Bone-eating kidney disease

In the current era of early detection of chronic kidney disease and efficient therapeutic options for management of its complications, skeletal manifestations of renal hyperparathyroidism are increasingly rare. A 31-year-old female patient presented for evaluation of severe pain in the left forearm, right hand, right knee, right hip, and lower back following a fall sustained 3 days prior to presentation. She had a history of end-stage renal disease and received maintenance hemodialysis. Review of the medical records revealed that she had poor compliance with her diet, medications, and dialysis treatments. Laboratory values were significant for marked elevation in serum parathyroid hormone level (1735 pg/mL), as well as hyperphosphatemia and normal serum calcium levels. Interestingly, X-ray images showed generalized severe demineralization of the extremities with the pelvic computed tomography scan revealing presence of diffuse brown tumors. In addition, she had insufficiency fractures of the extremities that left her incapacitated and had to be managed conservatively due to her poor functional status and ongoing severe hyperparathyroidism. Unfortunately, the patient refused surgical removal of the parathyroid glands and was hence treated with a high-dose phosphate binder and a calcimimetic agent together with reinforcement of compliance. This case highlights the importance of metabolic assessment of patients presenting with unexpected bone complications and can be used to raise awareness of the physicians on the extreme cases of mineral bone complications secondary to renal disease that are observed rarely.