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Right: multiple osteolytic/mixed excrescent lesions in the upper jaw.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Secondary hyperparathyroidism (SHPT) is a common complication of chronic kidney disease (CKD). Two types of renal bone disease resulting from SHPT are described: high remodelling disease, called osteitis fibrosa, and low remodelling disease, represented by osteomalacia.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Severe brown tumour-type lesions of osteitis fibrosa are currently rare, as attempts are made to correct phosphorus and calcium abnormalities in early stages. However, factors such as non-compliance with treatment can lead to serious bone manifestations in patients with poorly controlled SHPT.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The occurrence of brown tumours with multiple bone involvement is considered uncommon with an incidence of 1.5%–1.7% in patients with CKD, predominantly young women. They are the result of a bone destructive process, an expression of severe osteitis fibrosa cystica.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">It manifests as a uni- or multi- focal lesion, predominantly affecting ribs and pelvis, with the lower jaw being the most common craniofacial involvement. Maxillary involvement is rarer, as well as involvement of the base of the skull (orbit and sinuses) or spine. Other affected bones include femur, tibia, humerus, clavicle and scapula. Multiple myeloma, carcinoma metastases, osteosarcomas, giant cell tumours, histiocytosis or osteomyelitis (when the lesions are more localised) should be present in our differential diagnosis.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Treatment of SHPT is the first step in controlling this disorder. Restoring parathormone (PTH) levels with medical treatment or parathyroidectomy may cause the tumour(s) to resolve with gradual mineralisation status recovery. Surgical approach to the mass is indicated when it causes symptoms requiring decompression.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">This case has a high-remodelling renal bone disease complication, such as a brown tumour in an unusual location, such as the maxilla or the spine. We report the case of a 30-year-old woman with end-stage CKD after pre-eclampsia in her last pregnancy, on haemodialysis for 8 years. She was originally from Honduras, where she underwent a parathyroidectomy in 2021 for poorly controlled severe hyperparathyroidism. She had been living in Spain for 8 months. The patient was taking calcium carbonate 2.5 g and cholecalciferol 800 IU every 24 h as home treatment.</p><p id="par0035" class="elsevierStylePara elsevierViewall">She presented with dyspnoea that did not improve with dialysis. A chest X-ray was performed where a right unilateral pleural effusion was observed, which was drained and a brownish liquid was obtained. A chest-abdominal CT scan showed multiple mixed lesions, some osteolytic, others with osteosclerosis, distributed throughout the thoracic cage, compatible with brown tumours secondary to SHPT. In some areas there were fracture lines with callus formation. Lesions in the lumbosacral spine and pelvis were observed at the abdominal level, compatible with brown tumours.</p><p id="par0040" class="elsevierStylePara elsevierViewall">A scintigraphic study was requested to rule out other aetiologies, reporting extensive bone involvement with a superscan pattern of metabolic origin in the context of SHPT (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The examination revealed a palatal tumour of 2 years' progression, initially painful, which after parathyroid surgery was asymptomatic. A CT scan of the face showed multiple osteolytic/mixed lesions in the cranial vault, mandible and clivus, as well as other expansive and excrescent lesions in the upper jaw, dependent on the floor of the palate and ethmoid bone (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><p id="par0050" class="elsevierStylePara elsevierViewall">The laboratory parameters were: urea 95 mg/dl (17−43 mg/dl), creatinine 8.52 mg/dl (0.51−0.95 mg/dl), total protein 6.8 g/dl (6.6–8.3 g/dl), albumin 4.3 g/dl (3.5–5.2 g/dl), sodium 138 mEq/l (136–146 mEq/l), potassium 4,8 mEq/l (3.5–5.1 mEq/l), calcium 7.3 mg/dl (8.8–10.6 mg/dl), phosphorus 2.4 mg/dl (2.3–4.5 mg/dl), PTH 139 pg/ml (12–88 pg/ml), CRP 11.9 mg/l (0−5 mg/l) and haemoglobin 9.4 g/dl (12–15.6 g/dl).</p><p id="par0055" class="elsevierStylePara elsevierViewall">This case illustrates an aggressive complication of SHPT such as severe osteitis fibrosa cystica in haemodialysis patients. It is interesting because very few cases of multiple brown tumours in the same patient have been reported and because the sites of the tumours are so unusual.</p><p id="par0060" class="elsevierStylePara elsevierViewall">To encounter such lesions in our current medical practice is very rare. The prevalence of different types of renal bone disease is considerably different between developed and developing countries, which is related to suboptimal phosphorus treatment together with difficult access to haemodialysis in a context of limited resources.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> For young nephrologists it may be a neglected disease in times where medical treatment of SHPT has improved and much experience has been gained with surgical parathyroidectomy in cases of SHPT refractory to medical treatment.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">CKD-related bone and mineral disease is a global challenge in haemodialysis patients. This clinical entity should not be overlooked, as on many occasions the clinical and biological manifestations are non-specific. We must also increase our alertness and suspect its presence in patients from resource-constrained settings in order to anticipate the diagnosis, preventing its progression, complications and sequelae.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethical considerations</span><p id="par0070" class="elsevierStylePara elsevierViewall">Informed consents were not required as no patient data appear in the manuscript.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0075" class="elsevierStylePara elsevierViewall">No funding was required for this paper.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Ethical considerations" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Funding" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1428 "Ancho" => 2508 "Tamanyo" => 238923 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Left: extensive bone involvement with superscan pattern of metabolic origin in scintigraphy, in the context of SHPT. Right: multiple osteolytic/mixed excrescent lesions in the upper jaw.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Múltiples tumores pardos en una paciente en hemodiálisis con hiperparatiroidismo secundario grave" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "R. Peces" 1 => "F. Gil" 2 => "F. González" 3 => "P. Ablanedo" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Nefrología." 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Journal Information
Vol. 161. Issue 9.
Pages 409-410 (November 2023)
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Vol. 161. Issue 9.
Pages 409-410 (November 2023)
Letter to the Editor
Multiple brown tumors in a patient on hemodialysis
Múltiples tumores pardos en una paciente en tratamiento con hemodiálisis
Elena Hernández García
, Ana Delgado Ureña, Miriam Barrales Iglesias
Corresponding author
Servicio de Nefrología, Hospital Universitario Clínico San Cecilio, Granada, Spain
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