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Mixed uremic osteodystrophy: an ill-described common bone pathology in patients with chronic kidney disease

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Abstract

Renal osteodystrophy (ROD) starts early and progresses with further loss of kidney function in patients with chronic kidney disease (CKD). There are four distinct types of ROD based on undecalcified bone biopsy results. Adynamic bone disease and osteomalacia are the predominant forms of low bone turnover, while hyperparathyroid bone disease and mixed uremic osteodystrophy (MUO) are typically associated with high bone turnover. MUO is a prevalent but poorly described pathology that demonstrates evidence of osteomalacia on top of the high bone formation/resorption. The prevalence of MUO ranges from 5 to 63% among different studies. The pathogenesis of MUO is multi-factorial. Altered phosphate homeostasis, hypocalcemia, vitamin D deficiency, increased FGF-23, interleukins 1 and 6, TNF-α, amyloid, and heavy metal accumulation are the main inducers of MUO. The clinical findings of MUO are usually non-specific. The use of non-invasive testing such as bone turnover markers and imaging techniques might help to suspect MUO. However, it is usually impossible to precisely diagnose this condition without performing bone biopsy. The principal management of MUO is to control the maladaptive hyperparathyroidism along with correcting any nutritional mineral deficiencies that may induce mineralization defect. MUO is a common but still poorly understood bone pathology category; it demonstrates the complexity and difficulty in understanding ROD. A large prospective bone biopsy-based studies are needed for better identification as proper diagnosis and management would improve the outcome of patients with MUO.

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Acknowledgement for ISN and USAID associations for their support.

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Authors and Affiliations

  1. Mansoura pathology department, Mansoura University, Mansoura, Egypt

    Ekbal Elkhouli

  2. Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt

    Eman Nagy

  3. Division of Nephrology, Department of Internal Medicine, Federal University of Paraná, Curitiba, Paraná, Brazil

    Cassia Gomes S. Santos & Fellype Carvalho Barreto

  4. University of São Paulo, Department of Internal Medicine, São Paulo, Brazil

    Juliana Chaer & Vanda Jorgetti

  5. Division of Nephrology & Bone and Mineral Metabolism, University of Kentucky, Lexington, USA

    Amr El-Husseini

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Elkhouli, E., Nagy, E., Santos, C.G.S. et al. Mixed uremic osteodystrophy: an ill-described common bone pathology in patients with chronic kidney disease. Osteoporos Int 34, 2003–2012 (2023). https://doi.org/10.1007/s00198-023-06886-5

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