CJASN
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Clin J Am Soc Nephrol 3: S140-S150, 2008
© 2008 American Society of Nephrology
doi: 10.2215/CJN.02430508
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Miller, P. D.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Miller, P. D.

Article

The Role of Bone Biopsy in Patients with Chronic Renal Failure

Paul D. Miller

University of Colorado Health Sciences Center, Colorado Center for Bone Research, Lakewood, Colorado

Address correspondence to: Dr. Paul D. Miller, Colorado Center for Bone Research, 3190 S. Wadsworth Boulevard, #250, Lakewood, CO 80227. Phone: 303-980-9985; Fax: 303-980-1367; E-mail: millerccbr{at}aol.com


   Abstract
Top
 Abstract
Introduction
 How "Osteoporosis" Is Diagnosed...
 Case Reports
 Conclusion
 Disclosures
 References
 
Renal bone disease is a heterogeneous group of metabolic bone diseases that requires quantitative bone histomorphometry to make the correct differential diagnosis. Included in this group is osteoporosis. However, osteoporosis in stage 4 to 5 chronic kidney disease cannot be diagnosed on the basis of bone mineral density criteria established by the World Health Organization or the presence of fragility fractures because patients with all forms of renal bone disease can demonstrate low bone mineral density and fragility fractures. Clinical cases in patients with either low bone mineral density and/or low-trauma fractures will be used to demonstrate the value of bone biopsy and quantitative histomorphometry in making a diagnosis of the specific renal bone disease and assisting with subsequent management decisions.


   Introduction
Top
 Abstract
 Introduction
How "Osteoporosis" Is Diagnosed...
 Case Reports
 Conclusion
 Disclosures
 References
 
Renal osteodystrophy (ROD) is a heterogeneous group of metabolic bone diseases that accompanies progressive chronic kidney disease (CKD (1–4) (Table 1). These metabolic bone diseases have both specifically defined quantitative histomorphometric diagnostic criteria as well as clinical features (5,6). More recently, the Kidney Disease Improving Global Outcomes working group offered a new and more encompassing definition of renal bone disease (7). The recent recognition that disorders of bone and mineral metabolism that accompany CKD involve multiple organ systems and are associated with cardiovascular events and death has led investigators to propose a new definition of renal bone disease. This more general definition recognizes that the pathophysiology of renal bone disease extends beyond the skeleton and that there are links between abnormal bone remodeling activity and the risk for soft tissue and vascular calcification (7–11). CKD-mineral and bone disorder (7) is the proposed new term for the changes in bone and mineral metabolism associated with declining kidney function (Table 1). In this new construct, the term "renal osteodystrophy" is limited to the specific changes in bone histology that accompany moderate and end-stage CKD and defined according to histomorphometric criteria.


View this table:
[in this window]
[in a new window]

  		Table 1. Metabolic bone diseases associated with renal disease

 
In the specific arena of renal bone disease, it is the specific quantitative histomorphometric criteria that defines the renal bone disease and makes the specific diagnosis (5,12,13). For example, from a clinical standpoint, while osteomalacia may be associated with an elevated bone specific alkaline phosphatase (BSAP) and parathyroid hormone (PTH), proximal (shoulders/hips) bone pain, and muscle weakness, these identical clinical combinations may also be seen in hyperparathyroid bone disease. Hypercalcemia may be a feature of hyperparathyroid, aluminum, or adynamic renal bone disease; and, even although the intact 1 to 84 serum PTH level is often low to low-normal in adynamic renal bone disease, PTH levels (1 to 84) may also be elevated at times in adynamic renal bone disease (1–4,14–20). In addition, either by natural biologic means or induced by pharmacologic agents used to treat specific forms of renal bone disease (such as calcimimetics or vitamin D analogs), a patient can transition from one histologic form of renal bone disease to another. For example, an osteomalacic, histomorphometric form of renal bone disease may normalize to normal osteoid surfaces or transform from low bone turnover and impaired mineralization to high bone turnover and increased mineralization as vitamin D deficiency is corrected (21,22); or, as aluminum is removed by desoferoxamine (DFO) chelation, the histology may change from an aluminum-induced low bone turnover to a high bone turnover as the bone becomes more responsive to PTH with aluminum withdrawal from osteoid surfaces (23). Treatment of secondary hyperparathyroidism with vitamin D analogs or cinacalcet may correct the underlying high bone turnover (24–32) or, if PTH suppression is excessive, lead to very low (or no) bone turnover, the so-called adynamic renal bone disease (33,34). In addition, low (or no) bone turnover may be reversible by modulating the PTH level (35,36). Thus, the evolving framework of redefining the quantitative morphology of renal bone disease as well as recognition of its systemic nature is both an advancement as well as a challenge in the management of patients with CKD (7,37). The challenge is how to appropriately use bone biopsies to define the often changing landscape of renal bone disease to manage the systemic disorders that may accompany such change (12–14,38,39).

The heterogeneous group of renal metabolic bone diseases is associated with certain abnormalities in blood biochemical tests that can be helpful in the differential diagnosis in groups of patients (Tables 2, 3) (40,41). However, there is enough overlap in the biochemical profile among the renal bone diseases that makes the distinction between these histomorphometric forms of renal bone disease uncertain in individual patients (6, 7, 11, 14, and 15). Additionally, because osteoporosis is an increasingly prevalent form of metabolic bone disease in all populations, including CKD patients, has no distinctly characteristic biochemical derangement, and can range from low to high bone turnover on histomorphometry, it is a unique diagnostic challenge to make in CKD patients and one that is important to differentiate from the other more traditional forms of renal bone disease (42–45). Two forms of renal bone disease that are particularly important to discriminate from osteoporosis, especially in the CKD patient that has a low bone mineral density (BMD) or low-trauma fragility fractures, are the very low bone turnover and impaired mineralization forms of renal osteodystrophy: adynamic and osteomalacia bone disease. One major reason for this important distinction is that osteoporosis therapies that reduce bone turnover and increase bone strength in specific forms of osteoporosis (postmenopausal, male, or glucocorticoid-induced osteoporosis) are bisphosphonates (46–55) may be contraindicated in specific low bone turnover renal bone diseases or in patients with glomerular filtration rates <30 ml/min (56,57). It is intuitive that the administration of a bone-active agent, such as a bisphosphonate that reduces bone turnover, may not be desirable in a patient with low-bone turnover to begin with. Nevertheless, bisphosphonates could be an effective therapy for specific forms of osteoporosis in patients with stage 4 CKD where post hoc analysis does suggest efficacy and safety through 3 yr of use (58,59). The major clinical issue is making the correct diagnosis of osteoporosis.


View this table:
[in this window]
[in a new window]

  		Table 2. Patient profiling by groups: PTH levels

 

View this table:
[in this window]
[in a new window]

  		Table 3. Patient profiling by groups: BSAP levels

 

   How "Osteoporosis" Is Diagnosed in CKD
Top
 Abstract
 Introduction
 How "Osteoporosis" Is Diagnosed...
Case Reports
 Conclusion
 Disclosures
 References
 
Postmenopausal osteoporosis can be diagnosed on the basis of BMD criteria or the presence of a fragility fracture once secondary causes of bone fragility are excluded (60–62). The BMD criteria were established in 1994 by a working group of the World Health Organization (WHO) (63). The WHO BMD criteria, a T-score at the lumbar spine by anteroposterior dual energy x-ray absorptiometry, or hip or forearm of –2.5 or lower, is the SD cut-off point chosen for the BMD criteria. This level was chosen because the prevalence of a BMD at or below this level at these 3 skeletal sites in white postmenopausal women (~40%) matched the lifetime fracture risk at the vertebrae, forearm, or hip as well (~40%). In addition, the development of a low-trauma fracture in postmenopausal women or elderly men can also be a criterion for the diagnosis of osteoporosis because fragility fractures of the hip, vertebrae (even morphometric), wrist, shoulder, humerus, pelvis, and ribs are associated with a high risk for other fragility fractures, and this risk is independent of the prevailing BMD or T-score (64–70). Hence, once other etiologies for fragility fractures are excluded (e.g., osteogenesis imperfecta, osteomalacia), then the diagnosis of osteoporosis can be established.

The major clinical problem in using either the WHO criteria or fragility fractures to make a clinical diagnosis of osteoporosis in the CKD (especially stage 4 to 5 CKD) is that all of the previously described histomorphometric forms of renal osteodystrophy may have low BMD and/or T-scores and can develop low-trauma fractures (71–74). Thus, the traditional criteria accepted as diagnostic criteria for osteoporosis in the postmenopausal or elderly male population cannot be used as diagnostic criteria for the diagnosis of osteoporosis in the more severe (stage 4 to 5) CKD population.

There are as of yet no established criteria for the diagnosis of osteoporosis in more advanced CKD (stage 4 to 5) (42–45). Early hyperparathyroidism may be seen in stage 3 CKD and may be associated with histologic changes of high bone turnover in these patients who have not been shown to have an increased fracture risk (24,75,76) There may be a role for suppressing the elevated PTH levels as a therapeutic option in mild secondary hyperparathyroidism in stage 3 to 4 CKD as there clearly is for stage 5 CKD, and the vitamin D analogs have achieved Food and Drug Administration registration for this indication (77). Fracturing postmenopausal women and elderly men with mild primary or secondary hyperparathyroidism and stage 3 CKD are more likely to have osteoporosis as the etiology of their fractures (78,79), and it is far more probable that in these patients with low BMD and/or low trauma fractures the WHO criteria can be used for the diagnosis of osteoporosis.

However, this may not be a valid approach for patients with stage 4 to 5 CKD where fractures may be the result of some other form of renal bone disease just as likely as osteoporosis. In stage 4 to 5 CKD, diagnosis of osteoporosis is first established by excluding the other forms of renal bone disease and the finding of a low trabecular bone volume. It requires a bone biopsy to make this important clinical diagnosis in the individual patient with stage 4 to 5 CKD, and it is a decision upon which the diagnosis of osteoporosis is mandated.


   Case Reports
Top
 Abstract
 Introduction
 How "Osteoporosis" Is Diagnosed...
 Case Reports
Conclusion
 Disclosures
 References
 
The following cases highlight the value of quantitative bone histomorphometry in management of patients with CKD and fragility fractures.

Case 1
A 66-yr-old Hispanic woman with end-stage renal disease (ESRD) (type 1 diabetes mellitus and hypertension) was on hemodialysis for 2 yr when she developed 2 clinical (painful) vertebral compression fractures. She was 16 yr postmenopausal on no hormonal replacement therapy, received calcium carbonate and acetate as phosphate binders, and had never been exposed to aluminum phosphate binders. Her clinical/biochemical profile is as follows: BMD, T-score at femoral neck –3.2 (osteoporosis by WHO criteria); serum calcium, 9.6 mg/dl (normal, 8.5 to 10.5 mg/dl); serum phosphorus, 3.7 mg/dl (normal, 3.0 to 5.0 mg/dl); serum intact PTH, 64 pg/ml (normal, 10 to 65 pg/ml); serum BSAP, 14 IU/ml (normal, 10 to 65 IU/ml); and 25 hydroxyvitamin D, 32 ng/ml (normal, 30 to 100 ng/ml). Bone biopsy is shown in Figures 1 to 4. Diagnosis is low bone turnover/aluminum bone disease.


Figure 1
View larger version (124K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		Figure 1. Bone biopsies. (Top left panel) von Kossa (left) and hematoxylin and eosin (right); original magnification x40; shows thin trabeculae with incipient perforations and very small numbers of calcified trabeculae. (Top right panel) Eosin fluorescence stain for osteoid (original magnification x40); shows very thin osteoid in yellow. (Bottom left panel) von Kossa hematoxylin and eosin stain; shows inactive bone lining cells and thin osteoid. (Bottom right panel) Unstained, florescent for mineralization, original magnification x200); shows minimal tetracycline labels.

 

Figure 4
View larger version (70K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		Figure 4. Bone biopsies. Both are stained with Prussian blue stain for iron. (Left panel) Original magnification x250; shows positive iron stained on osteoid. (Right panel) Original magnification x400; shows iron in blue covered by inactive bone lining cells.

 
Comment:  The histomorphometry and quantitative data show thin osteoid (matrix) and low bone formation rates consistent with low bone turnover. The osteoid surfaces were covered by aluminum, and this is aluminum bone disease. Aluminum bone disease still may develop without known aluminum exposure (e.g., aluminum phosphate binders) because of the ubiquitous presence of aluminum in the environment and the inability of the patient with CKD to excrete aluminum. After the biopsy was diagnostic, both a basal as well as post-DFO aluminum challenge test were negative (basal level <20 µg/L and post-DFO rise <50 µg/L). It is recognized that serum aluminum levels may not adequately reflect systemic (bone or brain) aluminum accumulation. In this case, the biopsy confirmed the diagnosis and guided therapy. It is possible that she could have been assumed to have osteoporosis (based on her T-score or vertebral fractures) and treated with a bisphosphonate. Although in the future management of this patient, Food and Drug Administration-approved osteoporosis pharmacologic therapies might be a consideration, identification of her aluminum bone disease was an important discovery that required proper management as the first step.

Case 2
A 56-yr-old white woman on hemodialysis for chronic glomerulonephritis for 10 yr had a low trauma fracture of her pelvis and then her femur 3 yr apart. She was 10 yr postmenopausal on hormonal replacement therapy and calcitriol (0.25 µg twice daily) but had received no aluminum phosphate binders. Her clinical and laboratory data are as follows: BMD T-score, –4.0 (osteoporosis by WHO criteria); serum calcium, 9.7 mg/dl (normal); serum phosphorus, 5.2 mg/dl (slightly elevated); serum PTH, 98 pg/ml (mild elevation); serum 25 hydroxyvitamin D, 36 ng/ml (normal); and BSAP, 41 IU/ml (normal). Bone biopsy is shown in Figures 5 and 6. Diagnosis is low bone turnover/osteomalacia-aluminum.


Figure 5
View larger version (115K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		Figure 5. Bone biopsies. (Top panel) von Kossa stain for calcium; shows thick osteoid seams (pink) and tunneling bone resorption with cavity containing many osteoclasts. (Bottom left panel) Tartrate-resistant acid phosphatase (TRAP) stain for osteoclasts; shows many osteoclasts. (Bottom right panel) TRAP stain with azure for osteoblasts; shows very few osteoclasts.

 

Figure 6
View larger version (112K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		Figure 6. Bone biopsies. (Top left panel) Prussian blue stain for iron; shows iron staining of osteoid. (Top right panel) Solochrome azurine stain for aluminum; shows aluminum on the mineralization front. (Bottom left panel) Prussian blue stain for iron; shows iron on osteoid. (Bottom right panel) Solochrome azurine stain for aluminum; shows aluminum on the mineralization front as well as on the cement line.

 
Comment:  The histomorphometry is diagnostic of osteomalacia with a very high osteoid surface percent, thick osteoid, and an infinite mineralization lag time. The etiology of osteomalacia in this case was aluminum accumulation. The patient had never been exposed to any aluminum. On the basis of her low BMD and fractures, she could have been assumed to have osteoporosis. Proper management involves first removal of aluminum and then addressing the low bone strength that might be related to osteoporosis.

Case 3
This 22-yr-old man with known nephrocalcinosis associated with long-term vitamin D-resistant rickets and long-term replacement with phosphorus (potassium phosphate, 250 mg 4 times a day) and calcitriol (0.25 µg twice daily), with little data on the levels of serum calcium/phosphorus over many years, has been on hemodialysis for 15 yr. He developed nontraumatic bilateral mid-shaft femur fractures at age 21 yr. His laboratory data are as follows: BMD T-score, –3.7 at femoral neck; serum calcium, 9.8 mg/dl; serum phosphorus, 2.5 mg/dl; serum PTH, 70 pg/ml (elevated); serum BSAP, 85 IU/ml (elevated); serum 25 hydroxyvitamin D, 45 ng/ml; and serum 1,25 dihydroxyvitamin D, 4 ng/ml (low). Bone biopsy is shown in Figures 7 and 8. Diagnosis is osteomalacia.


Figure 7
View larger version (103K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		Figure 7. Bone biopsy showing osteomalacia. (Top left panel) von Kossa hematoxylin and eosin stain for calcium and osteoid; shows a high osteoid surface and thick osteoid (pink). (Bottom left panel) Fluorescence stain for tetracycline; shows single or diffuse labels (tallow). (Bottom right panel) von Kossa hematoxylin and eosin stain with fluorescence for osteoid; shows abundant and thick osteoid (yellow).

 

Figure 8
View larger version (116K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		Figure 8. Bone biopsies. (Top left panel) TRAP stain for osteoclasts; shows octeoclast precursors and osteoclasts. (Top right panel) Hematoxylin and eosin stain; shows osteoblasts and inactive bone lining cells. (Bottom left panel) Prussian blue stain for iron; shows iron on the osteoid-marrow interface and in macrophages. (Bottom right panel) Solochrome azurine stain for aluminum; shows no aluminum.

 
Comment:  This was a known case of hereditary hypophosphatemic vitamin-D resistant rickets that had new fractures after having been off his phosphorus and vitamin D replacement for 3 yr. The bone biopsy is classic for severe osteomalacia; the fractures healed with calcitriol and phosphorus replacement, and his elevated bone-specific alkaline phosphatase also normalized with treatment. Although one could have assumed that his elevated BSAP was a return of his osteomalacia, it was important to make the exact diagnosis in an ESRD patient before giving phosphorus in this ESRD state. In addition, it could have been assumed, with femur fractures and very low T-scores, that he might have had osteoporosis, which would have been the incorrect diagnosis.

Case 4
This 47-yr-old white woman received a live-related renal transplant in Switzerland 15 yr before being evaluated for her metabolic bone disease. Her original renal disease was chronic poststreptococcal glomerulonephritis. She had had generalized and often incapacitating "bone pain" and low trauma fractures (pelvis in 1999 and tibia 2002), had never been on glucocorticoids, but had received long-term cyclosporine. Her data are as follows: serum calcium, 9.5 mg/dl; serum phosphorus, 3.8 mg/dl; serum BSAP, 150 to 300 IU/ml (elevated); serum PTH, 45 pg/ml; serum 25 hydroxyvitamin D, 16 ng/ml (low); serum 1,25 dihydroxyvitamin D, 12 ng/ml (low); serum creatinine, 1.6 mg/dl (elevated); BMD T-score, –4.8 (femoral neck); WHO diagnosis, osteoporosis; serum c-telopeptide, 454 (elevated); serum carbon dioxide, 15 mEq/ml (low); serum chloride, 121 mEq/ml (elevated); serum calculated anion gap, 13 mEq/ml (normal); and arterial blood gases: pH = 7.30, Pco2 = 32, HCO3 = 14, metabolic acidosis). Bone biopsy is shown in Figures 9 and 10. Diagnosis is high bone turnover resulting from cyclosporine.


Figure 9
View larger version (98K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		Figure 9. Bone biopsies. (Top left panel) von Kossa hematoxylin and eosin stain for calcium; shows tunneling resorption and thinning of trabeculae. (Top right panel) von Kossa hematoxylin and eosin stain, fluorescence for osteoid; shows abundant osteoid in yellow. (Bottom left panel) von Kossa hematoxylin and eosin for calcium and osteoid; shows scalloping resorptive surfaces in high bone remodeling. (Bottom right panel) TRAP stain for osteoclasts and osteoblasts; shows abundant osteoclasts and osteoblasts.

 

Figure 10
View larger version (130K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		Figure 10. Bone biopsies. (Right panel) von Kossa hematoxylin and eosin for general histology; shows active bone formation and resorptive surfaces. (Right panel) Unstained, fluorescence for osteoid; shows multiple double tetracycline labels.

 
The clinical course is as follows: 1) treatment with bicarbonate to maintain serum bicarbonate 23 mEq/L; no effect on high turnover markers; 2) normalized 25 vitamin D; no effect on high bone turnover markers; and 3) high doses (90 mg pamidronate intravenously every 4 mo) in Switzerland with normalization of turnover markers, increase in BMD, and no subsequent fractures over 4 yr of follow-up and no change in serum creatinine concentration.

Comment:  This was a patient with fractures and exceptionally high bone turnover by both biochemical marker levels as well as histomorphometry. The histomorphometry confirmed that exceptional bone resorption was occurring, and this process could have been related either to her metabolic acidosis and/or cyclosporine. Normalization of her acid-base balance did not reduce her high bone turnover. It required a large dose of intravenous bisphosphonate and bicarbonate replacement to normalize her very high bone turnover, eliminate her bone pain, and heal her fractures. Intravenous bisphosphonate would not have been considered in this patient with a posttransplant serum creatinine of 1.6 mg/dl and who had not received glucocorticoids without clear documentation of high bone turnover and fractures.

Case 5
This 49-yr-old Hispanic woman with stage 4 CKD (glomerular filtration rate, 20 ml/min by creatinine clearance) had several low trauma fractures od humerus and later mid-femoral shaft. She was postmenopausal and not on hormonal therapy. Her data are as follows: BMD (T-score, –4.4 at total hip and –4.4 at anteroposterior spine and –5.2 at forearm); serum calcium, 9.1 mg/dl; serum phosphorus, 4.4 mg/dl; serum 25 hydroxyvitamin D, 13 ng/ml (low); serum 1,25 dihydroxyvitamin D, 8 ng/ml (low); serum PTH, 271 pg/ml (elevated); and serum BSAP, 125 IU/ml (elevated).

The clinical course is as follows: The patient was replaced with 25 hydroxyvitamin D, and her biochemical testing changed to: repeat 25 vitamin D, 34 (normal); repeat PTH, 184 (elevated); repeat serum calcium, 10.7 and 11.2 mg/dl (elevated); BSAP, 122 (elevated); and Sestamibi scan (parathyroid scan), normal. Bone biopsy results are shown in Figures 11 to 13. Diagnosis is high bone turnover/increased mineralization/increased resorption. The clinical course is as follows: treatment, parathyroidectomy (histology, 4.2 g adenoma).


Figure 11
View larger version (122K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		Figure 11. Bone biopsies. (Top left panel) von Kossa hematoxylin and eosin stain for calcium; shows enlarged cortical Haversian canals and prominent osteoid. (Top right panel) von Kossa hematoxylin and eosin for calcium; shows tunneling bone resorption and abundant osteoid. (Bottom left and right panels) von Kossa hematoxylin and eosin stain, fluorescence for osteoid; shows Haversian systems and bone surfaces covered by tetracycline.

 

Figure 13
View larger version (148K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		Figure 13. Bone biopsies. Both are unstained, fluorescence for tetracycline; show abundant tetracycline. This is all active bone remodeling.

 
Comment:  This stage 4 CKD patient had fractures, very low BMD, hypercalcemia after vitamin D replacement, and moderately elevated PTH and bone alkaline phosphatase. The bone biopsy was striking for severe high bone turnover with tunneling bone resorption, which is consistent with hyperparathyroidism. This might have been either severe secondary or primary hyperparathyroidism, but the severity of the clinical course (fractures) and much lower forearm BMD (often seen in primary hyperparathyroidism) and exceptional bone histology made the suspicion of primary hyperparathyroidism stronger; indeed, at neck exploration, only a single large adenoma was discovered with 3 other normal parathyroid glands. Postoperatively, her elevated PTH, BSAP, and serum calcium all returned to normal.

Case 6
This 45-yr-old white woman with stage 4 CKD (creatinine clearance, 28 ml/min) resulting from polycystic kidney disease was postmenopausal and on hormonal replacement therapy. She has had 3 fragility fractures in the past year of her tibia, forearm, and ankle. Her laboratory data are as follows: BMD (T-score), –1.4 at hip and –1.6 at spine (WHO classification, osteopenia); serum calcium, 9.6 mg/dl; serum phosphorus, 4.1 mg/dl; serum PTH, 86 pg/ml (elevated); serum 25 hydroxyvitamin D, 38 ng/ml; serum 1,25 dihdroxyvitamin D, 30 ng/ml; and serum BSAP, 16 IU/ml. Bone biopsy is shown in Figures 14 and 15. Diagnosis is low bone turnover/ low mineralization, unknown etiology.


Figure 14
View larger version (119K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		Figure 14. Bone biopsies. (Top left and right panels) von Kossa hematoxylin and eosin for calcium; shows normal trabecular number (left) but very little osteoid (right). (Bottom panels on left) Flat bone lining cells. (Bottom panel on right) Flat lining cells (inactive) and little bone resorption.

 

Figure 15
View larger version (98K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		Figure 15. Bone biopsies. (Top 2 panels) Very few osteoblasts or osteoclasts. (Panels 3 and 4) Very few bone lining cells and little osteoid (matrix). (Panels 5 and 6) Very thin osteoid (left) and no aluminum (right). (Bottom 2 panels) Few tetracycline labels. This is all characteristic of adynamic bone disease.

 
The clinical course is as follows: treatment with teriparatide; 1-yr posttreatment spine BMD increased to 0.089 g/cm2 (significant increase); currently in second year of treatment; and no incident fractures.

Comment:  This patient has stage 4 CKD and fragility fractures despite being on hormonal replacement therapy. She had a mild secondary hyperparathyroidism, but bone biopsy showed a very low bone turnover with no single labels of tetracycline. This is the histomorphometric picture of adynamic bone disease of unknown etiology. Because she had fractures, she was treated with the anabolic agent teriparatide and her BMD increased; she has had no further fractures. She will be rebiopsied after her 2-yr therapeutic course of teriparatide. Without biopsy, she could have been treated with a bisphosphonate, which would have been a theoretical incorrect management choice because she had nearly no bone turnover to start with.


   Conclusion
Top
 Abstract
 Introduction
 How "Osteoporosis" Is Diagnosed...
 Case Reports
 Conclusion
Disclosures
 References
 
These cases demonstrate the value of quantitative bone histomorphometry in making management decisions in the CKD population. Although bone biopsy is invasive, it is a nearly painless procedure with very low morbidity when performed in trained operators. Physicians caring for these complex patients where clinical and biochemical evaluation make a distinct diagnosis need to consider bone histomorphometry before making management decisions in these high-risk for fracture patients.


   Disclosures
Top
 Abstract
 Introduction
 How "Osteoporosis" Is Diagnosed...
 Case Reports
 Conclusion
 Disclosures
References
 
None.


Figure 2
View larger version (99K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		Figure 2. Bone biopsies. Both are stained with tartrate-resistant acid phosphatase (TRAP) for osteoclasts. (Left panel) Original magnification x100; shows no osteoclasts. (Right panel) Original magnification x400; shows very few osteoclasts in Howship's lacunae.

 

Figure 3
View larger version (88K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		Figure 3. Bone biopsies. Both are stained with solochrome azurine for aluminum. (Left panel) Original magnification x250. (Right panel) Original magnification x400. Both panels show abundant aluminum on osteoid.

 

Figure 12
View larger version (131K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		Figure 12. Bone biopsies. (Left panel) von Kossa hematoxylin and eosin for calcium; shows active bone formation and resorption. (Right panel) TRAP stain for osteoclasts and osteoblasts; shows abundant osteoblasts and osteoclasts.

 

   References
Top
 Abstract
 Introduction
 How "Osteoporosis" Is Diagnosed...
 Case Reports
 Conclusion
 Disclosures
 References
 
  1. Goodman WG, Coburn JW, Slatopolsky E, Salusky I: Renal osteodystrophy in adults and children. In: Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism, 4th ed, edited by Favus MJ, Philadelphia, Lippincott-Raven,1999 , pp347 –363
  2. Hruska KA, Teitelbaum SL: Renal osteodystrophy. N Engl J Med333 :166 –167,1995[Free Full Text]
  3. Andress DL, Sherrard DJ: The osteodystrophy of chronic renal failure. In: Diseases of the Kidney and Urinary Tract, 7th ed, edited by Schrier RW, Philadelphia, Lippincott, Williams & Wilkins,2003 , pp224 –236
  4. Sherrard DJ, Hercz G, Pei Y, Maloney NA, Greenwood C, Manuel A, Saiphoo C, Fenton SS, Segre GV: The spectrum of bone disease in end-stage renal failure: an evolving disorder. Kidney Int43 :436 –442,1993[Medline]
  5. Parfitt AM, Drezner MK, Glorieux FH, Kanis JA, Malluche H, Meunier PJ, Ott SM, Recker RR: Bone histomorphometry: standardization of nomenclature, symbols, and units. Report of the ASBMR Histomorphometry Nomenclature Committee. J Bone Miner Res2 :595 –610,1987[Medline]
  6. Massry SG, Coburn JW: K/DOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease. Am J Kidney Dis42 [Suppl 3]:S10 –S135,2003
  7. Moe S, Drueke T, Cunningham J, Goodman W, Martin K, Olgaard K, Ott S, Sprague S, Lameire N, Eknoyan G: Definition, evaluation, and classification of renal osteodystrophy: a position statement from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int69 :1945 –1953,2006[CrossRef][Medline]
  8. Moe SM: Vascular calcification and renal osteodystrophy relationship in chronic kidney disease. Eur J Clin Invest36 [Suppl 2]:51 –62,2006[CrossRef][Medline]
  9. Moe SM, Chen NX: Pathophysiology of vascular calcification in chronic kidney disease. Circ Res95 :560 –567,2004[Abstract/Free Full Text]
  10. London GM, Marty C, Marchais SJ, Guerin AP, Metivier F, de Vernejoul MC: Arterial calcifications and bone histomorphometry in end-stage renal disease. J Am Soc Nephrol15 :1943 –1951,2004[Abstract/Free Full Text]
  11. Martin KJ, Olgaard K, Coburn JW, Coen GM, Fukagawa M, Langman C, Malluche HH, McCarthy JT, Massry SG, Mehls O, Salusky IB, Silver JM, Smogorzewski MT, Slatapolsky EM, McCann L: Bone Turnover Working Group: diagnosis, assessment, and treatment of bone turnover abnormalities in renal osteodystrophy. Am J Kidney Dis43 :558 –565,2004[CrossRef][Medline]
  12. Miller PD, Huffer W: Renal osteodystrophy. In: Essential Atlas of Nephrology and Hypertension, 2nd ed, edited by Schrier RW, San Diego, Academic Press,2005 , pp261 –276
  13. Malluche HH, Langub MC, Monier-Fuagere MC: The role of bone biopsy in clinical practice and research. Kidney Int73 [Suppl 73]:S20 –S25,1999[CrossRef]
  14. Ferreira MA: Diagnosis of renal osteodystrophy. When and how to use biochemical markers and non-invasive methods: when bone biopsy is needed. Nephrol Dial Transplant15 [Suppl 5]:8 –14,2000[Free Full Text]
  15. Elder G: Pathophysiology and recent advances in the management of renal osteodystrophy. Osteoporos Int17 :2094 –2105,2002
  16. Ritz E, Schomig M, Bommer J: Osteodystrophy in the millennium. Kidney Int56 [Suppl 73]:S94 –S98,1999[CrossRef]
  17. Wang M, Hercz G, Sherrard D, Maloney NA, Segre GV, Pei Y: Relationship between intact 1–84 parathyroid hormone levels and bone histomorphometric parameters in dialysis patients without aluminum toxicity. Am J Kidney Dis26 :836 –844,1995[Medline]
  18. Gerakis A, Hutchison AJ, Apostolou T, Freemont AJ, Billis A: Biochemical markers for non-invasive diagnosis of hyperparathyroid bone disease and adynamic bone in patients on haemodialysis. Nephrol Dial Transplant11 :2430 –2438,1996[Abstract/Free Full Text]
  19. Quarles LD, Lobaugh B, Murphy G: Intact parathyroid hormone over-estimates the prevalence and severity of parathyroid hormone-mediated osseous abnormalities in uremia. J Clin Endocrinol Metab75 :145 ,1992[Abstract]
  20. Malluche HH, Maward H, Trueba D, Monier-Faugere MC: Parathyroid hormone assays: evolution and revolutions in the care of dialysis patients. Clin Nephrol59 :313 –318,2003[Medline]
  21. Andress DL: Vitamin D treatment in chronic kidney disease. Semin Dial18 :315 –321,2005[CrossRef][Medline]
  22. Chandra P, Binongo JN, Ziegler TR, Schlanger LE, Wang W, Someren JT, Tangpricha V: Cholecalciferol (vitamin D3) therapy and vitamin D insufficient in patients with chronic kidney disease: a randomized controlled pilot study. Endocr Pract14 :10 –17,2008[Medline]
  23. Malluche HH: Aluminum and bone disease in chronic renal failure. Nephrol Dial Transplant17 [Suppl 2]:21 –24,2002[Abstract]
  24. Cunningham J: The management of secondary hyperparathyroidism. Ann Endocrinol67 :176 –179,2006[Medline]
  25. Moe SM, Chertow GM, Coburn JW, Quarles LD, Goodman WG, Block GA, Drüeke TB, Cunningham J, Sherrard DJ, McCary LC, Olson KA, Turner SA, Martin KJ: Achieving NKF-K/DOQI bone metabolism and disease treatment goals with cinacalcet HCl. Kidney Int67 :760 –771,2005[CrossRef][Medline]
  26. Coburn JW, Maung HM, Elangovan L, Germain MJ, Lindberg JS, Sprague SM, Williams ME, Bishop CW: Doxercalciferol safely suppresses PTH levels in patients with secondary hyperparathyroidism associated with chronic kidney disease stages 3 and 4. Am J Kidney Dis43 :877 –890,2004[CrossRef][Medline]
  27. Zisman AL, Ghantous W, Schinleber P, Roberts L, Sprague SM: Inhibition of parathyroid hormone: a dose equivalency study of paricalcitol and doxercalciferol. Am J Nephrol25 :591 –595,2005[CrossRef][Medline]
  28. Coyne D, Acharya M, Qui P, Abboud H, Battle D, Rosansky S, Fadem S, Levine B, Williams L, Andress DL, Sprague SM: Paricalcitol capsule for the treatment of secondary hyperparathyroidism in stages 3 and 4 CKD. Am J Kidney Dis47 :263 –276,2006[CrossRef][Medline]
  29. Cunningham J: New vitamin D analogs for osteodystrophy in chronic kidney disease. Pediatr Nephrol19 :705 –708,2004[CrossRef][Medline]
  30. Moe SM, Cunningham J, Bommer J, Adler S, Rosansky SJ, Urena-Torres P, Albizem MB, Guo MD, Zani VJ, Goodman WG, Sprague SM: Long-term treatment of secondary hyperparathyroidism with the calcimimetic cinacalcet HCl. Nephrol Dial Transplant20 :2186 –2193,2005[Abstract/Free Full Text]
  31. Block GA, Martin KJ, de Francisco AL, Turner SA, Avram MM, Suranyi MG, Hercz G, Cunningham J, Abu-Alfa AK, Messa P, Coyne DW, Locatelli F, Cohen RM, Evenepoel P, Moe SM, Fournier A, Braun J, McCary LC, Zani VJ, Olson KA, Drueke TB, Goodman WG: Cinacalcet for secondary hyperparathyroidism in patients receiving hemodialysis. N Engl J Med350 :1516 –1525,2004[Abstract/Free Full Text]
  32. Gal-Moscovici A, Sprague SM: The role of calcimimetics in chronic kidney disease. Kidney Int104 [Suppl]:S68 –S72,2006
  33. Malluche HH, Monier-Faugere MC, Wang G, Fraza OJM, Charytan C, Coburn JW, Coyne DW, Kaplan MR, Baker N, McCary LC, Turner SA, Goodman WG: An assessment of cinacalcet HCL on bone histology in dialysis patients with secondary hyperparathyroidism. Clin Nephrol69 :269 –278,2008[Medline]
  34. Salusky IB, Goodman WG: Reversible and non-reversible adynamic renal bone disease. J Am Soc Nephrol12 :1978 –1985,2001[Free Full Text]
  35. Torres PU, Canaud B: How to slow down parathyroid hormone (PTH) secretion without the risk of inducing an adynamic bone disease. Nephrol Ther1 [Suppl]:S337 –S341,2005[Medline]
  36. Spasovski G, Gelev S, Masin-Spasovska JM, Selim G, Sikole A, Vanholder R: Improvement in bone and mineral parameters related to adynamic bone disease by diminishing dialysate calcium. Bone41 :698 –703,2007[CrossRef][Medline]
  37. Parfitt AM: Renal bone disease: a new conceptual framework for the interpretation of bone histomorphometry. Curr Opin Nephrol Hypertens12 :387 –403,2003[CrossRef][Medline]
  38. Pecovnik BB, Bren A: Bone histomorphometry is still the gold standard for diagnosing renal osteodystrophy. Clin Nephrol54 :463 –469,2000[Medline]
  39. Trueba D, Sawaya BP, Mawad H, Malluche HH: Bone biopsy: indications, techniques, and complications. Semin Dial16 :341 –345,2003[CrossRef][Medline]
  40. Miller PD, Lerma EV. Renal bone diseases. In: The Bone and Mineral Manual: A Practical Guide, 2nd ed, edited by Kleerekoper M, Siris E, McClung M, Burlington, MA, Elsevier,2005
  41. Miller PD, Shane E. Management of transplantation renal bone disease: interplay of bone mineral density and decisions regarding bisphosphonate use. In: Medical Management of Kidney Transplantation, edited by Weir MR, Philadelphia: Lippincott, Williams & Wilkins,2004 , pp359 –375
  42. Lindberg JS, Moe SM: Osteoporosis in end-stage renal disease. Semin Nephrol19 :115 –122,1999[Medline]
  43. Cunningham J, Sprague SM, Cannata-Andia J, Coco M, Cohen-Solal M, Fitzpatrick L, Goltzmann D, Lafage-Proust MH, Leonard M, Ott S, Rodriguez M, Stehman-Breen C, Weisinger J: Osteoporosis Working Group, Osteoporosis in Chronic Kidney Disease. Am J Kidney Dis43 :566 –571,2004[CrossRef][Medline]
  44. Miller PD: Treatment of osteoporosis in chronic kidney disease and end-stage renal disease. Curr Osteoporos Rep3 :5 –12,2005[Medline]
  45. Gal-Moscovici, Sprague S. Osteoporosis and chronic kidney disease. Semin Dial2 :423 –430,2007
  46. Miller PD: Bisphosphonates for the prevention and treatment of corticosteroid-induced osteoporosis. Osteoporos Int3 [Suppl]:S3 –S10,2001
  47. Skagg KG, Emky R, Schnitzer TJ, Brown JP, Hawkins F, Goemaere S, Thamsborg G, Liberman UA, Delmas PD, Malice MP, Czachure M, Daifotis AG: Alendronate for the prevention of steroid-induced osteoporosis. N Engl J Med339 :292 –299,1998[Abstract/Free Full Text]
  48. Cohen S, Levy RM, Keller M, Boling E, Emkey RD, Greenwald M, Zizic TM, Wallach S, Sewell KL, Lukert BP, Axelrod DW, Chines AA: Risedronate therapy prevents corticosteroid-induced bone loss. Arthritis Rheum42 :2309 –2318,1999[CrossRef][Medline]
  49. Black DM, Cummings SR, Karpf DB, Cauley JA, Thompson DE, Nevitt MC, Bauer DC, Genant HK, Haskell WL, Marcus R, Ott SM, Torner JC, Quandt SA, Reiss TF, Ensrud KE: Randomized trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Lancet348 :1535 –1541,1996[CrossRef][Medline]
  50. Harris S, Watts N, Genant H, McKeever CD, Hangartner T, Keller M, Chesnut CH 3rd, Brown J, Eriksen EF, Hoseyni MS, Axelrod DW, Miller PD: Effects of risedronate treatment on vertebral and nonvertebral fractures in women with postmenopausal osteoporosis: a randomized controlled trial. JAMA282 :1344 –1352,1999[Abstract/Free Full Text]
  51. Reginster J-Y, Minne H, Sorensen OH, Hooper M, Roux C, Brandi ML, Lund B, Ethgen D, Pack S, Roumagnac I, Eastell R: Randomized trial of the effects of risedronate on vertebral fractures in women with established postmenopausal osteoporosis. Osteoporos Int11 :83 –91,2000[CrossRef][Medline]
  52. McClung MR, Geusens P, Miller PD, Zippel H, Bensen WG, Roux C, Adami S, Fogelman I, Diamond T, Eastell R, Meunier PJ, Reginster JY; Hip Intervention Program Study Group: effect of risedronate on the risk of hip fracture in elderly women. N Engl J Med344 :333 –340,2001[Abstract/Free Full Text]
  53. Sorensen OH, Crawford GM, Mulder H, Hosking DJ, Gennari C, Mellstrom D, Pack S, Wenderoth D, Cooper C, Reginster JY: Long-term efficacy of risedronate: a 5-year placebo-controlled clinical experience. Bone32 :120 –126,2003[CrossRef][Medline]
  54. Chesnut CH, Ettinger MP, Miller PD, Baylink D, Emkey R, Harris ST, Wasnich RD, Watts NB, Schimmer RC, Recker RR: Ibandronate produces significant, similar antifracture efficacy in North American and European women: new clinical findings from BONE. Curr Med Res Opin21 :391 –401,2005[CrossRef][Medline]
  55. Orwoll ES, Ettinger M, Weiss S, Miller P, Kendler D, Graham J, Adami S, Weber K, Lorenc R, Pietschmann P, Vandormael K, Lombardi A: Alendronate for the treatment of osteoporosis in men. N Engl J Med343 :604 –610,2000[Abstract/Free Full Text]
  56. Miller PD: Is there a role for bisphosphonates in chronic kidney disease? Semin Dial20 :191 –195,2007[CrossRef][Medline]
  57. Boonen S, Sellmeyer D, Lippuner K, Orlov-Morozov A, Abrams K, Messenbrink P, Eriksen EF, Miller PD. Renal safety of annual infusion of zolendronic acid in osteoporotic postmenopausal women. Kidney Int2008 May 28 [Epub ahead of print]
  58. Miller PD, Roux C, Boonen S, Barton IP, Dunlap LE, Burgio DE: Safety and efficacy of risedronate in patients with age-related reduced renal function as estimated by the Cockcroft and Gault Method: a pooled analysis of nine clinical trials. J Bone Miner Res20 :2015 –2115,2005
  59. Jamal SA, Bauer DC, Ensrud KE, Cauley JA, Hochberg M, Ishani A, Cummings SR: Alendronate treatment in women with normal to severely impaired renal function: an analysis of the Fracture Intervention Trial. J Bone Miner Res22 :503 –508,2007[CrossRef][Medline]
  60. Miller PD, Zapalowski C, Kulak CAM, Bilezikian JP: Bone densitometry: the best way to detect osteoporosis and to monitor therapy. J Clin Endocrinol Metab84 :1867 –1871,1999[Free Full Text]
  61. Miller PD, Bonnick SL: Clinical application of bone densitometry. In: Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism, 4th ed, edited by Favus M, Philadelphia, Lippincott, Williams & Wilkins,1999 , pp152 –159
  62. Miller PD, Leonard M: Clinical use of bone densitometry in children and adults for the assessment and management of osteoporosis. In: Primer in Metabolic Bone Disease, 6th ed, edited by Favus M, Philadelphia, Lippincott, Williams & Wilkins,2006 , pp150 –160
  63. WHO Study Group: Assessment of Fracture Risk and Its Application to Screening for Postmenopausal Osteoporosis, Geneva, World Health Organization,1994
  64. Kanis JA, Johnell O, Oden A, Dawson A, De Laet C, Jonsson B: Ten year probabilities of osteoporotic fractures according to BMD and diagnostic thresholds. Osteoporos Int12 :989 –995,2001[CrossRef][Medline]
  65. Chang KP, Center JR, Nguyen TV, Eisman JA: 2004 Incidence of hip and other osteoporotic fractures in elderly men and women: Dubbo Osteoporosis Epidemiology Study. J Bone Miner Res19 :532 –536,2004[CrossRef][Medline]
  66. Siris ES, Brenneman SK, Barrett-Connor E, Miller PD, Sajjan S, Berger ML, Chen YT: The effect of age and bone mineral density on the absolute, excess, and relative risk of fracture in postmenopausal women age 50–99: results from the National Osteoporosis Risk Assessment (NORA). Osteoporos Int17 :565 –574,2006[CrossRef][Medline]
  67. Klotzbuecher CM, Ross PD, Landsman PB, Abbott TA 3rd, Berger M: Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res15 :721 –739,2000[CrossRef][Medline]
  68. Kanis JA, Johnell O, De Laet C, Johansson H, Oden A, Delmas P, Eisman J, Fuliwara S, Garnero P, Kroger H, McCloskey EV, Mellstrom EV, Melton LJ III, Pols H, Reeve J, Silman A, Tenenhous A: A meta-analysis of previous fracture and subsequent fracture risk. Bone35 :375 –382,2004[CrossRef][Medline]
  69. Barrett-Conner E, Siris E, Miller PD, Sajjan S, Chen YT: Association of wrist fracture with subsequent hip, spine, rib, and wrist or forearm fractures in postmenopausal women: results from National Osteoporosis Risk Assessment (NORA). Osteoporos Int2007
  70. Miller PD, Barlas S, Brenneman SK, Abbott TA, Chen Y-T, Barrett-Connor E, Siris ES: An approach to identifying osteopenic women at increased short-term risk of fracture. Arch Intern Med164 :1113 –1120,2004[Abstract/Free Full Text]
  71. Atsumi K, Kushida K, Yamazaki K, Shimizu S, Ohmura A, Inoue T: Risk factors for vertebral fractures in renal osteodystrophy. Am J Kidney Dis33 :287 –293,1999[Medline]
  72. Gupta A, Kallenbach LR, Divine GW: Increased risk of hip fracture in U.S. Medicare end-stage renal disease patients. J Bone Miner Res12 [Suppl 1]:S274 ,1997
  73. Stehman-Breen CO, Sherrard DJ, Alem AM, Gillen DL, Heckbert SR, Wong CS, Ball A, Weiss NS: Risk factors for hip fracture among patients with end-stage renal disease. Kidney Int58 :2200 –2205,2000[CrossRef][Medline]
  74. Ball AM, Gillen DL, Sherrard D, Weiss NS, Emerson SS, Seliger SL, Kestenbaum BR, Stehman-Breen C: Risk of hip fracture among dialysis and renal transplant recipients. JAMA288 :3014 –3018,2002[Abstract/Free Full Text]
  75. Quarles LD, Lobaugh B, Murphy G: Intact parathyroid hormone over-estimates the prevalence and severity of parathyroid hormone-mediated osseous abnormalities in uremia. J Clin Endocrinol Metab75 :145 –150,1992[Abstract]
  76. Martin KJ, Gonzalez EA: Parathyroid hormone assay: problems and opportunities. Pediatr Nephrol22 :1651 –1654,2007[CrossRef][Medline]
  77. Andress DL, Coyne DW, Kalantar-Zadeh K, Molitich ME, Zangeneh F, Sprague SM: Management of secondary hyperparathyroidism in stages 3 and 4 chronic kidney disease. Endocr Pract14 :18 –27,2008[Medline]
  78. Ambrogini G, Cetani F, Cianferotti L, Vignali E, Viccica G, Oppo A, Miccoli P, Bilezikian JP, Marcocci C: Surgery or surveillance for mild asymptomatic primary hyperparathyroidism: a prospective, randomized clinical trial. J Clin Endocrinol Metab92 :3114 –3311,2007[Abstract/Free Full Text]
  79. Bilezikian JP. Bone strength in primary hyperparathyroidism Osteoporos Int14 [Suppl 5]:S113 –S115,2003[CrossRef][Medline]




This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Miller, P. D.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Miller, P. D.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS