Bone Disease- Can daily dialysis halt/reverse?

Discussions for Patients, Family, and Friends HD For Patients
1

Moving the discussion on bone disease to a new topic. Kidney patients have serious issues with bone disease and often nephrologists are not forthcoming with preventative education unless we know the questions to ask. Hopefully, this thread can serve to identify problems and solutions and provide a basis with which to discuss same with our nephrologists.

Jane
Guest

Posted: Thu Mar 02, 2006 7:43 pm Post subject:

Pierre, I’m glad everytime you pipe up with how good nocturnal dialysis is. There have been a few patients who said they didn’t feel that much better ( not sure if they were SDD or SND) and the thought has crossed my mind whether I will be like them or be one of the fortunate ones who feels tremendously better. It must be incredible to stop feeling like a yo-yo and have your life back. I have wondered if anyone doing nocturnal txs finds an improvement in muscle/bone problems in addition to improved energy/nutrition?

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Beth Witten MSW ACSW

Joined: 25 Jun 2004
Posts: 525
Location: Kansas
Posted: Thu Mar 02, 2006 9:48 pm Post subject:

You might want to read this brief summary of the benefits of nocturnal and short daily dialysis, including better control of bone disease, blood pressure, and heart problems in the U.S. and other countries:
http://www.hdcn.com/ch/dailyhd/content/blagg1.htm

Beth Witten MSW ACSW LSCSW
Medical Education Institute, Inc.

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Jane
Guest

Posted: Fri Mar 03, 2006 8:42 am Post subject:

Thank you for the article, Beth. Can someone interpret the following from article?..specifically the part about “biopsies showed low turnover in 13 of 17 patients, but bone mass was normal in all but three of them…Oversupression of PTH may be an issue, but a high dialysate calcium is necessary to maintain or improve bone density.”:

Quote:
When nocturnal dialysis was first done, serial studies showed a decline in bone density and so dialysate calcium was then increased to 3.0 or 3.5 mEq/L or patients added calcium to the acid concentrate. With this, PTH levels were easily suppressed, and no new or increased arterial or soft tissue calcification was seen on annual soft tissue X-rays. Bone biopsies showed low turnover in 13 of 17 patients, but bone mass was normal in all but three of them. Three patients had hyperparathyroid bone disease and one had a mild lesion. Oversuppression of PTH may be an issue, but a high dialysate calcium is necessary to maintain or improve bone density.

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Heather
Guest

Posted: Fri Mar 03, 2006 9:00 am Post subject:

Does anyone know how HRT (hormone replacement therapy) enters the picture for post menapausal female patients and elderly male patients? What meds or natural substances can they take with kdiney disease?

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Beth Witten MSW ACSW

Joined: 25 Jun 2004
Posts: 525
Location: Kansas
Posted: Fri Mar 03, 2006 9:20 am Post subject:

The National Kidney Foundation’s K/DOQI guideline on cardiovascular diseases discusses use of HRT in women and the controversy surrounding it in light of the Women’s Health Initiative study. The conclusion of this research-based guideline states:

Given the lack of data from the CKD population, it may be prudent to follow the recently published guidelines from North American Menopause Society, which state that the treatment of menopause symptoms remains the primary indication for HRT, and that HRT not be used solely for primary or secondary prevention of CHD.728 For those women with CKD on HRT, doses of estrogen replacement that are 50%-70% lower than those among women with normal renal function would have an equivalent effect.

http://www.kidney.org/professionals/kdoqi/guidelines_cvd/menopause.htm

Men on dialysis who have low levels of testosterone in their blood by blood test may be provided testosterone by their doctors to improve their sexual functioning.

You might want to read the module on sexuality in Kidney School at http://www.kidneyschool.org. It discusses the use of hormones in women and men.

Beth Witten MSW ACSW LSCSW
Medical Education Institute, Inc.

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Dori Schatell

Joined: 17 Aug 2004
Posts: 235

Posted: Fri Mar 03, 2006 8:55 pm Post subject:

Hi y’all,

Jane wondered about:
Quote:
"biopsies showed low turnover in 13 of 17 patients, but bone mass was normal in all but three of them…

Keeping in mind that I’m not a doctor, I believe this means that nocturnal home hemo was suppressing PTH so much that it actually leans in the direction of oversuppressing PTH, leading to low bone turnover. So far, this hadn’t caused a clinical problem in most patients, since their bone mass was still normal. The risk would seem to be that over time, more bone suppression could occur, perhaps to the point where fractures became more likely. I believe that it’s possible to treat oversuppression by giving synthetic PTH, but I’m not sure.

In most people on in-center hemo, the opposite problem occurs–it’s impossible to shut off the parathyroid glands, so you end up with high turnover bone disease. This is treated with Vitamin D analogs (Zemplar, Hectorol), phosphate binders, and Amgen’s new drug which makes the parathyroid glands more sensitive to calcium–Cinacalcet. If these treatments don’t work, surgery is needed to remove the parathyroid glands.

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Pierre

Joined: 06 Mar 2005
Posts: 481

Posted: Sat Mar 04, 2006 6:54 am Post subject:

As I understand it, it’s not so much anything to do with the parathyroids themselves as it is the fine balance between how calcium, phosphorus and PTH work together. I’m not sure I understand the whole thing, but basically…

In daily nocturnal, because of the length of the treatment, you are removing more phosphorus than any other dialysis method, but you are also removing more calcium. So, initially, calcium is added to the dialysate so less calcium will be removed. Removing too much calcium would obviously be detrimental to bone density over time. To keep tabs on this, the nephrologist looks at both calcium and PTH (intact PTH test is done periodically - seems to be every 6 months in my case). Deliberately making calcium higher also seems to make PTH higher. They look at the balance to determine if added calcium is needed or not. In my case, while I started out the first 6 months adding calcium, I don’t at present (though I continue to add phosphorus to my dialysate, otherwise my phosphorus level would definitely be too low).

Now, what that article seems to be saying is that in some cases, it may be necessary to supplement calcium in the dialysate even at the price of elevated PTH.

This is a good example of one of the many things about daily dialysis (both short and long) which we don’t really know in terms of how it will work out for the patient in the long term. There are many assumptions, but very few clinically-proven things. There have been many observations, but almost no randomized trials. Even observational studies are not that reliable, simply because there haven’t been enough patients to study for a long enough period of time. It’s also difficult to randomize and to double blind in the context of dialysis. All of us on daily hemodialysis are living out one long experiment, even though we already know there are lifestyle and health advantages, and we know it can’t be worse than what inadequate dialysis can do to us. We do have some fairly good observational evidence from the program in Toronto though, simply because it has been running for over a decade now.

Pierre

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Jane
Guest

Posted: Sat Mar 04, 2006 11:10 am Post subject:

Dori writes:
Quote:
The risk would seem to be that over time, more bone suppression could occur, perhaps to the point where fractures became more likely. I believe that it’s possible to treat oversuppression by giving synthetic PTH, but I’m not sure.

This is scary. Of course, it happens with in-center hemo, too. I read an article that stated that about 50-60% of hemo patients have had their PTH oversuppressed making them adynamic. Doctors have told me the problem is they are not sure what levels are in the best balance for dialysis patients. I am not clear on once the damage is done if it is reversable? Does synthetic PTH have another name…have not heard of this? I would love to know if an expert in this area could shed more light on the subject. Anyone know how experts are located?

Dori writes:
Quote:
Amgen’s new drug which makes the parathyroid glands more sensitive to calcium–Cinacalcet.

How does making PTH more sensitive to calcium lower PTH?

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Heather
Guest

Posted: Sat Mar 04, 2006 12:19 pm Post subject:

KDOQI:
Quote:
The use of HRT in the general population has become increasingly controversial. Reports from the WHI have documented significant reductions in hip fracture and colorectal cancer rates among postmenopausal women treated with HRT.724 Although estrogens have been reported to improve the lipid profile by increasing high-density lipoprotein and decreasing low density lipoprotein,725 the WHI did not find an overall benefit among those receiving both estrogen and progesterone.724 In addition, studies have demonstrated an increased risk of venous thrombosis among women who use estrogen.724,725 Patients with CKD have an increased risk for pulmonary embolus and are at risk for vascular access thrombosis. The association between HRT and venous thrombosis, particularly vascular access thrombosis, among women with CKD remains unstudied.

This is the section that speaks to bone fractures, but can someone interpret?

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Jane
Guest

Posted: Sun Mar 05, 2006 12:46 pm Post subject:

I came across the following discussion on the net:

debbie

Joined: 28 Jan 2003
Posts: 15

Posted: Sat Aug 23, 2003 5:00 pm Post subject: bone pain

Hi,<
> I can’t walk sometimes because my joints and bones are so painful, it makes no difference what I do, it evens hurts to lie or sit as well. It has been worse in the last 18 months or so. I have had a parathyroidectomy as well and wonder if that contributed…

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Founding RN

Joined: 10 Jan 2003
Posts: 172

Posted: Sun Aug 24, 2003 1:04 pm Post subject: Debbie

I wish this wasn’t so common among dialysis patients, but it is. This problem is because in order for the body to get rid of phosphorus it has to bind with calcium to be excreted from the body. If there isn’t enough in your blood, then it robs your bones. And if your phosphorus is too high, then you itch! That is why it is so important to take those binders! Vit D analogs like Calcitriol, Zemplar and now Hectorol, help to control this along with your PTH levels. But for some patients there comes a time when even these meds don’t work and the PTH gets out of control, it makes all this even worse and a partial or even a total parathyroidectomy is the only solution. <
><
>Please consult with your Dr. about this problem and solutions that are tailored to your particular needs. Make sure that you are taking an adequate amount of calcium and make sure you take those binders. Your Calcium levels need to be monitored so they don’t get too high. Your dietician can help with calcium and phosphorus in your diet.

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patient

Joined: 30 Oct 2002
Posts: 138

Posted: Sun Aug 24, 2003 4:47 pm Post subject: bones and joints

Do you mean that all dilaysis patients will have these problems after years of dialysis and will eventually need a para., or only if everything is not managed properly?

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Founding RN

Joined: 10 Jan 2003
Posts: 172

Posted: Sun Aug 24, 2003 7:55 pm Post subject: Patient

Yes, all dialysis patients have varing degrees of osteoporosis, some worse than others. Being inconsistant with your binders and diet just speeds up the problems for many patients. And yes, the longer you are on dialysis, the more your chances of having bone and joint problems like this seem to increase. I wish it wasn’t so, but it is. That is why staff are always telling patients to take those binders and watch their phos. intake. <
>By doing your part to take care of yourself, you can help minimize this problem and keep major problems at bay.<
><
>It is another good reason to keep yourself healthy and try to go for a transplant.

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patient

Joined: 30 Oct 2002
Posts: 138

Posted: Mon Aug 25, 2003 11:38 am Post subject: bones and joints

It makes me sad that I’ve been on dialysis all this time and none of my staff have educated me about this. Of course I know to take my binders and what it could cause if I didn’t. But I feel betrayed that I haven’t been told the full truth of my condition…just one more thing I’m kept in the dark about. I really dislike that about the medical profession. Are there any other long term affects from dialysis and after how many years do they occur?<
><
>How does transplant make for better bones and joints? Aren’t the immunosuppressant drugs hard on the body in other ways? I’ve heard of patients needing hip replacements after transplants.

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Founding RN

Joined: 10 Jan 2003
Posts: 172

Posted: Mon Aug 25, 2003 1:06 pm Post subject: Patient

Other complications really depend on what caused the renal failure in the first place and each individuals health and response to their co-morbids. For example, diabetic patients are more likely to develop circulatory problems and their blood vessels to become
ittle. They also become more susceptible to infections that usually result in amputations. <
><
>As for the staff not educating, I suspect that most of them were not even educated themselves about all this. <
><
>Transplant drugs have vastly improved in the years I have been in dialysis. As I have not worked in the transplant field, I can’t give you detailed answers. Your Dr should be able to help you in that area better than I can. But by getting a transplant, your kidney does act like your old one did, making the hormones needed to regulate your bodys functions, like BP, making red blood cells, etc. <
>As for hip transplants, this is usually from being on dialysis for years and the damage from osteoporosis from the renal failure.

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Heather
Guest

Posted: Fri Mar 10, 2006 8:39 am Post subject: osteoporosis

Public release date: 9-Mar-2006
[ Print Article | E-mail Article | Close Window ]

Contact: Christopher James
christopher.james@nyu.edu
212-998-6876
New York University

New study reveals promising osteoporosis treatment
Calcium phosphate-based supplement improves bone strength and thickness
A New York University College of Dentistry professor has developed a calcium phosphate-based supplement that – even at low concentrations – significantly improves bone strength and thickness without the side effects of many current drug treatments. Dr. Racquel Z. LeGeros, a Professor of Biomaterials and Biomimetics and of Implant Dentistry, presented her research on the supplement at the American Association for Dental Research annual meeting on March 9, 2006.
Current FDA-approved pharmaceutical-based osteoporosis treatments, such as bisphosphonate drugs and hormone therapies, do not effectively repair bone that has already been lost. In fact, bisphosphonates have been shown to actually inhibit bone redevelopment. Many of these treatments also have serious side effects, including increasing the risk of heart disease, strokes, and breast cancer.

But the supplement Dr. LeGeros developed by combining magnesium (Mg), zinc (Zn), and fluoride (F) ions in a calcium-phosphate (CaP) matrix does not have the side effects of the current pharmaceutical-based treatments. Perhaps more importantly, a Mg/Zn/F-CaP supplement would be inexpensive to produce and would not require FDA approval. Dr. LeGeros’ formulation could be available to market as an over-the-counter supplement, pending patent approval.

In her study, Dr. LeGeros investigated the effect in rats of Mg/Zn/F-CaP ion combinations on several bone properties: strength, thickness, quality, and composition of bones.

Dr. LeGeros divided a sample of 72 (36 males, 36 females) adult Sprague-Dawley rats (average weight, 160g) into six groups receiving the following diets: control; mineral deficiency-induced osteoporosis (MD); MD supplemented with Mg-CaP; Zn-CaP; F-CaP; and Mg/Zn/F-CaP. Each supplement was 0.6% of the MD diet. The post-mortem examination of the femurs in the MD Mg/Zn/F-CaP group showed that even this small amount of Mg/Zn/F-CaP supplement substantially improved bone strength and thickness. More studies will be needed, ultimately using human trials to confirm the results.

Dr. LeGeros’ paper, Effect of Mg/Zn/F-CaP Supplements on Bone Properties: Phase 1, describes initial results of her research, which is funded by a four-year, $2 million grant from the National Institute of Biomedical Imaging and Bioengineering of the National Institutes of Health.

Osteoporosis is a silent, progressive, and debilitating disease characterized by bone loss and the thinning of cortical bone leading to bone fracture. In the United States, the disease affects an estimated 10 million older adults, resulting in more than 1.5 million fractures annually; the overwhelming majority of those afflicted with osteoporosis (80%) are women.

Dr. LeGeros said future research may also focus on using Mg/Zn/F-CaP compounds to repair fractures and periodontal bone defects.

For more information or to schedule an interview with Dr. LeGeros, please contact Christopher James, 212.998.6876 or christopher.james@nyu.edu

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2

I am learning that due to our kidney disease we are subject to various types of bone disease. The following article is written for the general public, but contains information specific to kidney disease.

Osteoporosis Overview

Osteoporosis, or porous bone, is a disease characterized by low bone mass and structural deterioration of bone tissue, leading to bone fragility and an increased risk of fractures of the hip, spine, and wrist. Men as well as women are affected by osteoporosis, a disease that can be prevented and treated.

Facts and Figures

Osteoporosis is a major public health threat for 44 million Americans, 68 percent of whom are women.

In the U.S. today, 10 million individuals already have osteoporosis and 34 million more have low bone mass, placing them at increased risk for this disease.

One out of every two women and one in four men over 50 will have an osteoporosis-related fracture in their lifetime.

More than 2 million American men suffer from osteoporosis, and millions more are at risk. Each year, 80,000 men have a hip fracture and one-third of these men die within a year.

Osteoporosis can strike at any age.

Osteoporosis is responsible for more than 1.5 million fractures annually, including 300,000 hip fractures, approximately 700,000 vertebral fractures, 250,000 wrist fractures, and more than 300,000 fractures at other sites.

Based on figures from hospitals and nursing homes, the estimated national direct expenditures for osteoporosis and related fractures total $14 billion each year.

What Is Bone?

Bone is living, growing tissue. It is made mostly of collagen, a protein that provides a soft framework, and calcium phosphate, a mineral that adds strength and hardens the framework.

This combination of collagen and calcium makes bone both flexible and strong, which in turn helps it to withstand stress. More than 99 percent of the body?s calcium is contained in the bones and teeth. The remaining 1 percent is found in the blood.

Throughout your lifetime, old bone is removed (resorption) and new bone is added to the skeleton (formation). During childhood and teenage years, new bone is added faster than old bone is removed. As a result, bones become larger, heavier, and denser. Bone formation outpaces resorption until peak bone mass (maximum bone density and strength) is reached around age 30. After that time, bone resorption slowly begins to exceed bone formation.

For women, bone loss is fastest in the first few years after menopause, and it continues into the postmenopausal years. Osteoporosis – which mainly affects women but may also affect men – will develop when bone resorption occurs too quickly or when replacement occurs too slowly. Osteoporosis is more likely to develop if you did not reach optimal peak bone mass during your bone-building years.

Risk Factors

Certain risk factors are linked to the development of osteoporosis and contribute to an individual?s likelihood of developing the disease. Many people with osteoporosis have several risk factors, but others who develop the disease have no known risk factors. There are some you cannot change and others you can.

Risk factors you cannot change:

Gender – Your chances of developing osteoporosis are greater if you are a woman. Women have less bone tissue and lose bone faster than men because of the changes that happen with menopause.

Age – The older you are, the greater your risk of osteoporosis. Your bones become thinner and weaker as you age.

Body size – Small, thin-boned women are at greater risk.

Ethnicity – Caucasian and Asian women are at highest risk. African American and Hispanic women have a lower but significant risk.

Family history – Fracture risk may be due, in part, to heredity. People whose parents have a history of fractures also seem to have reduced bone mass and may be at risk for fractures.

Risk factors you can change:

Sex hormones – Abnormal absence of menstrual periods (amenorrhea), low estrogen level (menopause), and low testosterone level in men can bring on osteoporosis.

Anorexia nervosa – Characterized by an irrational fear of weight gain, this eating disorder increases your risk for osteoporosis.

Calcium and vitamin D intake – A lifetime diet low in calcium and vitamin D makes you more prone to bone loss.

Medication use – Long-term use of glucocorticoids and some anticonvulsants can lead to loss of bone density and fractures.

Lifestyle – An inactive lifestyle or extended bed rest tends to weaken bones.

Cigarette smoking – Cigarettes are bad for bones as well as the heart and lungs.

Alcohol intake – Excessive consumption increases the risk of bone loss and fractures.

Prevention

To reach optimal peak bone mass and continue building new bone tissue as you age, there are several factors you should consider.

Calcium: An inadequate supply of calcium over a lifetime contributes to the development of osteoporosis. Many published studies show that low calcium intake appears to be associated with low bone mass, rapid bone loss, and high fracture rates. National nutrition surveys show that many people consume less than half the amount of calcium recommended to build and maintain healthy bones. Good sources of calcium include low-fat dairy products, such as milk, yogurt, cheese, and ice cream; dark green, leafy vegetables, such as broccoli, collard greens, bok choy, and spinach; sardines and salmon with bones; tofu; almonds; and foods fortified with calcium, such as orange juice, cereals, and breads. Depending upon how much calcium you get each day from food, you may need to take a calcium supplement.

Calcium needs change during one?s lifetime. The body?s demand for calcium is greater during childhood and adolescence, when the skeleton is growing rapidly, and during pregnancy and breastfeeding. Postmenopausal women and older men also need to consume more calcium. Also, as you age, your body becomes less efficient at absorbing calcium and other nutrients. Older adults also are more likely to have chronic medical problems and to use medications that may impair calcium absorption.

Recommended Calcium Intakes (mg/day)
National Academy of Sciences (1997)

Ages
mg/day

Birth-6 months
210

6 months-1 year
270

1-3
500

4-8
800

9-13
1300

14-18
1300

19-30
1000

31-50
1000

51-70
1200

70 or older
1200

Pregnant or lactating

14-18
1300

19-50
1000

Vitamin D: Vitamin D plays an important role in calcium absorption and in bone health. It is made in the skin through exposure to sunlight. While many people are able to obtain enough vitamin D naturally, studies show that vitamin D production decreases in the elderly, in people who are housebound, and for people in general during the winter. Depending on your situation, you may need to take vitamin D supplements to ensure a daily intake of between 400 to 800 IU of vitamin D. Massive doses are not recommended.

Exercise: Like muscle, bone is living tissue that responds to exercise by becoming stronger. Weight-bearing exercise is the best for your bones because it forces you to work against gravity. Examples include walking, hiking, jogging, stair climbing, weight training, tennis, and dancing.

Smoking: Smoking is bad for your bones as well as for your heart and lungs. Women who smoke have lower levels of estrogen compared to nonsmokers, and they often go through menopause earlier. Smokers also may absorb less calcium from their diets.

Alcohol: Regular consumption of 2 to 3 ounces a day of alcohol may be damaging to the skeleton, even in young women and men. Those who drink heavily are more prone to bone loss and fractures, because of both poor nutrition and increased risk of falling.

Medications that cause bone loss: The long-term use of glucocorticoids (medications prescribed for a wide range of diseases, including arthritis, asthma, Crohn?s disease, lupus, and other diseases of the lungs, kidneys, and liver) can lead to a loss of bone density and fractures. Bone loss can also result from long-term treatment with certain antiseizure drugs – such as phenytoin (Dilantin¹) and barbiturates; gonadotropin-releasing hormone (GnRH) drugs used to treat endometriosis; excessive use of aluminum-containing antacids; certain cancer treatments; and excessive thyroid hormone. It is important to discuss the use of these drugs with your physician and not to stop or change your medication dose on your own.

¹ Brand names included in this publication are provided as examples only, and their inclusion does not mean that these products are endorsed by the National Institutes of Health or any other Government agency. Also, if a particular brand name is not mentioned, this does not mean or imply that the product is unsatisfactory.

Preventive medications: Various medications are available for preventing and treating osteoporosis. See section entitled ?Therapeutic Medications.?

Symptoms

Osteoporosis is often called the ?silent disease? because bone loss occurs without symptoms. People may not know that they have osteoporosis until their bones become so weak that a sudden strain, bump, or fall causes a hip to fracture or a vertebra to collapse. Collapsed vertebrae may initially be felt or seen in the form of severe back pain, loss of height, or spinal deformities such as kyphosis (severely stooped posture).

Detection

Following a comprehensive medical assessment, your doctor may recommend that you have your bone mass measured. A bone mineral density (BMD) test is the best way to determine your bone health. BMD tests can identify osteoporosis, determine your risk for fractures (broken bones), and measure your response to osteoporosis treatment. The most widely recognized bone mineral density test is called a dual-energy x-ray absorptiometry or DXA test. It is painless – a bit like having an x ray, but with much less exposure to radiation. It can measure bone density at your hip and spine. Bone density tests can:

Detect low bone density before a fracture occurs.
Confirm a diagnosis of osteoporosis if you already have one or more fractures.
Predict your chances of fracturing in the future.
Determine your rate of bone loss, and/or monitor the effects of treatment if the test is conducted at intervals of a year or more.

Treatment

A comprehensive osteoporosis treatment program includes a focus on proper nutrition, exercise, and safety issues to prevent falls that may result in fractures. In addition, your physician may prescribe a medication to slow or stop bone loss, increase bone density, and reduce fracture risk.

Nutrition: The foods we eat contain a variety of vitamins, minerals, and other important nutrients that help keep our bodies healthy. All of these nutrients are needed in balanced proportion. In particular, calcium and vitamin D are needed for strong bones, and for your heart, muscles, and nerves to function properly. (See Prevention section for recommended amounts of calcium.)

Exercise: Exercise is an important component of an osteoporosis prevention and treatment program. Exercise not only improves your bone health, but it increases muscle strength, coordination, and balance, and leads to better overall health. While exercise is good for someone with osteoporosis, it should not put any sudden or excessive strain on your bones. As extra insurance against fractures, your doctor can recommend specific exercises to strengthen and support your back.

Therapeutic Medications: Currently, alendronate, raloxifene, risedronate, and ibandronate are approved by the U. S. Food and Drug Administration (FDA) for preventing and treating postmenopausal osteoporosis. Teriparatide is approved for treating the disease in postmenopausal women and men at high risk for fracture. Estrogen/hormone therapy (ET/HT) is approved for preventing postmenopausal osteoporosis, and calcitonin is approved for treatment. In addition, alendronate is approved for treating osteoporosis in men, and both alendronate and risedronate are approved for use by men and women with glucocorticoid-induced osteoporosis.

Bisphosphonates – Alendronate (Fosamax), risedronate (Actonel), and ibandronate (Boniva) are medications from the class of drugs called bisphosphonates. Like estrogen and raloxifene, these bisphosphonates are approved for both prevention and treatment of postmenopausal osteoporosis. Alendronate is also approved to treat bone loss that results from glucocorticoid medications like prednisone or cortisone and is approved for treating osteoporosis in men. Risedronate is also approved to prevent and treat glucocorticoid-induced osteoporosis.
Alendronate and risedronate have been shown to increase bone mass and reduce the incidence of spine, hip, and other fractures. Ibandronate has been shown to reduce the incidence of spine fractures.

Bisphosphonates should be taken on an empty stomach and with a full glass of water first thing in the morning. It is important to remain in an upright position and refrain from eating or drinking for at least 30 minutes after taking a bisphosphonate.

Side effects for all bisphosphonates include gastrointestinal problems such as difficulty swallowing, inflammation of the esophagus, and gastric ulcer. There have been rare reports of osteonecrosis of the jaw and of visual disturbances with all bisphosphonates.

Raloxifene – Raloxifene (Evista) is approved for the prevention and treatment of postmenopausal osteoporosis. It is from a class of drugs called Selective Estrogen Receptor Modulators (SERMs) that appear to prevent bone loss in the spine, hip, and total body. Raloxifene has beneficial effects on bone mass and bone turnover and can reduce the risk of vertebral fractures. While side effects are not common with raloxifene, those reported include hot flashes and blood clots in the veins, the latter of which is also associated with estrogen therapy. Additional research studies on raloxifene will continue for several more years.
Calcitonin – Calcitonin is a naturally occurring hormone involved in calcium regulation and bone metabolism. In women who are at least 5 years past menopause, calcitonin slows bone loss, increases spinal bone density, and according to anecdotal reports, relieves the pain associated with bone fractures. Calcitonin reduces the risk of spinal fractures and may reduce hip fracture risk as well. Studies on fracture reduction are ongoing. Calcitonin is currently available as an injection or nasal spray. While it does not affect other organs or systems in the body, injectable calcitonin may cause an allergic reaction and unpleasant side effects including flushing of the face and hands, frequent urination, nausea, and skin rash. The only side effect reported with nasal calcitonin is a runny nose.
Teriparatide – Teriparatide (Forteo) is an injectable form of human parathyroid hormone. It is approved for postmenopausal women and men with osteoporosis who are at high risk for having a fracture. Teriparatide stimulates new bone formation in both the spine and the hip. It also reduces the risk of vertebral and nonvertebral fractures in postmenopausal women. In men, teriparatide reduces the risk of vertebral fractures. However, it is not known whether teriparatide reduces the risk of nonvertebral fractures. Side effects include nausea, dizziness, and leg cramps. Teriparatide is approved for use for up to 24 months.
Estrogen/Hormone Therapy – Estrogen/hormone therapy (ET/HT) has been shown to reduce bone loss, increase bone density in both the spine and hip, and reduce the risk of hip and spine fractures in postmenopausal women. ET/HT is approved for preventing postmenopausal osteoporosis and is most commonly administered in the form of a pill or skin patch. When estrogen – also known as estrogen therapy or ET – is taken alone, it can increase a woman?s risk of developing cancer of the uterine lining (endometrial cancer). To eliminate this risk, physicians prescribe the hormone progestin – also known as hormone therapy or HT – in combination with estrogen for those women who have not had a hysterectomy. Side effects of ET/HT include vaginal bleeding, breast tenderness, mood disturbances, blood clots in the veins, and gallbladder disease.
The Women?s Health Initiative, a large Government-funded research study, recently demonstrated that the drug Prempro, which is used in hormone therapy, is associated with a modest increase in the risk of breast cancer, stroke, and heart attack. The WHI also demonstrated that estrogen therapy is associated with an increase in the risk of stroke. It is unclear whether estrogen therapy is associated with an increased risk of breast cancer or cardiovascular events. A large study from the National Cancer Institute indicated that long-term use of estrogen therapy may be associated with an increased risk of ovarian cancer. It is unclear whether hormone therapy carries a similar risk.

Any estrogen therapy should be prescribed for the shortest period of time possible. When used solely for the prevention of postmenopausal osteoporosis, any ET/HT regimen should only be considered for women at significant risk of osteoporosis, and nonestrogen medications should be carefully considered first.

Fall Prevention

Preventing falls is a special concern for men and women with osteoporosis. Falls can increase the likelihood of fracturing a bone in the hip, wrist, spine, or other part of the skeleton. In addition to the environmental factors listed below, falls can also be caused by impaired vision and/or balance, chronic diseases that affect mental or physical functioning, and certain medications, such as sedatives and antidepressants. It is important that individuals with osteoporosis be aware of any physical changes that affect their balance or gait, and that they discuss these changes with their health care provider. Here are some tips to help eliminate the environmental factors that lead to falls.

Outdoors:

Use a cane or walker for added stability.
Wear rubber-soled shoes for traction.
Walk on grass when sidewalks are slippery.
In winter, carry salt or kitty litter to sprinkle on slippery sidewalks.
Be careful on highly polished floors that become slick and dangerous when wet.
Use plastic or carpet runners when possible.
Indoors:

Keep rooms free of clutter, especially on floors.
Keep floor surfaces smooth but not slippery.
Wear supportive, low-heeled shoes even at home.
Avoid walking in socks, stockings, or slippers.
Be sure carpets and area rugs have skid-proof backing or are tacked to the floor.
Be sure stairwells are well lit and that stairs have handrails on both sides.
Install grab bars on bathroom walls near tub, shower, and toilet.
Use a rubber bath mat in shower or tub.
Keep a flashlight with fresh batteries beside your bed.
If using a step stool for hard-to-reach areas, use a sturdy one with a handrail and wide steps.
Add ceiling fixtures to rooms lit by lamps.
Consider purchasing a cordless phone so that you don?t have to rush to answer the phone when it rings, or so that you can call for help if you do fall.

For Your Information

This publication contains information about medications used to treat the health condition discussed here. When this fact sheet was printed, we included the most up-to-date (accurate) information available. Occasionally, new information on medication is released.

For updates and for any questions about any medications you are taking, please contact the U.S. Food and Drug Administration at 1-888-INFO-FDA (1-888-463-6332, a toll-free call) or visit their Web site at www.fda.gov.

The National Resource Center acknowledges the assistance of the
National Osteoporosis Foundation in the preparation of this publication.

Revision Date: 6/2005

The NIH Osteoporosis and Related Bone Diseases ~ National Resource Center is supported by the
National Institute of Arthritis and Musculoskeletal and Skin Diseases
with contributions from the National Institute of Child Health and Human Development, National Institute of
Dental and Craniofacial Research, National Institute of Diabetes and Digestive and Kidney Diseases,
NIH Office of Research on Women’s Health, DHHS Office on Women’s Health, and National Institute on Aging.

3

I doubt, but most likely not…perhaps in nsome cases yes. If the patient doesn’t have any other health problems like thyroid disease or any other gland diseases then chances are high that then patient will not get bone disease while on dialysis long term, under one condition…good nutrition and excercise…

4

Does anyone know, do good labs ensure against bone disease or is it just not possible for kidney patients to avoid bone disease?

5

In the best of my knowledge,

good labs and management of your renal care minimizes, and decreases the risks of severe symptoms of bone disease in dialysis patients…you can’t halt it, but you can manage it…

Unless closely monitored, renal bone disease (renal osteodystrophy) is a problem that will be experienced by most people suffering from end stage renal disease (ESRD). Renal bone disease is a complex issue and involves many more factors than can be listed in this limited space.

Basic Analysis

First, the kidneys are involved in the synthesis of vitamin D, which is the most essential factor regulating intestinal absorption of calcium in humans. When the kidneys fail and less vitamin D is created, the amount of calcium absorbed by the intestines is reduced. Calcium is most essential substance for bone maintenance and health. Next, calcium and phosphorus levels in the blood (which are normally regulated by the kidneys) are dependent upon each other. Therefore, when the kidneys fail and the phosphorus level in the blood goes up, the (free) calcium level in the blood decreases. In response to these two factors that lower serum calcium, the body then increases the parathyroid hormone (PTH) level in the blood. PTH causes calcium to be released from the bones in order to increase the serum calcium level. Left untreated, an ESRD patient will have bones that are depleted of calcium, brittle, and likely to fracture.

Treatment and prevention of renal bone disease usually include the use of phosphate binders and vitamin D analogs (to reduce PTH levels). In the past, treatment frequently included the removal of the parathyroid glands.

Normal serum calcium is 8.5-10.8 mg/dL.

Normal serum phosphorus for dialysis patients is 3.5 to 5.5 mg/dl High phosphorus levels also cause itchy skin.

It is recommended that ESRD patients maintain a calcium phosphorous product that is below 70.

6

It is recommended that ESRD patients maintain a calcium phosphorous product that is below 70.

Think the new standard is below 50-55.

7

The following is a recent article I found about prevention. Osteoporosis is mentioned. One can be doing everything he can to be an educated patient and still miss things. That’s why it is very essential that, as a group, we share experiences and info. Kidney patients have definite problems from bone disease etc. and it can be too late once the damage is done. In the same way kidney disease is slient until one begins to feel bad one day, bone issues can be happening which are slient, too. According to the following article, patients can slip through the cracks if they are soley depending on their doctors for guidance. It takes education, education, education! to be aware of all the side issues of kidney disease and to be pro-active at keeping them at bay.

Ignorance of doctors is risking lives
By Jacqueline Maley Medical Reporter
June 25, 2005

Patients who suffer from conditions including asthma, kidney disease,
high blood pressure and panic disorder are missing out on the most up-
to-date treatments because doctors are struggling to keep pace with
medical advances.
The National Institute of Clinical Studies yesterday launched a
report identifying 12 health care areas where doctors often failed to
treat patients with techniques learnt from the latest research.

Half of asthma sufferers, for example, were unaware of the need to
take regular preventative medication, despite a nationwide drive to
manage the illness with preventative measures.

The problems arose because many doctors were not keeping up with the
latest “evidence-based best practice” when treating ailments,
according to the institute’s report, which was co-ordinated by the
institute’s program director, Paul Ireland.

“Sometimes it might simply be that doctors aren’t aware of what the
latest evidence is,” Dr Ireland said. “Other times people maybe get
into habits or they might be sceptical of latest evidence, or not
feel able to give it a go.”

The findings also showed many asthmatics presenting to hospital
emergency departments are being given the wrong drug.
Evidence shows ipratropium bromide - a drug which reduces mucus
secretion - is useful in the treatment of severe asthma, but not in
the treatment of mild or moderate asthma.

Despite this, nearly 38 per cent of children with mild asthma and 66
per cent of children with moderate asthma were given the drug when
they arrived at hospital suffering an attack; 64 per cent of adults
with mild asthma and 83 per cent of adults with moderate asthma were
also given the drug.

The gap between knowledge and practice also extended to mental
health, high blood pressure, stroke and osteoporosis.

Only 2 per cent of patients with panic disorder were receiving
cognitive behavioural therapy - where distorted beliefs are
challenged and corrected - as an exclusive treatment. This was
despite the proven and lasting benefits of this treatment compared
with anti-depressants.

While the flu vaccination drive for Australians over 65 has proven
successful, those under 65 with high-risk conditions such as heart
disease, diabetes and lung disease, who are also advised to get
vaccinated, are mostly not receiving it. The research showed three
out of five Australians under 65 with high-risk conditions are not
vaccinated against influenza.

Another area was the treatment of dialysis patients, more than half
of whom begin treatment with the wrong sort of intravenous device -
resulting in a two- to three-fold increased risk of death.

Professor Bruce Armstrong, the head of School of Public Health at the
University of Sydney, said the study was “immensely valuable”.

“There’s evidence that there’s a big gap between what is optimal and
what’s being done,” he said. “It’s what’s referred to as the low-
hanging fruit, obvious things you can do to make a significant
difference to health.”

FALLING BEHIND

  • Many asthma patients are given the wrong drug in emergency.

  • Majority of under 65s are not being vaccinated against influenza.

  • Over half of dialysis patients begin treatment with a catheter-
    device which increases their risk of death two- to three-fold.

8

The following is an old post I found -think p.r.e.v.e.n…t.i.o.n.:

Post Message
Up Thread | Message Index | View Source | Unwrap Lines Message 28457 of 51882 < Previous Message | Next Message >

From: “Ann Gurley” <AnnGurley@…>
Date: Wed Apr 2, 2003 1:01 am
Subject: Re: ESRD Bone denisty zorp2001
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> Thank you all for your experiences. My Dad recently
> had his first scan and was told that his bones were
> “paper thin”. He’s 80, and began dialysis in Aug, 2001
> and received a transplant in July, 2002. No scan was
> taken as part of his transplant screening, and his
> nephrologist never ordered one during or before his
> dialysis.
>
> His current nephrologist has told him that there is
> nothing that can be done about the deterioration that
> has occurred. He says Fosomax (sp?) and like drugs are
> too hard on the new kidney and that they take “years”
> to be of benefit. He says that calcium supplements only
> build calcium in the blood, but do not build bone mass.
>
> I guess I’m just surprised that this wasn’t checked/
> monitored as a preventative measure and wondered what
> your experiences had been.

Katie,
My old unit did bone density studies right while we were on dialysis.
It was a procedure where you put your arm into a bath. I don’t remember
exactly what else but it was non-invasive. That procedure was
discontinued in the mid 90’s. But never was a scan ordered.
I had my first bone scan about 2000. Had a DXA scan June of last
year (14 years into dialysis). Then I found out my hip showed risk of
osteoporosis. I cannot take Fosamax because of my hepatitisC. But
my rheumatologist did put me on Miacalcin nasal spray. I don’t know
if it is helping control my bone loss or not. It will be difficult to say as
I also do weight training twice a week and have been for about 4 years.
My next DXA is scheduled for June this year. I look forward to seeing
the results.
My point is that my renal doc does not really follow my bone health.
Even when I broke my foot last November was there any attention
or change to my medications. I finally am back to regular shoes; the
arch on my ‘broken’ foot is now higher than it used to be, so I guess
I will have to shop (VBG) for some new shoes. Only my slippers and
Birkenstocks are comfortable now. However the Birks don’t look too
good with my dress up attire. Ah well, I digress.
Ann
p.s. vbg = very big grin and no, I don’t know what DXA stands for, it is
all over my test results in Bold capital letters.

9

Listen or don’t listen,

I am living proof…I have been on dialysis many years and not matter what you do you will get bone disease…

I have had good labs and management and the only benefit I’ve experienced is less pain…

YOU CAN’T STOP BONE DISEASE ON DIALYSIS PATIENTS, YOU CAN ONLY SLOW IT DOWN…

10

I’m with Gus on this one. It’s actually pretty hard to say, because there are so many interconnected factors involved with calcitriol, calcium, phosphorus and suppression/stimulation of PTH. Plus, it’s possible that any advantage with regard to bones is negated by the more frequent heparinization of daily dialysis. I know I’ve required more adjustment to calcitriol and calcium in my year so far of daily hemo than I ever did on conventional hemo. I didn’t even need calcitriol until I started daily. Daily hemo doesn’t restore full kidney function, and we know that even pre-ESRD kidney disease causes bone loss.
Pierre

11

By prevention I mean accurate education and management. My personal experience in numerous units has been no education is provided unless patients figure out the questions to ask. This should not be. If it were not for boards like this many patients would be in the dark about their tx issues and would certainly not know that there is a better tx.

12

Hi y’all,

Gus wrote:

YOU CAN’T STOP BONE DISEASE ON DIALYSIS PATIENTS, YOU CAN ONLY SLOW IT DOWN…

I wonder, actually.
– Years ago, we didn’t know about binders. Now, folks who learn about their kidney disease at stage 3 or 4 can start taking them even before their kidneys fail.
– We have better, more accurate measures of parathyroid hormone (PTH) levels now, to guide therapy.
– We have therapies to offer–vitamin D analogues to replace what the kidneys can no longer make, plus cinacalcet (Sensipar) to make the parathyroid glands themselves more sensitive to calcium that is present in the blood.

It seems to me that if we can maintain something close to normal physiologic levels of calcium, phosphorus, and PTH, that it should be possible to prevent the need for parathyroidectomy and the bone disease that can occur over the long term. When I get a chance, I’ll see if I can track down some of my old bone disease contacts and see if anyone can answer this question for us.

13

Thank you Dori, and while you’re at it could you ask if adynamic bone disease is reversable? My understanding is 50-60% of dialysis patients are adynamic due to previous dosing guidelines.

14

Believe me, its a very complex matter we’re dealing here, there are other factors that cause dialysis patients to suffer bone disease. It’s more than just managing your calcium and taking your vitamin D or whatever…it only helps to some point and after beeing on dialysis many years you will see the reality…

Even some people who are healthy and not on dialysis suffer from some sort of bone disease. Its so complex in a grandeur scale that further research and investigation is needed.

I mean c’mon, dialysis is not 100% perfect and I don’t think that your body which has no kidneys and not functioning normally throughout many years will find its way to a perfect satisfyinh life…

The key is management, reducing the pain and keeping it at bay but we’ll never get to the point of escaping that problem until we as patients get a kidney transplant…

15

I think their is an assumption that we know what happens with daily hemodialysis. Any honest nephrologist will tell you that we don’t know a thing. There are virtually no clinical trials that prove anything about daily hemodialysis. It is offered and we do it because of the perceived and observed benefits, but if you need proof of anything in terms of mortality and morbidity before you choose daily dialysis, you may be waiting for a long time. We have lots of opinions, lots of anecdotal and observational evidence, but that’s all we have. It’s still really an experimental therapy.

If someone tells you with assurance that daily hemo stops or reverse bone disease, they are only speculating.

Pierre

16

The point of my thread is simply for posters to contribute to what they know about kidney disease and how it should be managaged re bone disease. For all we know daily dialysis could make things worse for bones, although, hopefully, that is not the case… But I just wanted a thread where we can begin to compile accurate info.

Re adynamic bone disease, I have read it can be reversed and would like more verification of same.

17

DIALYSIS…kidney failure itself brings alot of health problems…

Dialysis ALONE, no matter 3x a week or more still results in bone problems…

Some of the dialysis techs I know have stated it, most of the patients in dialysis are having bone pain and some have gone far as getting the Parathyroid surgery to relieve the pain.

Of all my years on dialysis, this is what I know, see, and feel…

When I first started dialysis I didn’t have any bone problems and after I saw people suffering with bone problems I didn’t believe I would get that, I felt fortunate that I would not be like them, but today the truth has arrived.

18

I started getting calcification when I was on PD and in-centre HD. Now Im on nocturnal the calcium deposits havent gotten any bigger, and my phosphate and calcium levels have been normal.

19

Is the calcification reverseable? Or you can only halt it?

20

How do you know you have calcification…what does it feel like…where is it?