Clinical Investigation

Kidney International (1993) 44, 159–164; doi:10.1038/ki.1993.226

Renal osteodystrophy in diabetic patients

York Pei, Gavril Hercz, Celia Greenwood, Gino Segre, Arif Manuel, Carl Saiphoo, Stanley Fenton and Donald Sherrard

Department of Medicine, Toronto Hospital, and the Clinical Epidemiology Unit, Mount Sinai Research Institute, University of Toronto, Toronto, Ontario, Canada; the Veterans Administration Medical Center, Seattle, Washington, and the Endocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA

Correspondence: York Pei MD, 13 EN-228, Toronto Hospital (Toronto General Site), 200 Elizabeth Street, Toronto, Ontario, Canada, M5G 2C4.

Received 7 December 1992; Revised 4 February 1993; Accepted 4 February 1993.

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Abstract

Renal osteodystrophy in diabetic patients. To assess the effects of diabetes mellitus on renal osteodystrophy, we examined the database of 256 patients (45% on hemodialysis and 55% on peritoneal dialysis) who were prospectively studied in three Toronto dialysis centers between October of 1987 and 1989. All patients had serial documentation of their clinical, laboratory and risk parameters of bone disease, and completed a series of investigations that included the deferoxamine test, measurement of intact 1–84 PTH levels, and an iliac crest bone biopsy. Twenty-five percent of these patients were diabetic. When compared to non-diabetic patients, they were on dialysis for a shorter duration (2.4 plusminus0.3 vs. 4.7plusminus0.3 years; P < 0.0002), used calcium carbonate as the only phosphate binder more frequently (40 vs. 25%; P < 0.007), and had lower parathyroid hormone levels (12 plusminus 1.4 vs. 24 plusminus 2.3 pmol/liter; P < 0.002). High-turnover bone disorders (that is, osteitis fibrosa and mixed disorder) were distinctly uncommon (8 vs. 33%; P < 0.01 by Fisher's exact test), while the mild (19 vs. 9%; P = NS) and the aplastic disorders (with mean stainable bone surface aluminum of 6.5 plusminus 0.7%) (46 vs. 31%; P = NS) tended to be more common in diabetic patients. The prevalence of aluminum bone disease was the same in both groups (27%). Diabetic patients ingested a smaller cumulative dose of aluminum gels (3.7 plusminus 0.6 vs. 9.3 plusminus 1.1 kg; P < 0.005), yet had a higher rate of aluminum accumulation on bone surfaces than non-diabetic patients (1.5 plusminus 0.19 vs. 0.96 plusminus 0.10% per month on dialysis; P < 0.015). Although the cumulative exposure to aluminum gels remained the major risk factor for aluminum bone disease (P < 0.0001), a positive interaction was noted for diabetic mellitus to increase this risk (P < 0.05). Thus, diabetes mellitus appears to predispose dialysis patients to low bone-turnover states. In addition, it appears to increase aluminum accumulation on bone surfaces and predisposes to aluminum bone disease. The clinical significance of the aplastic disorder remains to be defined.

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References

  1. Popovich RP, Moncrief JW, Nolph KD, Ghods AJ, Twardowski ZJ, Pyle WK: Continuous ambulatory peritoneal dialysis. Ann Intern Med 88:449–452, 1978 | PubMed | ISI | ChemPort |
  2. Cohen D, Loertscher R, Rubin M, Tilney N, Carpenter C, Strom T: Cyclosporine: A new immunosuppressive agent for organ transplantation. Ann Intern Med 101:667–682, 1984 | PubMed | ISI | ChemPort |
  3. United states renal data system 1991 annual report: Incidence and causes of treated ESRD. Am J Kidney Dis 18(5)2:30–37, 1991
  4. Canadian Organ Replacement Register, 1990 Report: Hospital medical records institute, Ontario, Don Mills, April:49–101, 1992
  5. McNair P, Madsbad S, Christensen MS, Faber O, Binder C, Transbøl I: Bone mineral loss in insulin-treated diabetes mellitus: Studies on pathogenesis. Acta Endocrinol 463–472, 1979
  6. McNair P, Christensen MS, Madsbad S, Christiansen C, Transbøl I: Hypoparathyroidism in diabetes mellitus. Acta Endocrinol 96:81–86, 1981
  7. Andress DL, Hercz G, Kopp JB, Endres D, Norris K, Coburn J, Sherrard D: Bone histomorphometry of renal osteodystrophy in diabetic patients. J Bone Miner Res 2:525–531, 1987 | PubMed | ISI | ChemPort |
  8. Vincenti F, Arnaud SB, Recker R, Genant H, Amend W, Feduska N, Salvatierra O: Parathyroid and bone response of the diabetic patient to uremia. Kidney Int 25:677–682, 1984
  9. Heidbreder E, Götz R, Schafferhans K, Heidland A: Diminished parathyroid gland responsiveness to hypocalcemia in diabetic patients with uremia. Nephron 42:285–289, 1986 | PubMed | ISI | ChemPort |
  10. Sherrard DJ, Andress DL: Aluminum-related osteodystrophy. Adv Int Med 34:307–324, 1989
  11. Pei Y, Hercz G, Sherrard D, Chan W, Greenwood C, Saiphoo C, Manuel A, Fenton S: Multivariant analysis of risk factors for renal osteodystrophy in the 1990's. (abstract) J Am Soc Nephrol 1:572, 1990
  12. Pei Y, Hercz G, Greenwood C, Sherrard D, Segre G, Manuel A, Saiphoo C, Fenton S: Non-invasive prediction of aluminum bone disease in hemo- and peritoneal dialysis patients. Kidney Int 41:1374–1382, 1992 | PubMed | ISI | ChemPort |
  13. Sherrard D, Hercz G, Pei Y, Maloney N, Greenwood C, Manuel A, Saiphoo C, Fenton S, Segre G: The spectrum of bone disease in end-stage renal failure. Kidney Int 43:436–442, 1993 | PubMed | ISI | ChemPort |
  14. Nussbaum SR, Zahradnik RJ, Lavigne JR, Brennen GL, Nozewe-Ung K, Kim LY: Highly sensitive two-site immunoradiometric assay of parathyroid hormone and its clinical utility in evaluating patients with hypercalcemia. Clin Chem 33:1364–1367, 1987 | PubMed | ISI | ChemPort |
  15. Savory J, Wills MR: Analytical methods for aluminum measurement. Kidney Int 29(Suppl 18):S24–S27, 1986
  16. Nebeker HG, Andress DL, Milliner DS, Ott S, Alfrey A, Slatopolsky E, Sherrard D, Coburn J: Indirect methods for the diagnosis of aluminum bone disease: Plasma aluminum, the desferrioxamine infusion test and serum iPTH. Kidney Int 29(Suppl 18):S96–S99, 1986
  17. Norris KC, Goodman WG, Howard N, Nugent ME, Coburn JW: Iliac crest bone biopsy for diagnosis of aluminum toxicity and a guide to the use of deferoxamine. Semin Nephrol 6(4):S27–S34, 1986
  18. Andress DL, Maloney NA, Coburn JW, Endress DB, Sherrard DJ: Osteomalacia and aplastic bone disease in aluminum-related osteodystrophy. J Clin Endocrinol Metab 65(1):11–16, 1987 | PubMed | ISI | ChemPort |
  19. Coburn JW, Robertson JA: Aluminum and bone disease, in Text Book of Nephrology (2nd ed), edited by Massry S, Glassock R, Baltimore, Williams and Wilkins, 1989, pp. 1312–1322
  20. Cochran WG, Cox GM: Experimental Designs (2nd ed), New York, John Wiley and Sons, 1957
  21. Fleiss JL: Statistical Methods for Rates and Proportions (2nd ed), New York, John Wiley and Sons, 1981
  22. Hosmer DW, Lemeshow S: Applied Logistic Regression, New York, John Wiley and Sons, 1989
  23. SAS Institute Inc: SAS/STAT User's Guide (version 6, 4th ed) Cary, SAS Institute Inc., 1989
  24. Mora Palma FJ, Ellis HA, Cook DB, Dewar J, Ward M, Wilkinson R, Kerr D: Osteomalacia in patients with chronic renal failure before dialysis or transplantation. Q J Med 52:332–348, 1983 | PubMed | ChemPort |
  25. Andress D, Endres D, Maloney N, Kopp J, Coburn J, Sherrard D: Comparison of parathyroid hormone assays with bone histomorphometry in renal osteodystrophy. J Clin Endocrinol Metab 63:1163–1169, 1986 | PubMed | ISI | ChemPort |
  26. Chazan JA, Libbey NP, London MR, Pono L, Abuelo JG: The clinical spectrum of renal osteodystrophy in 57 chronic hemodialysis patients: A correlation between biochemical parameters and bone pathology findings. Clin Nephrol 35:78–85, 1991
  27. Llach F, Felsenfeld A, Coleman M, Keveney J, Pederson J, Medlock R: The natural course of dialysis osteomalacia. Kidney Int 29:S74–S79, 1986
  28. Chan YK, Furlong TJ, Cornish CJ, Posen S: Dialysis Osteodystrophy—A study involving 94 patients. Medicine 64:296–308, 1985 | PubMed |
  29. Andress DL, Kopp JB, Maloney NA, Coburn JW, Sherrard DJ: Early deposition of aluminum in bone in diabetic patients on hemodialysis. N Engl J Med 316:292–296, 1987
  30. Fournier A, Moriniere P, Cohen Solal M, Boudailliez B, Achard J, Marie A, Sebert J: Adynamic bone disease in uremia: May it be idiopathic? Is it an actual disease? Nephron 58:1–12, 1991 | PubMed | ISI | ChemPort |
  31. Hercz G, Pei Y, Chan W: Aplastic osteodystrophy: Role of suppressed PTH levels. Blood Purif 9:229–230, 1991
  32. Sugimoto T, Ritter C, Morrissey J, Hayes C, Slatopolsky E: Effects of high concentrations of glucose on PTH secretion in parathyroid cells. Kidney Int 37:1522–1527, 1990 | PubMed |
  33. Hough S, Avioli LV, Bergfeld MA, Fallon MD, Slatopolsky E, Teitelbaum SL: Correction of abnormal bone and mineral metabolism in chronic streptozotocin-induced diabetes mellitus in the rat by insulin therapy. Endocrinology 108:2228–2234, 1981 | PubMed | ISI | ChemPort |

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