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Images in Nephrology
(Section Editor: G. H. Neild)
Back pain in chronic renal failure
Ravi Bansal and Suresh C. Tiwari
Department of Nephrology, All India Institute of Medical Sciences, New Delhi 110029, India
Keywords: back pain; chronic renal failure; fluorosis
Back pain in chronic renal failure
Patient SK, a 40-yr-old female, resident of Bhagalpur
village in Bihar, India, was operated for gallstones
3 years previously. On pre-operative checkup, mild
renal dysfunction was detected. She was asymptomatic
for renal disease with serum creatinine of 159 mmol/l
(1.8 mg/dl), bland urinary sediment and small echo-
genic kidneys on ultrasound. She was put
on conservative management for chronic renal failure
(CRF) and was doing well till 1 year ago. Since then
she developed back pain, which increased on walking.
Pain was dull in character without any radiation. There
were no systemic complaints. In the past month when
her pain increased substantially, causing discomfort in
day-to-day activities. On investigation she was found
to have moderate renal failure with blood urea
nitrogen (BUN) of 11.8 mmol/l and serum creatinine
of 309 mmol/l (3.5 mg/dl). Other labs showed serum
calcium of 2.4 mmol/l, phosphorus 1.1 mmol/l, alkaline
phosphatase 243 U/l, uric acid 381 mmol/l and intact
parathyroid hormone (iPTH) of 182.0 pg/ml. X-rays
of bilateral forearms, pelvis and spine were taken
(Figures 1–3, respectively), which revealed generalized
increase in bone density, degenerative changes
with osteophytes in lumber vertebra, calcification of
bilateral iliolumbar and sacrospinous ligaments and
interosseous membrane calcification in forearms.
Definitive diagnosis was reached with estimation of
fluoride levels in blood and urine, which were
0.291 mg/l and 0.962 mg/l (15.3 and 50.6 mmol/l),
respectively. Her drinking water source, ground water
from a tubewell, was found to contain 3.910 mg/l
(205.9 mmol/l) of fluoride. She was diagnosed to have
fluorosis with moderate CRF and was advised to use
domestic reverse-osmosis-treated water for cooking
and drinking.
Main sources of fluoride include food and water.
About 50–70% of fluoride is excreted by the kidneys
[1]. Individuals with kidney disease have decreased
ability to excrete fluoride in urine and are at risk of
developing fluorosis even at normal recommended
limit of 0.7 to 1.2 mg/l (37–63 mmol/l) of fluoride in
drinking water [2]. In fluorosis with normal renal
function, urine fluoride rises above 0.5–4.48 mg/l
(26–236 mmol/l) and may reach 1.5–13.0 mg/l
(79–685 mmol/l) [3]. Serum fluoride rises to
0.04–0.28 mg/l (2.1–14.7 mmol/l) in such patients [1].
Fluoride is bone-seeking due to its high affinity for
calcium phosphate and therefore accumulates in bone.
Radiological changes can be quite similar to changes
of renal osteodystrophy, and therefore the diagnosis
may be missed unless specifically investigated.
Conflict of interest statement. None declared.
Correspondence and offprint requests to: Dr Ravi Bansal, Senior
Research Associate, Department of Nephrology, AIIMS,
New Delhi 110029, India. Email: dr_ravibansal@yahoo.com
Fig. 1. Plain film of both forearms showing interosseous membrane
calcification.
Nephrol Dial Transplant (2006) 21: 2331–2332
doi:10.1093/ndt/gfl254
Advance Access publication 23 May 2006
ßThe Author [2006]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.
For Permissions, please email: journals.permissions@oxfordjournals.org
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References
1. Reddy DR, Deme SR, Fluorosis . In: Chopra JS, Sawhney IMS
eds. Neurology in Tropics, B.I. Churchill Livingstone, New Delhi,
India: 1999; 82–92
2. Arnala I, Alhava EM, Kauranen P. Effects of fluoride on bone in
Finland. Histomorphometry of cadaver bone from low and high
fluoride areas. Acta Orthop Scand 1985; 56: 161–166
3. Sesikaran B, Rao SM, Krishnamurti D, Reddy DR. Studies in
sural nerve biopsies in endemic skeletal fluorosis. Fluride 1994; 27:
189–193
Received for publication: 6.3.06
Accepted in revised form: 10.4.06
Fig. 2. Plain film of pelvis showing calcification of bilateral
iliolumbar (black arrow) and sacrospinous ligaments (white arrow).
Fig. 3. Plain film lateral view of lumbar spine showing increase
in bone density with osteophytes.
2332 R. Bansal and S. C. Tiwari
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