A 58-year-old obese woman with hypertension, type 2 diabetes, and chronic kidney

Question

A 58-year-old obese woman with hypertension, type 2 diabetes, and chronic kidney disease is admitted to hospital after a right femoral neck fracture sustained in a fall. Recently, she has been complaining of fatigue and was started on epoetin alfa (erythropoietin) subcutaneous injections. Her other medications include an angiotensin-converting enzyme inhibitor, a ?-blocker, a diuretic, calcium supplementation, and insulin. On review of systems, she reports mild tingling in her lower extremities. On examination, her blood pressure is 148/60 mm Hg. She is oriented and able to answer questions appropriately. There is no evidence of jugular venous distention or pericardial friction rub.

Which of the following is true of the pathogenesis of bone disease in chronic kidney disease? (select all that apply)

In this patient, calcium is poorly absorbed from the gut because of decreased renally generated vitamin 1,25-(OH)2 D3 levels.

In this patient, low serum calcium and hyperphosphatemia trigger PTH secretion, which depletes bone calcium and contributes to osteomalacia and osteoporosis.

Explanation / Answer

Answer

Option 2, 3

Explaination:

Findings:

First finding:

Erythropoietin is a hormone released by kidneys in response to lower oxygen content in the blood. It stimulates bone marrow to prepare red blood cells.

So women must be anemic that is the red blood cells are not effectively formed in the bone barrow

Second finding:

It is mentioned here that the elderly women was on the calcium supplementation and also calcium was not getting absorbed effectively from the intestine; hence administration of PTH(parathyroid hormone) becomes necessary as it helps in the increased calcium absorption form the intestines.

Lack of PTH had led the lady experience tingling in her lower extremities.

Third finding:

Chronic kidney disease is characterized by a condition wherein the kidneys gradually gets impaired and stops to function.

It was due to this defect in kidneys that the women had the problems of fatigue, decreased secretions of erythropoietin, excessive loss of water and many solutes from the body .

This also justifies why the women was on medications with anti diuretic drugs, and or many other medications.

The implication of the chronic kidney disease is such that it also impacts much other body part. Likewise it can also have an effect over the bones as it impacts the bone metabolism in the following given ways-

Leads to abnormalities of calcium, phosphate, vitamin D metabolism, Parathyroid metabolism gets impaired.

Hence keeping in mind all the possible findings, the best possible condition which justifies the suffering of the elderly women is that the patient probably suffers from osteoporosis which is accelerated by her underlying renal failure. And the pathogenesis of the bone disease is multifactorial.

As we know that osteoporosis is a disease in which the bone loses its minerals and fibers from the matrix; it becomes more prone to the fractures.

Individuals, who are under prolonged treatment of medicines, can suffer from this disease. Also osteoporosis is common in women who have a ceased menstruation. This is due to the deficiency of the steroidal hormone circulation in the body.

Further, fully functional kidneys can remove or excrete the extra amount of phosphate from the body. However in a chronic kidney disease, where in the kidneys can cannot excrete the phosphate from the body; the levels of phosphate becomes high in the blood and it can bring about some changes like pulling calcium form the bones; again increasing the chance of their fractures.

A discussed previously; PTH is administered due to which calcium is effectively absorbed by the gut. Only excess of PTH in the blood levels can mark the problems associated with more calcium withdrawal from the bones thus leading to fractures. Hence this option is not marked.

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