**3.11 Histological evidence of rod on postmortem bone biopsy**

10 Postmortem bone biopsies were carried out. This was made up of 7 (70%) males and 3 (30%) females. 9 (90%) had histological evidence of ROD, while 1 had normal bone histology. Of the 9 that had histological evidence, 6 (66%) were males while 3 (34%) were females. 6 (66%) had Osteitis Fibrosa. This was made up of 4 (50%) males and 2 (34%) females. 2 (22%) had Osteomalacia, 1 each (50%) of male and female, while 1 (12%) male had evidence of mixed type ROD (see Appendices 2-4). All the patients who had histological evidence of ROD had their creatinine clearance < 15mls/min (ESRD). 8 (88%) of the patient with histological evidence of ROD did not have any radiological evidence of ROD.

All the patients that had bone histological evidence of ROD had elevated total serum alkaline phosphatase and serum phosphatase. There is a positive correlation between histological evidence of ROD and total serum alkaline phosphatase and serum phosphate, (r = 0.04) and (r = 0.036) respectively. There was no correlation between histological evidence of ROD and symptoms of ROD (r = 0.48), see table 11.


\* Patient 7 had normal histology

OF = Osteitis Fibrosa, OM = Osteomalacia

Table 11. Characteristics of patients with bone histological evidence of ROD.

10 Postmortem bone biopsies were carried out. This was made up of 7 (70%) males and 3 (30%) females. 9 (90%) had histological evidence of ROD, while 1 had normal bone histology. Of the 9 that had histological evidence, 6 (66%) were males while 3 (34%) were females. 6 (66%) had Osteitis Fibrosa. This was made up of 4 (50%) males and 2 (34%) females. 2 (22%) had Osteomalacia, 1 each (50%) of male and female, while 1 (12%) male had evidence of mixed type ROD (see Appendices 2-4). All the patients who had histological evidence of ROD had their creatinine clearance < 15mls/min (ESRD). 8 (88%) of the patient

All the patients that had bone histological evidence of ROD had elevated total serum alkaline phosphatase and serum phosphatase. There is a positive correlation between histological evidence of ROD and total serum alkaline phosphatase and serum phosphate, (r = 0.04) and (r = 0.036) respectively. There was no correlation between histological evidence

> Calcium (mg/dl)

6.8 12.5 5.3 7.5 8.7 9.8 10.2 6.1 6.4

Phosp (mg/dl)

9.9 9.0 8.5 9.2 5.4 14.0 9.0 8.3 10.6 Ca x P04 (mg2/dl2)

64.4 112.5 45.1 69.0 47.0 137.5 91.8 50.6 67.8

Total Alk. Phosp (iu/L)

Alk Phosp (iu/l)

Serum P04 (mg/dl) Ca x P04 (mg2/dl2)

Crcl (mls/min)

Serum Ca (mg/dl)

54 M 7.8 7.6 6.5 156 9.9 64.4 6.0

Table 10. Characteristics of the only patient with radiological evidence of ROD.

with histological evidence of ROD did not have any radiological evidence of ROD.

Histological

Mixed type

Table 11. Characteristics of patients with bone histological evidence of ROD.

type

OF OM OF OM

OF OF OF OF

**3.11 Histological evidence of rod on postmortem bone biopsy** 

Age (Years) Sex RS

(Rugger Jersey Spine).

(cm)

P04 = Phosphate, Ca = Calcium, RS = Renal Size.

Left Right

Crcl = Creatinine clearance, Alk phosp = Alkline phosphatase,

of ROD and symptoms of ROD (r = 0.48), see table 11.

(Year)

Patients Gender Age

M M M F M M F M F

\* Patient 7 had normal histology

OF = Osteitis Fibrosa, OM = Osteomalacia

APPENDIX 2: PHOTOMICROGRAMS OF BONE HISTOLOGY SHOWING OSTEITIS FIBROSA, OSTEOMALACIA AND OSTEITIS FIBROSA IN PATIENTS 1, 2 AND 3 RESPECTIVELY.

The Prevalence of Renal Osteodystrophy in

PATIENT 7, 8, 9 AND 10 RESPECTIVELY.

Chronic Renal Failure Patients in Urban Niger Delta of Nigeria 65

APPENDIX 4: PHOTOMICROGRAMS OF BONE HISTOLOGY SHOWING NORMAL HISTOLOGY, OSTEITIS FIBROSA, OSTEITIS FIBROSA AND OSTEITIS FIBROSA IN

APPENDIX 3: PHOTOMICROGRAMS OF BONE HISTOLOGY SHOWING OSTEOMALACIA, MIXED TYPE ROD AND OSTEITIS FIBROSA IN PATIENT4, 5 AND 6 RESPECTIVELY.

OSTEOMALACIA, MIXED TYPE ROD AND OSTEITIS FIBROSA IN PATIENT4, 5 AND 6

APPENDIX 3: PHOTOMICROGRAMS OF BONE HISTOLOGY SHOWING

RESPECTIVELY.

APPENDIX 4: PHOTOMICROGRAMS OF BONE HISTOLOGY SHOWING NORMAL HISTOLOGY, OSTEITIS FIBROSA, OSTEITIS FIBROSA AND OSTEITIS FIBROSA IN PATIENT 7, 8, 9 AND 10 RESPECTIVELY.

The Prevalence of Renal Osteodystrophy in

chronic renal failure (ESRD). 5. ROD may be more prevalent in males.

predialysis CRF patient in England.

hyperparathyroidism (HPTH).

**phoshatase**

**patients**

**4.2 Osteitis fibrosa is the commonest type of rod** 

Chronic Renal Failure Patients in Urban Niger Delta of Nigeria 67

4. Radiological and biochemical evidence of ROD seems to be more prevalent in severe

6. There is no correlation between symptoms of ROD and biochemical or radiological evidence of ROD. This suggests that many patients may have ROD with no symptoms.

Osteitis Fibrosa is a form of high turnover bone disease as a result of hyperparathyroidism. PTH assay was not done because of lack of facility in our center. However serum alkaline phosphatase was used as a surrogate. 78% of the CRF patients had raised levels of total serum alkaline phosphatase which correlate well with PTH levels and histological features of secondary hyperparathyroidism. This is in agreement with the work done by Duursma et al, (1975); Ritz et al (1974) and Hruska et al (1978). 66% of patients had Osteitis Fibrosa on histology. This finding agrees with the work of Jarava et al (1996) who found bone histological evidence of Osteitis Fibrosa cystica in 17 (85%) out of 20 haemodialysis patients in England. Our findings also agrees with that of shin et al (1999) who found Osteitis Fibrosa as the commonest type of ROD in predialysis patients in Canada (44%). This finding contradicts that if Coen et al (1996) who found mixed type ROD as the commonest type in

**4.3 There is correlation between histological evidence of rod and serum alkaline** 

In this study, it was found that 90% of patient had histological evidence of ROD on postmortem bone biopsy. This agrees with the finding Sanchez (2001), who found that 90% of patients with ESRD on maintenance dialysis have abnormal bone histology. Majority of patients are either predialysis or those who were not dialyzing adequately. It is known that once a patient start on maintenance, the prevalence of ROD increases. One of the contributing factors being aluminum deposition (from dialysate fluid), it means that the prevalence may even be higher if our patients are dialyzed adequately. In our study we found that all the patients that had histological evidence of ROD had elevated serum alkaline phosphatase levels. This finding may possibly be pointing to the fact that serum alkaline phosphatase can be used as a surrogate of parathyroid hormone as a predictor of ROD in our patients. This agrees with the finding of Urena et al, (1991) that in the absence of liver disease, serum alkaline phosphatase can be used to predict the presence of ROD. The finding is also in agreement with that of Duursma et al and Ritz et al who found that plasma alkaline phosphatase levels correlates with histological features of secondary

**4.4 The yield of rod using radiological examination is low in our chronic renal failure** 

In our study, we found only 2% of ROD using radiological examination. This agrees with Odenigbo (2003) who found 3.35% of ROD in Enugu using radiological examination. In this study, radiological evidence of ROD was not found in all 9(100%) patients who had histological evidence of ROD on postmortem bone biopsy. This agrees with the finding of

7. Hypocalcaemia and hyperphosphataemia is prevalent in our CRF patients.


\* Patient 7 had normal histology

OF = Osteitis Fibrosa, OM = Osteomalacia

Table 11. Characteristics of patients with bone histological evidence of ROD.
