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Does Strict Phosphorus Control Precipitate Renal Osteomalacia^*

Chromalloy American Kidney Center and Renal Division at Washington University Medical Center and the Department of Pathology and Laboratory Medicine The Jewish Hospital at Washington University Medical Center St. Louis, Missouri 63110

Address requests for reprints to: James A. Delmez, M.D., Department of Medicine, Chromalloy American Kidney Center, Washington University School of Medicine, 4949 Barnes Hospital Plaza, St. Louis, Missouri 63110.

Hyperphosphatemia leads to the development of osteitis fibrosa in patients with chronic renal failure. In contrast, crippling osteomalacia may appear in uremic patients who are hypophosphatemic or aluminum intoxicated or who undergo total or subtotal parathyroidectomy. Thus, strict phosphorus control by use of aluminum-containing gels may ameliorate renal osteitis fibrosa, but may potentiate the development of osteomalacia. To evaluate this possibility, we compared the bone histologies of 10 chronic renal hemodialysis patients who consistently maintained predialysis phosphorus levels between 4–5 mg/dl (Strict-P) to those of 46 randomly selected dialysis patients (Random-P).

We found that the Strict-P group had lower circulating immunoreactive PTH (P <0.02) and alkaline phosphatase (P < 0.05) levels and, as expected, less evidence of hyperparathyroid bone disease. On the other hand, the Strict-P patients had osteomalacia, as evidenced by moderate osteoid accumulation and reduced capacity of bone to assume a fluorescent tetracycline label. Furthermore, all Strict-P patients had histological evidence of bone aluminum accumulation. We conclude that maintenance of normal serum P levels with aluminum-containing gels in hemodialysis patients prevents severe hyperparathyroid bone disease. Such treatment, however, is also attended by a moderate degree of aluminum-associated osteomalacia.

^* This work was supported in part by NIH Grants AM-09976, AM-11674, AM-07126, and RR-00036, the Shriners Hospital for Crippled Children (St. Louis Unit), and the Jewish Hospital Auxiliary.

Received February 20, 1985.