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RADIOGRAPHIC CORRELATION IN ESRD

STEVE DOAK   (27 April 2007)

RADIOGRAPHIC CORRELATION IN ESRD 27 April 2007
STEVE DOAK, RADIOLOGIST PRIVATE PRACTICE Send letter to journal: Re: RADIOGRAPHIC CORRELATION IN ESRD STEVEDOAKMD{at}COMCAST.NET STEVE DOAK	I noticed in your article that you were determining the BMD of these HD patients in the forearm because of the presence of vascular calcification in the aorta, more prominent in these patients with their tendency for increased arteriosclerotic changes overall, which tended to increase the apparent BMD in the lumbar spine, confounding measurements. That is very true but there is a second issue. As a radiologist I am aware that there is often an increase in bone density in renal osteodystrophy, perhaps most prominent in the lumbar spine. This sometimes has a rugger jersey effect, somewhat reminiscent of the changes seen in osteopetrosis, but sometimes just an increase in density of a peculiar sort easily recognized by those who are familiar with it. But many are not familiar with these changes because the nephrologists according to their own protocols do not routinely order bone films on their patients, but instead prefer to “treat the PTH values” and I find no fault with this. I assume that you are in a position to order lumbar spine and hip films on some of these HD patients, or have the nephrologists do it for you, so that you could see what some of these changes are. Merely as an intellectual exercise to get a better idea of how real these changes can be, for background in other words. I am not aware of how much work has been done in this area, but radiologists simply don’t see a lot of films on these patients, but it might be of interest to do a study of the changes of the osteosclerois (increased bone density) in these patients, comparing BMD in the lumbar spine and hip to that in the forearm. The vascular calcification in the hip area is in the femoral arteries, medial to the bones in question,and should not influence the BDM. If for no other reason, if changes in BMD in the hip could be shown to correlate with fracture risk, reporting those changes would carry more intuitive weight with those involved in clinical decisions. As an aside, the nuclear medicine bone scans in these patients often have a “metabolic superscan look” with increased bone uptake, leading to less soft tissue activity. The look is often quite impressive, with increased uptake in the distal extremities and in the skull, quite different from the look of a “metastatic superscan” seen in patients with lots of skeletal metastases from malignant disease and quite similar to the changes seen in the other major metabolic bone diseases, osteomalacia and hyperparathyroidism, primary and secondary. Even if you don’t intend to publish anything in this area, just getting some X-rays and bone scans on these patients as an intellectual exercise might help to reinforce in your mind and in minds of your readers exactly how systemic all these diseases are. I have sent the author the letter above and some X-rays of renal osteodystrophy in the lumbar spine and some metabolic superscans of various sorts. Steve Doak MD