P-025 A RAY OF HOPE FOR A FEARED COMPLICATION: TERIPARATIDE IN ADYNAMIC BONE DISEASE IN CHRONIC KIDNEY DISEASE

Abstract Introduction Adynamic bone disease is a form of renal osteodystrophy seen in patients with end-stage renal disease, especially following parathyroidectomy or prolonged exposure to active vitamin D analogues. Teriparatide is a potential treatment in such cases, although its use remains off-label in dialysis patients. Here we present a hemodialysis patient with adynamic bone disease and was successfully treated with teriparatide. Clinical Case A 75-year-old female patient had been on thrice-weekly hemodialysis since 2005 due to chronic kidney disease secondary to nephritis. In 2016, subtotal (3.5-gland) parathyroidectomy operation was performed for tertiary hyperparathyroidism. In August 2024, she presented with complaints of upper extremity weakness and neck pain without trauma. Cervical radiography showed a fracture at C5 with kyphotic deformity. (Figure-1) She was treated with C4–C5 discectomy followed by C5 corpectomy and decompression of the spinal cord was achieved. Following surgery, endocrinology consultation was requested. She had menopause at age 40. There was no history of other fractures, corticosteroid use, rheumatic disease. Her regular medications included sevelamer 800 mg three times daily, and she received paricalcitol 2 mcg once weekly before dialysis. On physical examination strength in the upper extremities was 3/5–4/5. A dialysis fistula was present in the left arm. Pulse 89/min regular, blood pressure 115/60 mmHg. Laboratory results showed; creatinine 3.4 mg/dL(0.51-0.95), eGFR 15.3 mL/min/1.73m2, WBC 5.820/µL(4000-10.000/µL), Hb 9g/dL(12-15), platelets 259,000/µL(150.000-400.00/µL), AST 15 U/L(8-35), ALT 12 U/L(7-35), ALP 81U/L(33-98), 25(OH) vitamin D 28.34 µg/L, calcium 10 mg/dL(8.5-10.5), phosphorus 1.7 mg/dL(2.5-4.5), parathormone 26 ng/L(12-88), TSH 2.818 mIU/L (0.38–5.3), free T4 2.45 ng/dL (0.58–1.38), beta-crosslaps 1.320 ng/mL (0.15–0.86) (Table 1). Bone mineral density showed: L1–L4 T-score –1.7 (BMD: 0.978), femoral neck T-score –2.9 (BMD: 0.631). Based on the history of parathyroidectomy, concomitant active vitamin D therapy, and biochemical profile, a diagnosis of adynamic bone disease with pathological fracture was made. Teriparatide therapy (20 mcg subcutaneously once daily) was initiated. Active vitamin D was discontinued, and calcium levels were monitored. At the third month of therapy, serum calcium fell below 8 mg/dL, and oral calcium supplementation (500 mg/day) was introduced. At the 6th and 12th months of therapy, improvement in T-scores and BMD values were observed (Table 2). Serum calcium levels were 9.2, 9.0, and 9.4 mg/dL at the 3rd, 6th, and 12th months, respectively. Hypercalcemia was not observed. Conclusion In a patient on hemodialysis and prior 3.5 parathyroidectomy with adynamic bone disease, treatment with teriparatide led to significant improvement in BMD within 12 months and was well tolerated without hypercalcemia. This case supports its role as a therapeutic option in carefully selected patients.Figure 1:C5 Fracture Table 1:Laboratory Results Table 2:Teriparatide effect on BMD