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"subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0211699512001457?idApp=UINPBA000064" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251412001454?idApp=UINPBA000064" "url" => "/20132514/0000003200000004/v0_201502091610/X2013251412001454/v0_201502091610/en/main.assets" ] "en" => array:12 [ "idiomaDefecto" => true "titulo" => "Asymptomatic polyostotic Paget's disease associated with secondary hyperparathyroidism in a peritoneal dialysis patient" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "542" "paginaFinal" => "544" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Erika De Sousa-Amorim, Gloria del Peso-Gilsanz, M. Auxiliadora Bajo-Rubio, Rafael Selgas-Gutiérrez" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Erika" "apellidos" => "De Sousa-Amorim" "email" => array:1 [ 0 => "erikades4@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 1 => array:3 [ "nombre" => "Gloria" "apellidos" => "del Peso-Gilsanz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 2 => array:3 [ "nombre" => "M. 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Universidad Autónoma de Madrid, Madrid, " "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Enfermedad de Paget poliostótica asintomática asociada a hiperparatiroidismo secundario en un paciente en diálisis peritoneal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11477_16025_33365_en_f1_811477.jpg" "Alto" => 787 "Ancho" => 1388 "Tamanyo" => 354442 ] ] "descripcion" => array:1 [ "en" => "Pagets disease in chronic kidney disease" ] ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor,</span></p><p class="elsevierStylePara">Paget’s disease (PD) is a focal bone remodelling disorder that can affect one or more bones.<span class="elsevierStyleSup">1</span> It is the second most common bone disease after osteoporosis, and its diagnosis usually derives from routine biochemical analyses, when elevated alkaline phosphatase (AP) levels are observed, or during imaging tests for other reasons.<span class="elsevierStyleSup">1-3</span></p><p class="elsevierStylePara">The incidence of PD in patients with chronic kidney disease (CKD) is unknown. Few cases have been described in the medical literature,<span class="elsevierStyleSup">4-8</span> and in some of them PD was masked by secondary hyperparathyroidism (SHP),<span class="elsevierStyleSup">4-6</span> making its diagnosis quite difficult. With this in mind, we present the first case of a patient on peritoneal dialysis with coexisting polyostotic PD and SHP.</p><p class="elsevierStylePara">Our patient was a 72-year-old male with a history of arterial hypertension and gouty arthritis, who was diagnosed with CKD of unknown aetiology in 1990 and referred to our hospital in December 2007. In February 2008, he started continuous ambulatory peritoneal dialysis. Before starting dialysis, the patient had elevated parathyroid hormone (PTH) and AP levels. He was diagnosed with SHP and initially received cinacalcet and calcitriol, followed by paricalcitol and cinacalcet. However, PTH levels remained high despite high drug doses, and were accompanied by persistently high AP levels.</p><p class="elsevierStylePara">In May 2011, he underwent computed tomography imaging for inclusion on the kidney transplant waiting list, and a sclerotic lesion was observed in the right iliac bone. A bone scintigraphy showed increased uptake of the radiotracer in the cervical spine, first finger of the right hand, left ulna, right sacroiliac joint, and, to a lesser extent, the external malleolus of the left ankle. Bone scans confirmed the presence of sclerotic lesions in the cervical spine, left ulna, and right sacroiliac joint (Figure).</p><p class="elsevierStylePara">During the follow-up period, the patient remained asymptomatic, without bone pain, fractures, or other complications. He was diagnosed with polyostotic PD. Given the absence of current indications for treatment, the patient is under periodic follow-up with strict surveillance and receives cinacalcet and calcifediol for SHP.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">PD is a bone remodelling disorder characterised by a marked increase in bone reabsorption mediated by osteoclasts, followed by a compensatory increase in bone formation. The bone tissue created has altered biomechanical properties and structure and induces clinical complications such as pain and bone deformities, secondary osteoarthritis, fractures, headache, stenosis of the spinal canal, neurological compression symptoms, and sarcomatous degeneration.<span class="elsevierStyleSup">1-3</span> The prevalence of this disease in the general population ranges between 1.5% and 4.5% in individuals older than 40 years, and increases with age, with a slight predominance in males and its distribution varies depending on the geographical region.<span class="elsevierStyleSup">2</span> Follow-up of disease progression with periodical measurements of AP helps to determine the extent and level of activity of the disease.<span class="elsevierStyleSup">1</span> The primary treatment is bisphosphonates, drugs capable of regulating osteoclast activity.<span class="elsevierStyleSup">2</span> Randomised studies have suggested that these drugs are capable of reducing bone pain and decreasing AP levels.<span class="elsevierStyleSup">1</span> Scientific evidence does support treating patients with bone pain, neurological complications, hypercalcaemia due to prolonged immobilisation, patients that undergo elective orthopaedic surgery, and patients with localised activity in the base of the cranium, the spinal column, and long bones.<span class="elsevierStyleSup">2</span></p><p class="elsevierStylePara">Treatment in asymptomatic patients is a controversial topic. The PRISM study<span class="elsevierStyleSup">9</span> was a randomised trial that sought to standardise AP that compared the efficacy of bisphosphonates in an intensive treatment regimen that sought to normalize AP levels against symptomatic treatment in patients with bone pain. It analysed a cohort of 1324 patients and found that intensive treatment did not provide any clinical advantages (in terms of incidence of fractures, need for orthopaedic surgery, quality of life, bone pain, and auditory thresholds) compared to symptom management. As such, additional studies are needed to evaluate whether the effects of bisphosphonates translate into clinical benefits for the patient, and therefore, treating asymptomatic patients is not recommended.<br></br><br></br></p><p class="elsevierStylePara">In patients with advanced CKD, the prevalence of PD is unknown. Until now, only 5 cases have been reported in the medical literature (Table), four of which were on haemodialysis (HD)<span class="elsevierStyleSup">4-6,8</span> and one on peritoneal dialysis.<span class="elsevierStyleSup">7</span> In three of the patients on HD, SHP masked PD, and the diagnosis was made based on persistent AP elevation following parathyroidectomy.<span class="elsevierStyleSup">5,6,8</span> With respect to the treatment of these patients, one received intravenous and nasal calcitonin<span class="elsevierStyleSup">7</span> and the other two, intravenous bisphosphonates (Table).<span class="elsevierStyleSup">5,8</span> The indications for treatment were bone pain in two cases and a slight, long-standing fever in another case that was resolved upon treatment. No patients had adverse effects from treatment.</p><p class="elsevierStylePara">It is unclear the safety of bisphosphonates in CKD patients on dialysis.<span class="elsevierStyleSup">10</span> Some cases have been described of successful treatment of dialysis patients with bisphosphonates, but they very few cases and the majority of the patients were on HD. Since bisphosphonates are taken up by the bones at a rate of 50%-80%, they are capable of reducing bone remodelling, and this could lead to difficulties in repairing microfractures and deteriorated bone quality.11 Even in patients with CKD, the deposition of bisphosphonates in the bones is believed to be proportionally higher and is also correlated with the severity of SHP, which implies a risk of inducing adynamic bone disease in these patients<span class="elsevierStyleSup">11,12</span></p><p class="elsevierStylePara">In conclusion, SHP can mask the diagnosis of PD in CKD patients, so a high level of clinical suspicion in these patients, and in these cases, persistently high levels of AP originating in the bones, which tends to remain even after parathyroidectomy, may suggest the diagnosis of PD. However, in many cases, radiological images taken for other reasons may lead to the diagnosis.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">The authors affirm that they have no conflicts of interest related to the content of this article.</p><p class="elsevierStylePara"><a href="grande/11477_16025_33365_en_f1_811477.jpg" class="elsevierStyleCrossRefs"><img src="11477_16025_33365_en_f1_811477.jpg" alt="Pagets disease in chronic kidney disease"></img></a></p><p class="elsevierStylePara">Figure 1. Pagets disease in chronic kidney disease</p><p class="elsevierStylePara"><a href="grande/11477_16025_33366_en_t1_8114772_copy1.jpg" class="elsevierStyleCrossRefs"><img src="11477_16025_33366_en_t1_8114772_copy1.jpg" alt="Cases of Paget&"></img></a></p><p class="elsevierStylePara">Table 1. Cases of Paget&</p>" "pdfFichero" => "P1-E541-S3640-A11477-EN.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11477_16025_33365_en_f1_811477.jpg" "Alto" => 787 "Ancho" => 1388 "Tamanyo" => 354442 ] ] "descripcion" => array:1 [ "en" => "Pagets disease in chronic kidney disease" ] ] 1 => array:8 [ "identificador" => "fig2" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11477_16025_33366_en_t1_8114772_copy1.jpg" "Alto" => 1011 "Ancho" => 2187 "Tamanyo" => 620788 ] ] "descripcion" => array:1 [ "en" => "Cases of Paget&" ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Whyte, M. 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Year/Month | Html | Total | |
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2024 November | 9 | 4 | 13 |
2024 October | 79 | 44 | 123 |
2024 September | 104 | 71 | 175 |
2024 August | 93 | 141 | 234 |
2024 July | 73 | 64 | 137 |
2024 June | 71 | 70 | 141 |
2024 May | 97 | 39 | 136 |
2024 April | 80 | 31 | 111 |
2024 March | 104 | 18 | 122 |
2024 February | 49 | 37 | 86 |
2024 January | 41 | 23 | 64 |
2023 December | 43 | 35 | 78 |
2023 November | 58 | 36 | 94 |
2023 October | 59 | 25 | 84 |
2023 September | 60 | 29 | 89 |
2023 August | 56 | 32 | 88 |
2023 July | 67 | 39 | 106 |
2023 June | 84 | 26 | 110 |
2023 May | 94 | 33 | 127 |
2023 April | 65 | 23 | 88 |
2023 March | 89 | 28 | 117 |
2023 February | 66 | 37 | 103 |
2023 January | 83 | 30 | 113 |
2022 December | 67 | 37 | 104 |
2022 November | 72 | 36 | 108 |
2022 October | 76 | 62 | 138 |
2022 September | 83 | 38 | 121 |
2022 August | 78 | 51 | 129 |
2022 July | 65 | 54 | 119 |
2022 June | 66 | 37 | 103 |
2022 May | 72 | 38 | 110 |
2022 April | 111 | 66 | 177 |
2022 March | 104 | 45 | 149 |
2022 February | 107 | 41 | 148 |
2022 January | 116 | 43 | 159 |
2021 December | 76 | 52 | 128 |
2021 November | 85 | 38 | 123 |
2021 October | 77 | 32 | 109 |
2021 September | 104 | 39 | 143 |
2021 August | 60 | 38 | 98 |
2021 July | 93 | 41 | 134 |
2021 June | 84 | 35 | 119 |
2021 May | 97 | 39 | 136 |
2021 April | 149 | 69 | 218 |
2021 March | 124 | 44 | 168 |
2021 February | 120 | 37 | 157 |
2021 January | 64 | 21 | 85 |
2020 December | 55 | 18 | 73 |
2020 November | 43 | 12 | 55 |
2020 October | 48 | 18 | 66 |
2020 September | 60 | 9 | 69 |
2020 August | 56 | 11 | 67 |
2020 July | 95 | 15 | 110 |
2020 June | 56 | 17 | 73 |
2020 May | 72 | 13 | 85 |
2020 April | 58 | 13 | 71 |
2020 March | 71 | 16 | 87 |
2020 February | 78 | 16 | 94 |
2020 January | 90 | 21 | 111 |
2019 December | 77 | 21 | 98 |
2019 November | 64 | 22 | 86 |
2019 October | 60 | 8 | 68 |
2019 September | 67 | 24 | 91 |
2019 August | 50 | 8 | 58 |
2019 July | 91 | 26 | 117 |
2019 June | 60 | 19 | 79 |
2019 May | 94 | 20 | 114 |
2019 April | 112 | 31 | 143 |
2019 March | 56 | 20 | 76 |
2019 February | 43 | 20 | 63 |
2019 January | 44 | 24 | 68 |
2018 December | 148 | 52 | 200 |
2018 November | 154 | 19 | 173 |
2018 October | 147 | 16 | 163 |
2018 September | 120 | 14 | 134 |
2018 August | 102 | 12 | 114 |
2018 July | 92 | 22 | 114 |
2018 June | 95 | 15 | 110 |
2018 May | 91 | 15 | 106 |
2018 April | 104 | 10 | 114 |
2018 March | 100 | 5 | 105 |
2018 February | 100 | 9 | 109 |
2018 January | 109 | 10 | 119 |
2017 December | 111 | 7 | 118 |
2017 November | 78 | 9 | 87 |
2017 October | 71 | 6 | 77 |
2017 September | 68 | 9 | 77 |
2017 August | 66 | 8 | 74 |
2017 July | 52 | 5 | 57 |
2017 June | 87 | 15 | 102 |
2017 May | 115 | 9 | 124 |
2017 April | 69 | 8 | 77 |
2017 March | 94 | 30 | 124 |
2017 February | 148 | 11 | 159 |
2017 January | 69 | 9 | 78 |
2016 December | 98 | 7 | 105 |
2016 November | 145 | 6 | 151 |
2016 October | 215 | 11 | 226 |
2016 September | 342 | 3 | 345 |
2016 August | 327 | 5 | 332 |
2016 July | 262 | 6 | 268 |
2016 June | 210 | 0 | 210 |
2016 May | 173 | 0 | 173 |
2016 April | 113 | 0 | 113 |
2016 March | 116 | 0 | 116 |
2016 February | 116 | 0 | 116 |
2016 January | 102 | 0 | 102 |
2015 December | 123 | 0 | 123 |
2015 November | 79 | 0 | 79 |
2015 October | 116 | 0 | 116 |
2015 September | 74 | 0 | 74 |
2015 August | 90 | 0 | 90 |
2015 July | 52 | 0 | 52 |
2015 June | 48 | 0 | 48 |
2015 May | 56 | 0 | 56 |
2015 April | 5 | 0 | 5 |