causes 4. Unusual causes 5. Renal osteodystrophy (CKD-MBD)
Rickets/Osteomalacia
1. Nutritional 2. Gastrointestinal-biliary 3. Renal tubular causes 4. Unusual causes 5. Renal osteodystrophy (CKD-MBD)
Renal rickets
1. Hypophosphatemic rickets (VDRR, Albright) 2. VDDR I 3. VDDR II 4. Fanconi 5. Renal tubular acidosis: I, dRTA : distal tubule
II, IV
Unusual causes
• Fibrous dysplasia/Neurofibromatosis • Oncogenic osteomalacia (TIO) • Anti-epileptic drug
CKD-MBD (renal osteodystrophy)
Pathogenesis
Renal injury: Loss of skeletal anabolism
2nd HPT : high turnover osteodystrophy If we suppress PTH : adynamic bone
Pathogenetic factors in 2nd HPT
• Hyperphosphatemia • Calcitriol deficiency • Hypocalcemia • PT gland hyperplasia • FGF23 elevated • Hypogonadism
• Others: Al, B2 microglobulin, acidosis, GFs
Problems in CKD
• Fracture • Cardiovascular disease vascular calcification • Mortality
Prevention & Treatment
CKD III • Regulate P and Ca: phosphate binder • Hypocalcemia: suppl only in symptomatic • Calcitriol • Cinacalcet • Parathyroidectomy
Primary hyperparathyroidism
Osteitis fibrosa cystica
• stone
• bone pain
• Groan
• throne
• psychiatric overtone
Classical 1ry HPT
Classical 1ry HPT
Skeletal • Subperiosteal resorption
of distal phalanx • Tapering distal clavicle • Salt & pepper skull • Bone cyst • Brown tumor
Renal • Nephrolithiasis • Nephrocalcinosis • Hypercalciuria (F: 250 mg, M: 300 mg) • CCr reduction
Classical 1ry HPT
Neuromuscular : myopathy, weakness, aging, cognitive, distinct psychiatric feature
GI : peptic ulcer, pancreatitis CV : valvular calcification, vascular
stiffness Others
Clinical forms of 1ry HPT
Most common presentation : Asymptomatic hypercalcemia : within 1mg/dl above upper limits Incidence: 1 in 500 to 1 in 1,000 (USA) F:M = 3:1 51-60 y.o. In children: MEN I, II Acute 1ry HPT or HPT crisis is rare.
Evaluation & diagnosis
History & PE Established by laboratory tests X-ray (bone survey) BMD (included distal forearm)
Biochemical Hallmarks
• Hypercalcemia • PTH elevated
Treatment
Natural history
• A decade after Dx Ca2+, inP, PTH, 25(OH)D, 1,2(OH)2D, u-Ca,
BMD : stable
• Afterwards : 25% progressive
• Age <50 yr : 65% progressive
Guideline for asymptomatic 1ry HPT
Surgery
>1 mg/dl above upper lim. >400 mg/d Reduced by 30% NA T-score <-2.5, any site <50 yr
Follow-up of non-surgery
Two times/ year Do not measure Do not measure Measure annually Annually 3 sites
Serum Ca++ Urinary Ca++
Renal function CCr serum Cr BMD Age
Adapted from NIH workshop on Asymptomatic 1ry HPT 2002
Medical treatment
• Adequate hydration & ambulation • Avoid Thiazide & Lithium
• Dietary calcium : moderate >1 g/d avoid in high 1,25(OH)2D low calcium: stim PTH secretion
Medical treatment
Drug • Oral phosphate • Estrogen • SERM • Bisphosphonate • Calcimimetic agent: Cinacalcet HCL
•Ectopic calcification •Elevate PTH •GI tolerance
Non-parathyroid Hypercalcemia
Non-parathyroid Hypercalcemia
Pathophysiology Total calcium 9.5 mg/dl ionized 4.2 mg/dl Ca complex 0.3 mg/dl bound to protein 4.5 mg/dl Hypercalcemia > 2 SD means 10.6 mg/dl
• Mild < 12 mg/dl • Moderate 12-14 mg/dl • Severe >14 mg/dl
Disorders lead to Hypercalcemia
• Cancer • Granulomatous diseases • Endocrine disorder • Milk-Alkali syndrome • TPN • Abnormal protein binding • Medication: Lithium, Estrogen, SERM, Foscarnet, 8-
chlorocyclicAMP
• Acute & CRF • Hypophosphatemia
Malignancy-associated hyperalcemia (MAHC)
• Hypercalcemia of malignancy (HHM) • Local osteolytic hypercalcemia (LOH) • 1,25(OH)2D Induced hypercalcemia • Authentic ectopic hypercalcemia
HHM
• Humoral nature • 1987: PTHrP • Uncoupling bone turnover • Decrease 1,25(OH)2D • Squamous CA
LOH
• CA breast • Myeloma, lymphoma, leukemia • Skeletal metastasis • IL-1, IL-6, PTHrP, MIP-1a
Granulomatous disease
• Sarcoidosis, Tuberculosis • 1a-hydroxylase • Inapp production 1,25(OH)2D
• Treatment Eradicate granuloma antiTB, glucocorticoid limit Ca, D intake, sun exposure
Osteoporosis
Osteoporosis
Severe Osteoporosis
Normal
Courtesy Dr. A. Boyde
Practical approach to MBD