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Diagnostic Algoritm for Identifying the Type of Bone Turnover in Patients with Renal Osteopatia on Chronic Hemodialysis
1 1st Department of Obstetrics-Gynecology
2 2nd Department of Orthopedics and Traumatology, Victor Babes University of Medicine and Pharmacy, Timisoara

Correspondence to:
Ass. Prof. Dana Stoian, MD, PhD, Victor Babes University of Medicine and Pharmacy, 2 E. Murgu Sq.,
Timisoara, Tel. +40-256-204250.
Email: drd@nutritietimisoara.ro
REZUMAT
Introducere: Prezenta osteopatiei renale in evolutia cazurilor cu insuficienta renala cronica, este un lucru foarte bine cunoscut. Abordul therapeutic al acesteia depinde in cea mai mare parte de tipul de turnover osos. Studiul de fata isi propune sa evalueze impactul diagnostic, al diverselor metode de diagnostic. Material si metode: 131 pacienti, din centrul de Dializa si Transplant renal, din Spitalul Clinic nr.1, selectasi aleator. Fiecare pacient a consimsit participarea la intreaga perioada de urmarire. Evaluarea a fost facuta prin: examne clinic, radiografii standard, DXA coloana lombara si sold nondominant, ultrasonometrie, determinari biochimice si hormonale specifice: iPTH, OS, FAL-O, 25HOvitaminD. Analiza statistica a datelor a utilizat curbele diagnostice ROC, pentru a calcula sensibilitatea, specificitatea, valoarea predictiva pozitiva, valoarea preditiva negativa, valoare pragg optim diagnostica. Rezultate: Din otalul cazurilor, am identificat turnover osos accelerat la 61.8% din lot, 18 pacienti cu defecte de mineralizare osoasa associate, 16.79% subiecti au avut turnover osos dimineaut, restul de 21.37% avand nevoie de urmarire periodica pentru incadrarea riguroasa. Folosind aceasta clasificare ca standard, am evaluat calitatea diversilor parametrii, in diagnosticul turnoverului osos crescut - iPTH >400 pg/mL, FAL-O >20 µg/l, 25HOD <30ng/mL, volum paratiroidian >0.5 cm3, OS > 13 ng/L, modificari radiologice- , respectiv turnover osos diminuat - iPTH < 80 pg/mL, FAL-O<13 µg/l, 25HOD< 20 ng/mL, OS< 3 ng/L-. Cea mai buna metoda de diagnostic a fost iPTH (AUC=0.855), FAL-O (AUC=0.8566), OS (AUC=0.302), 25 HOD (AUC =0.646). Asocierea treptata a acestor analize a crescut exponential puterea diagnostica: turnover osos crescut- sensibilitate de la 50.080 (PTH izolat) la 98.78 (PTH + BAP), iar specificitatea pana la 100 (PTH+FAL-O+25 HOD+ecografie). in cazul turnoverului diminuat, rezultatele au fost similare. De asemenea am identificat valorile discrimitative prag, optime, pentru cele mai importante metode diagnostice: turnover crescut: iPTH> 214 pg/ml, FAL-O > 76,3 µg/L, tunroner diminuat: iPTH < 122 pg/ml, FAL-O < 34 µg/L, OS < 3,1. Concluzii: Combinarea ultrasonografiei regiunii cervicale anterioare, cu osteodensitometria cu raya X, dozarilor hormonale si cele ale markerilor de turnover osos, determina cresterea capacitatii diagnostice pozitive si discriminative.

ABSTRACT
Introduction: Uremic bone disease is a fact in the evolution of end stage renal disease patients. The type of bine disease remains a difficult task in face on the clinician. Bone biopsy is the golden standard of diagnostic, but is not recommended routinely and is not available to all hospital sites. Material and methods: 131 patients from the Hemodialysis and Renal Transplantation Center form the County Hospital nr.1, selected randomly, with their agreement of participating to the whole study. All patients performed: clinical evaluation, standard X-rays, DXA of lumbar spine and hip, QUS, biochemical assays and specific determinations: iPTH, OS, BAP, 25HOvitaminD. We analyze the data using ROC diagnostic curve to calculate sensitivity, specificity, PPV, NPV, best threshold values to compare different diagnostic methods. Results: From the 131 cases, we identified increased bone turnover in 61,8% cases, 18 patients with mineralization defects, 16.79% low turnover subjects, 21.37% needed a reevaluation after six months for diagnostic decision. Using this evaluation as standard, we analyzed all the different assays: iPTH >400 pg/mL, BAP >20 μg/l, 25HOD <30ng/mL, parathyroid volume >0.5 cm3, OS > 13 ng/L, positive X-ray changes in diagnostic of increased bone remodeling, respectively < 80 pg/mL, <13 μg/l, < 20 ng/mL, < 3 ng/L. The best diagnostic methods are iPTH (AUC=0.855), BAP (AUC=0.8566), OS (AUC=0.302), 25 HO-vitamin D (AUC =0.646). Combined stepwise approach increases the sensitivity of the diagnostic of high turnover: form 53.080 (for PTH alone) to 98.78 (PTH + BAP), and the specificity up to 100 (PTH+BAP+25 HO vitamin D + ultrasound). In the case of low turnover, the results were similar. We identified the best discriminative values for the most important diagnostic approaches: increased turnover: iPTH> 214 pg/ml, BAP > 76,3 μg/L, decreased turnover: iPTH < 122 pg/ml, BAP < 34 μg/L, OS < 3,1. Conclusion: Combining ultrasound, ostedensitometric, hormonal and bone turnover markers increases the diagnostic abilities of the clinician.


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