How to Manage Paget's Disease of Bone (PDB) in a Patient with Chronic Kidney Disease (CKD)?

Document Type

Conference Proceeding

Publication Date

9-27-2024

Publication Title

J Bone Miner Res

Abstract

Introduction: PDB is a skeletal disorder characterized by localized accelerated bone remodeling in specific skeletal locations with abnormal osteoclasts. The usual onset is in the fifth decade of life, with a slight male predominance. Skull, spine, pelvis, and long bones of the lower extremity are the most common sites. Most patients are asymptomatic, and the diagnosis is usually made incidentally on a routine biochemistry showing elevated serum alkaline phosphatase (ALP) or an imaging study showing pagetic changes in bone. The most common clinical manifestation of PBD is pain in the involved bone(s). We report a case of asymptomatic polyostotic-PDB involving wight bearing bones with progressive rise in ALP in the context of CKD. Case Presentation: 64-year-old African American man with history of hypertension, hyperlipidemia, diabetes mellitus, vitamin D deficiency, and CKD-4, was referred for evaluation of PDB, which was discovered by the marked cortical and trabecular thickening of the proximal right femur, pelvic bones, and sacrum, consistent with PBD on X-rays done about ten years ago. There was progressive elevation in ALP from 200s to 700s IU/L (normal 40-140 IU/L) over 7-years. Marker of bone turnover, C-telopeptide was high at 2897 pg/ml (normal 40-840 pg/ml). There is a strong family history of PDB. He denied bone pain, headache, or hearing loss and fractures or kidney stones. Bone scan revealed increased radiotracer uptake involving the right scapula, sternum, spine (involving cervical, mid thoracic, and lumbar), sacrum, pelvis, and both femurs. Discussion: The treatment of PDB is indicated in symptomatic patients and in asymptomatic patients with significant biochemical abnormalities or imaging changes indicating risk of complications from untreated disease. Bisphosphonates are the standard treatment for PDB, but are contraindicated in patients with CKD-4-5. Hence, management of PBD can be challenging in patients with CKD. Denosumab is an appropriate alternative in patients with CKD, but there is insufficient data and clinical experience, and its role in the treatment of PDB remains to be defined.

Volume

39

First Page

196

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