Destructive spondyloarthropathy and radiographic follow-up in hemodialysis patients

Radiographic changes of cervical destructive spondyloarthropathy in long-term hemodialysis patients: A 9-year longitudinal observational study

Analyses of radiographic changes and clinical symptom of destructive spondyloarthropathy (DSA) on consecutive 42 patients managed with long-term hemodialysis were performed to elucidate radiographic changes of DSA and the factors that influence to the destructive changes. Patients underwent plain radiographs of the cervical spine with 9 years interval. Grading of radiological feature from lateral view was classified into grade 0 to grade 3. Clinical symptom was evaluated using modified Japanese Orthopaedic Association scoring system for cervical myelopathy (mJOA score). Destructive changes were observed in 3 patients at the first examination, and those were observed in 15 patients 9 years after the first examination. There is no statistically significant difference between the duration of hemodialysis and the grade. The mean age at the onset of hemodialysis, however, was significantly higher in patients of grade 2 and 3 than those of grade 1. Older patients with long-term hemodialysis had destructive changes. Destructive changes commonly observed in lower cervical spine. The average numbers of the involved disc level were 1.6 in grade 2 and 1.0 in grade 3. Clinical symptoms were varied in each grade and there was no statistically significant difference in total mJOA score among these grades. J. Med. Invest. 64: 68-73, February, 2017.

Imaging in dialysis spondyloarthropathy

Destructive spondyloarthropathy has recently been described in patients who undergo maintenance hemodialysis for chronic renal disease. The condition most frequently involves the lower segment of the cervical spine, although the craniocervical junction also may be affected. Although the pathogenesis of destructive spondyloarthropathy remains unclear, the disorder is thought to relate to a hemodialysis-associated amyloidosis. It appears that the disease correlates with the duration of hemodialysis, although it has been reported in patients with chronic renal insufficiency not associated with hemodialysis. Radiographic features simulate those of an infectious process, encompassing a range of abnormalities from superficial erosions to large bony defects. Computed tomography (CT) images reveal osteolytic areas, with bone sclerosis of adjacent vertebral endplates, and minimal osteophytosis. The intervertebral spaces appear narrow or obliterated. On magnetic resonance imaging (MRI), the disorder may show the imaging characteristics of spondylodiskitis. The absence of high signal intensity on T2-weighted images generally helps to eliminate the diagnosis of an infection. With progression of the disease, collapse of a vertebral body and spinal instability may occur. Severe complications of destructive spondyloarthropathy in long-term dialysis patients may include spinal cord compromise, necessitating surgical decompression, with or without spinal stabilization.

Dialysis bone disease

The bone disease associated with end-stage renal failure (ESRD) and treatment are complex and multifactorial, and has changed in both clinical and imaging features over the past three decades. Whereas previously features of vitamin D deficiency (rickets/osteomalacia) and intense, and prolonged, secondary hyperparathyroidism (bone resorption, osteosclerosis, metastatic calcification) predominated, these features are now rarely evident radiologically. This has occurred through the better understanding of vitamin D metabolism and improvements in therapeutic management. However, metastatic calcification in soft tissues and 'adynamic" bone continue to be problematic. New complications have developed as a consequence of treatment (dialysis and transplantation), including amyloid deposition, noninfective sponyloarthropathy, osteonecrosis, and osteopenia/osteoporosis). Radiographs remain the most widely used imaging technique in examining for skeletal disease in patients with ESRD on maintenance dialysis. Occasionally, more sophisticated imaging (CT, MRI, nuclear medicine scanning) are helpful (parathyroid tumor localization, differentiation between infection and amyloid deposition). Developments in quantitative methods to assess bone density enable the effects of ESRD and treatment to be studied and monitored. Technical developments in computed tomography (rapid, multislice scanning) allow quantitation and monitoring of metastatic cardiac calcification in patients on hemodialysis, which has relevance to prognosis.

Imaging techniques in the diagnosis of dialysis-related amyloidosis

beta(2)-microglobulin amyloidosis (A beta(2)M) is a major determinant of morbidity in patients on dialysis treatment. Symptoms of A beta(2)M amyloid are mainly related to (peri-)articular amyloid deposition. Imaging techniques [i.e., joint ultrasonography, X-ray, computed tomography (CT), or magnetic resonance imaging (MRI) findings], as well as conventional bone scans, are helpful in the screening of local lesions but are relatively nonspecific and/or not sensitive enough. Scintigraphic techniques using radiolabeled serum amyloid P component (SAP) or the radiolabeled A beta(2)M precursor protein, beta(2)M, generate more specific results. A beta(2)M deposits have been visualized in several long-term hemodialysis patients by using (123)I-labeled SAP. However, this scan did not show tracer accumulation in some frequently involved sites such as hips or shoulders, and frequently labeled the spleen, which is usually spared from A beta(2)M deposits. Improvements in technical sensitivity and specificity could be achieved by scanning with (131)I-labeled beta(2)M: this technique detected tracer accumulations corresponding to the typical distribution pattern of A beta(2)M. Further, both the radiation exposure and the optical resolution of this latter scan have been refined by substituting (111)In for (131)I. In a final step we generated recombinant human beta(2)M (rh beta(2)M). While (111)In rh beta(2)M again failed to show significant tracer accumulation over joint regions in patients on short-term hemodialysis without evidence of A beta(2)M, local tracer accumulations similar to those observed with natural, (111)In-labeled beta(2)M could be demonstrated in long-term hemodialysis patients with evidence of A beta(2)M. In conclusion, scintigraphy for A beta(2)M with (111)In-labeled rh beta(2)M provides a homogeneous and safe recombinant protein source and represents a suitable detection method of beta(2)M amyloid deposits in dialysis patients.

Osteoarticular disorders of renal origin: disease-related and iatrogenic

Osteoarticular disorders significantly limit the quality of long-term survival with chronic renal failure. beta 2M amyloidosis is a complication of chronic renal failure that has been recognized mostly in patients receiving long-term haemodialysis. Patients with beta 2M amyloidosis typically present with the triad of shoulder periarthritis, carpal tunnel syndrome, and flexor tenosynovitis of the hands. Other musculoskeletal manifestations of beta 2M amyloidosis include destructive spondyloarthropathy, cervico-occipital pseudotumours, bone cysts, and pathological fractures. At present, only renal transplantation may slow or halt the progession of beta 2M amyloidosis. Crystal-induced arthropathy, most commonly caused by basic calcium phosphate crystals, is an important cause of acute joint inflammation in the patient with renal failure. The incidence of bone and joint infection is increased in patients undergoing dialysis. Haemodialysis and peritoneal dialysis are also associated with an erosive or destructive arthropathy of finger joints, which is not explained by local amyloid deposition.

Amyloid destructive spondyloarthropathy causing cord compression: related to chronic renal failure and dialysis

Destructive spondyloarthropathy is a recently recognized disease that has not been reported in the neurosurgical literature. It is associated with spinal amyloid deposition in long-term renal failure and dialysis, and it occurs increasingly as the number of dialysis patients and their survival times increase. Clinically, there is a multisegmental and often rapidly progressive radiculomyelopathy that may require emergency stabilization. The radiological features are disc space narrowing with erosion of vertebral end plates and subarticular cysts. The pathological features include deposition of amyloid, which stains with Congo Red and antibodies to beta-2-microglobulin. We present two cases with clinical, radiological, and pathological features and a review of the literature.

Erosive spondyloarthropathy in primary hyperparathyroidism without renal failure

A patient with erosive spondyloarthropathy (ESA) and primary hyperparathyroidism is described. In the past, ESA has been described exclusively in patients with chronic renal failure (CRF) and has been attributed to crystal deposition, amyloidosis, severe secondary hyperparathyroidism, or other abnormalities of chronic renal failure. This patient with normal renal function suggests that secondary hyperparathyroidism plays the major pathogenetic role in ESA in patients with renal failure.

Some commonly unrecognized manifestations of metabolic arthropathies

The metabolic arthropathies are characterized by the deposition of abnormal substances in or around joints. Certain features of some of these arthropathies and their significance have only recently been recognized and others have been insufficiently emphasized. An important group of conditions are the arthropathies related to renal failure and its treatment, namely, aluminum toxicity, periarticular calcification and crystal deposition, hyperparathyroidism, and dialysis-related amyloidosis. Crystal deposition diseases, specifically, gouty arthritis, calcium pyrophosphate deposition, and calcium hydroxyapatite deposition, are also reviewed.

Fatal destructive cervical spondyloarthropathy in two patients on long-term dialysis

Two patients with fatal cervical cord compressive myelopathy are described, both of whom had been on dialysis for more than 15 years. Destructive changes were noted in mid and upper cervical regions, with soft tissue mass in the atlanto-occipital region in one patient. Clinical and radiographic findings suggest both amyloid and hyperparathyroidism as possible etiologies for these destructive spinal changes. Clinicians should be aware that the full picture of quadriparesis may be associated with destructive spondyloarthropathy (DSA) in long-term dialysis patients.