tetracycline and Osteomalacia

Histomorphometry or quantitative histology is the analysis on histologic sections of bone resorption, formation and structure parameters. It is the only technique allowing a dynamic evaluation of osteoblast activity after labelling with tetracycline. In addition, the use of computed image analyzer allows the possibility to assess bone microarchitecture. Histomorphometric bone biopsy is a reliable and well-tolerated procedure. Bone samples are taken at iliac crest level under local anesthesia and sedation. Samples are put into methyl-metacrilate resin where the sections are prepared for the microscopic analysis of different histomorphometric parameters. Histomorphometry is used to exclude or confirm the diagnosis of osteomalacia and also to evaluate bone damage associated with particular treatments (for example, glucocorticoids, anticonvulsants) or in case of rare bone diseases (osteogenesis imperfecta). Recently, this approach has been repurposed for the evaluation of bone disease during Chronic Kidney Disease, particularly to differentiate high and low bone turnover osteodystrophy. Kidney Disease Improving Global Outcomes (KDIGO) guidelines have pointed out the situations requiring bone biopsy for histomorphometric analysis. New techniques using molecular biology will improve the accuracy and predictive value of this approach.

Topics: Biopsy; Bone and Bones; Bone Resorption; Chronic Kidney Disease-Mineral and Bone Disorder; Forecasting; Fractures, Spontaneous; Humans; Image Processing, Computer-Assisted; Mesenchymal Stem Cells; Osteoblasts; Osteomalacia; Practice Guidelines as Topic; Renal Dialysis; Renal Insufficiency, Chronic; Tetracycline

Topics: Bone and Bones; Calcifediol; Chronic Kidney Disease-Mineral and Bone Disorder; Humans; Hyperparathyroidism; Kidney Failure, Chronic; Osteoclasts; Osteomalacia; Tetracycline; Uremia

Topics: Absorptiometry, Photon; Adult; Aged; Aging; Bone Diseases; Bone Resorption; Calcium; Child; Estrogens; Female; Humans; Hydroxyproline; Hyperparathyroidism; Joint Diseases; Male; Microradiography; Middle Aged; Osteitis Deformans; Osteomalacia; Osteoporosis; Parathyroid Glands; Physical Therapy Modalities; Spine; Tetracycline

A histological evaluation of biopsies obtained from presumed osteoporotic vertebral compression fractures (VCF) to confirm possible osteomalacia after tetracycline labeling.. To describe the results of a series of biopsies obtained at the time of vertebral augmentation in presumed osteoporotic VCF, with special reference to the presence of unmineralized bone (osteomalacia) and occult or unconfirmed plasma cell dyscrasia.. Vertebral augmentation is now widely performed as a method to treat osteoporotic or osteolytic VCF. However, the influence of underlying pathology on the effect of treatment is unclear.. As of October 2003, 178 biopsies were obtained from 142 patients with VCF during 246 kyphoplasty procedures. There were 110 one-level, 28 two-level, and 4 three-level biopsies. Patients included 41 men and 101 women, with an average age of 72 years (range 40-90). The patients consented to this procedure, and 25 received tetracycline (1g/day, in 2 doses separated by 6 days). Vertebral body biopsies were taken using a trephine just before the kyphoplasty procedure. The biopsies were fixed, embedded, and stained with toluidine blue and hematoxylin eosin, and were viewed with transmitted light. Unstained sections were viewed under fluorescent light to detect tetracycline labels.. The 178 biopsy levels included: T4 (3), T5 (1), T6 (4), T7 (13), T8 (12), T9 (8), T10 (11), T11 (17), T12 (28), L1 (25), L2 (14), L3 (13), L4 (17), and L5 (12). All specimens showed fragmented bone with variable amounts of unmineralized bone (osteoid), suggesting bone remodeling and/or fracture healing. Woven bone and cartilaginous tissue were often present, representing fracture callus formation. The biopsies obtained from 30 patients (21%), including 4 who received tetracycline, showed significantly increased osteoid, suggesting either increased bone remodeling activity or mineralization defect (osteomalacia). One sample from these 4 patients who received tetracycline showed no tetracycline labels, essentially diagnostic of osteomalacia. The biopsies also provided definitive diagnoses for one case of unsuspected and 3 cases of unconfirmed plasma cell dyscrasia.. The majority of biopsies from this series of patients revealed findings consistent with various stages of fracture healing. Osteoid seams were increased in 30 patients, representing either increased bone remodeling or osteomalacia. More cases with tetracycline labeling will help elucidate the true incidence of osteomalacia in this population. As we confirmed 4 cases of plasma cell dyscrasia, we advocate a biopsy during each first-time vertebral augmentation procedure.

Topics: Adult; Aged; Aged, 80 and over; Bone Remodeling; Diagnosis, Differential; Female; Fracture Healing; Fractures, Compression; Humans; Lumbar Vertebrae; Male; Middle Aged; Multiple Myeloma; Osteomalacia; Spinal Fractures; Tetracycline; Thoracic Vertebrae

Alkaline phosphatase (ALP) activity is a new histomorphometric index of the extent of osteoblastic surfaces involved in mineralization. To assess its validity in the evaluation of bone formation, we carried out a comparative study between histomorphometric values obtained on the basis of the extent of tetracycline labeling and of the length of ALP-positive endosteal surfaces. The following variables were compared (indicated by ALP when based on the extent of ALP positivity): trabecular mineralizing surface (MS/BS vs. ALP.S/BS); osteoid mineralizing surface (MS/OS vs. ALP.S/OS); bone formation rate (BFR/BS vs. ALP.BFR/BS); and adjusted appositional rate (Aj.AR vs. ALP.Aj.AR). Bone biopsies from 39 patients with chronic renal failure and different types of renal osteodystrophy were considered (48 +/- 12 years of age; 19 men and 20 women). Patients were double labeled with tetracycline and biopsies were embedded in glycol-methacrylate at +4 degrees C. Patients showed various types of renal osteodystrophy and were assigned to different groups of pathologies. Although it differed in incidence according to the different groups, ALP activity was found in typical plump osteoblasts bordering osteoid seams and in flat cells, either in contact with osteoid or along the quiescent surfaces of bone in continuity with it. Tetracycline codistributed with all these features to variable extents, according to groups. In all patients, however, ALP.S/BS and ALP.S/OS respectively exceeded MS/BS and MS/OS. In consequence of this, ALP.BFR/BS and ALP.Aj.AR were greater than BFR/BS and Aj.AR, respectively. For each of the variable considered, differences among groups of patients with different types of renal osteodystrophy were highly significant. Good correlations were found between the variables measured with the two methods.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Adult; Alkaline Phosphatase; Biopsy; Bone Development; Calcification, Physiologic; Calcinosis; Calcium; Chronic Kidney Disease-Mineral and Bone Disorder; Female; Histocytochemistry; Humans; Hyperparathyroidism, Secondary; Ilium; Image Processing, Computer-Assisted; Kidney Failure, Chronic; Male; Middle Aged; Osteoblasts; Osteocalcin; Osteomalacia; Parathyroid Hormone; Phosphates; Tetracycline

The bone histology in patients with chronic renal failure and aluminum-related bone disease does not always show the excess accumulation of unmineralized osteoid (matrix) characteristic of osteomalacia. Frequently, bone aluminum accumulation is associated with normal or reduced amounts of unmineralized osteoid and low bone formation and is referred to as aplastic bone disease. In this study, we compared static and dynamic bone histomorphometric parameters and plasma PTH and aluminum levels in 12 patients with osteomalacia and 18 patients with aplastic bone disease who had been receiving dialysis for the same duration to determine if the difference in osteoid accumulation in these 2 lesions might be explained by differences in aluminum accumulation or PTH levels. The stainable bone surface aluminum level was significantly higher in the patients with osteomalacia compared to that in the group with aplastic bone [61 +/- 5% (+/- SEM) vs. 43 +/- 4%; P less than 0.02]. The rates of bone apposition and bone formation were lower in the group with osteomalacia (P less than 0.01). Plasma amino-terminal PTH was not significantly different in the 2 groups. The increment in plasma aluminum levels after a single infusion of deferoxamine was higher in the osteomalacic group than in the aplastic group, suggesting that the patients with osteomalacia accumulated more total body chelatable aluminum than did those with aplastic bone disease during a comparable length of time on dialysis. We conclude that the excess unmineralized osteoid in aluminum-related osteomalacia results from the high rate of total body aluminum accumulation, which directly causes uncoupling of matrix mineralization and matrix production, independent of PTH levels. Patients with aplastic bone disease who have accumulated lesser amounts of total body aluminum fail to develop excess unmineralized osteoid because production and mineralization of matrix are more closely coupled than in the osteomalacic lesion, despite a decline in osteoblast numbers.

Topics: Adult; Aluminum; Bone Diseases, Metabolic; Deferoxamine; Female; Humans; Male; Middle Aged; Osteomalacia; Parathyroid Hormone; Renal Dialysis; Tetracycline

Bone formation is impaired in aluminum-associated bone disease. Reductions in the number of osteoblasts or in the function of individual osteoblasts could account for this finding. Thus, quantitative bone histology and measurements of bone formation were done at three skeletal sites in piglets given aluminum (Al) parenterally, 1.5 mg/kg per d, for 8 wk (Al, n = 4) and in control animals (C, n = 4). Bone Al was 241 +/- 40 mg/kg per dry weight in Al and 1.6 +/- 0.9 in C, P less than 0.001. All Al-treated animals developed osteomalacia with increases in osteoid seam width, osteoid volume, and mineralization lag time at each skeletal site, P less than 0.05 vs. C for all values. Mineralized bone formation at the tissue level was lower in Al than in C, P less than 0.05 for each skeletal site, due to reductions in active bone forming surface. Bone formation at the cellular level was similar in each group, however, and total osteoid production by osteoblasts did not differ in C and Al. Aluminum impairs the formation of mineralized bone in vivo by decreasing the number of active osteoblasts, and this change can be distinguished from the effect of aluminum to inhibit, either directly or indirectly, the calcification of osteoid.

Topics: Aluminum; Animals; Bone and Bones; Bone Development; Bone Matrix; Calcium; Osteoblasts; Osteomalacia; Phosphorus; Swine; Tetracycline

Topics: Aluminum; Bone Development; Bone Resorption; Female; Humans; Kinetics; Male; Middle Aged; Osteomalacia; Tetracycline; Vitamin D Deficiency

Although this paper has dealt with well-established diagnostic procedures, I have attempted to present a practical summary based on experience with over 400 cases. A complete and modern approach to the evaluation of the bone biopsy for metabolic bone disease may be summarized as follows: Preoperative double labeling with tetracycline (two 3-day courses of tetracycline separated by 12 days); Full-thickness iliac bone biopsy yielding a 5- to 6-mm diameter specimen; Undecalcified sectioning (5-10 mu) processed in glycol or methyl methacrylate; Histomorphometric analysis with light microscope and planimeter; Tetracycline analysis with fluorescent microscope.

Topics: Biopsy; Bone and Bones; Histological Techniques; Humans; Microscopy, Fluorescence; Minerals; Osteoclasts; Osteomalacia; Osteoporosis; Tetracycline

In this article, an explanation and definition of basic terms used in metabolic bone disease are presented, with a review of histomorphometric findings in osteoporosis, osteomalacia, Paget's disease, and hyperparathyroidism. An appropriate bone biopsy protocol for diagnostic purposes is also presented.

Topics: Biopsy; Bone and Bones; Bone Diseases, Metabolic; Bone Marrow; Humans; Hyperparathyroidism; Microscopy, Fluorescence; Minerals; Osteitis Deformans; Osteoblasts; Osteoclasts; Osteomalacia; Osteoporosis; Tetracycline

The experiment aimed at describing effects of fluoride on structure and remodeling of vertebral trabecular bone in pigs. Eight animals receiving a supplement of 2 mg F-/kg b.w. per day from age eight to 14 mo were compared with eight controls. Plasma fluoride increased from 0.7 +/- 0.1 microM/1 to 12.7 +/- 2.0 microM/1 in pigs receiving fluoride. At slaughter, the concentration of fluoride in dry fat-free bone was 149.3 +/- 10.5 mM/kg for fluorotic animals and 9.5 +/- 0.9 mM/kg for controls. Morphologic changes were assessed in un-decalcified specimens of the fourth lumbar vertebra by quantitative histology using fluorochromes as intra-vital tissue time markers. The volume of trabecular bone tissue (bone + marrow) was unchanged in fluorotic animals, but the volume density of bone was increased by 17%. Surface densities of cancellous bone were almost unchanged, whereas the thickness of trabeculae increased in fluorosis. Fluoride enhanced remodeling of trabecular surfaces: The fraction of surface occupied by resorption lacunae increased 40%, and the formative surface approximately 30%. No changes were demonstrated at surface points undergoing formation: Osteoid thickness, calcification rate, lamellar thickness, and completed wall thickness were normal. It is concluded that the observed findings cannot be explained by fluoride-induced changes in a single cell. Fluoride appears to affect all cells involved in remodeling by direct or indirect mechanisms.

Topics: Animals; Bone Resorption; Female; Fluoride Poisoning; Fluorides; Lumbar Vertebrae; Osteoclasts; Osteomalacia; Swine; Tetracycline

We studied the bone histology by histomorphometric methods in transiliac bone-biopsy specimens from seventy-seven adult patients with aseptic osteonecrosis and normal kidney function. The trabecular bone volume, trabecular osteoid volume, trabecular osteoid surfaces, thickness index of osteoid seams, total resorption surfaces, calcification rate, tetracycline-labeled surfaces, and bone-formation rate at the basic multicellular unit level and at the tissue level were determined. Histological evidence of osteomalacia was found in nine patients, of whom four were alcoholics. In the remaining sixty-eight patients--fifteen treated with corticosteroids, twenty-nine alcoholics, and twenty-four who did not have any detectable etiological factor--a common histomorphometric profile was found. This consisted morphologically of a reduction in trabecular bone volume and in the thickness of osteoid seams, and dynamically of a reduction in calcification rate and in total labeled surfaces. All of these changes suggested a marked decrease in osteoblastic appositional rate and in bone-formation rate at the cell and tissue levels. This could induce a healing defect of microfractures and thus facilitate subchondral fractures.. This histological study indicated that non-apparent bone disease--either osteoporosis or osteomalacia--may underlie aseptic osteonecrosis in almost all patients, and be found even when blood and urinary biochemical parameters, usually reflecting bone-remodeling, are normal. An iliac-crest bone biopsy with static and dynamic histomorphometric study is the appropriate method for detecting these abnormalities. These results are of importance for understanding the pathophysiological mechanisms underlying osteonecrosis as well as its prevention and treatment.

Topics: Adult; Aged; Biopsy; Calcification, Physiologic; Female; Histological Techniques; Humans; Ilium; Male; Middle Aged; Osteogenesis; Osteomalacia; Osteonecrosis; Tetracycline

Aluminum in undemineralized, methyl methacrylate-embedded iliac bone from 16 hemodialyzed renal patients and six normal controls was stained by a modification of the aluminon method and quantitated histomorphometrically, and the results were compared with the aluminum values measured by atomic absorption spectrophotometry. There was a high degree of correlation between the two techniques (r = 0.955, p less than 0.0001). The amount of stained aluminum also showed a statistically significant relationship with the amount of bone that is not mineralized (r = 0.840, p less than 0.001), with the TM (r = 0.841, p less than 0.001), and with osteoid width (r = 0.771, p less than 0.0001). The aluminum was found as bright red bands mainly in the junction of mineralized bone and osteoid but was also observed in cement lines of mature bone, on neutral surfaces, and surrounding the osteocytes. Analysis of serial sections for aluminum and tetracycline showed that a majority of the sites with aluminum did not take up tetracycline, implying defective mineralization. Occasionally tetracycline uptake was observed in such places, suggesting that the aluminum "block" might be overcome eventually. The presence of aluminum in cement lines of mature bone supports this hypothesis. The histochemical staining of aluminum provides a quick and easy method for identifying, localizing, and quantifying aluminum within the bone and may prove to be a useful tool in the study of the mechanisms of metabolic bone disease.

Topics: Acute Kidney Injury; Adult; Aluminum; Bone Cements; Female; Histocytochemistry; Humans; Ilium; Male; Middle Aged; Osteomalacia; Renal Dialysis; Spectrophotometry, Atomic; Staining and Labeling; Tetracycline; Time Factors

Quantitative histomorphometric analyses of iliac crest biopsy specimens were performed after tetracycline double-labeling in 41 normal individuals, 20 hyper- and 10 hypothyroid patients, 18 patients with primary hyperparathyroidism, 20 epileptic patients receiving long-term anticonvulsant therapy, and 17 patients after jejunoileal bypass for morbid obesity. The mineralization lag time in trabecular bone or the period of time between apposition and subsequent mineralization of osteoid was calculated from the bone formation rate at BMU level (Basic Multicellular Unit) and the mean width of osteoid seams. The mineralization lag time was 8-52 days (median 21 days) in normal individuals and showed no variation with sex or age. The mineralization lag time was shortened in hyperthyroidism, normal in anticonvulsant bone disease and in primary hyperparathyroidism, and markedly prolonged in hypothyroidism and following jejunoileal bypass. Among all individuals an inverse hyperbolic relation (r = 0.94, p less than 0.001) was found between the mineralization lag time and the average cellular activity of the osteoblasts.

Topics: Adult; Aged; Biopsy; Bone and Bones; Bone Diseases; Female; Humans; Hyperparathyroidism; Hyperthyroidism; Hypothyroidism; Ileum; Ilium; Male; Middle Aged; Minerals; Obesity; Osteoblasts; Osteomalacia; Phenytoin; Postoperative Complications; Tetracycline; Time Factors

The ration of late to early uptake of several radionuclides was examined as a method for distinguishing states of abnormal bone metabolism. Nutritional osteoporosis (secondary hyperparathyroidism) and osteomalacia were produced in young rats and compared to a control group. The ratio of early (3-6 hrs.) to late (4-6 days) uptake of barium-131, nitrate, indium-111 EDTMP, and lead-203 were studied, as was that of strontium-85 chloride, a calcium analogue. Ratios of late to early uptake were found to distinguish osteomalacia from osteoporosis in the models when strontium-85 or barium-131 were used. Barium-131 may be a clinically useful alternative to strontium-85 in the evaluation of metabolic bone disease due to its shorter half-life and lower radiation dose.

Topics: Animals; Barium; Diagnosis, Differential; Indium; Lead; Osteomalacia; Osteoporosis; Radiation Dosage; Radioisotopes; Radionuclide Imaging; Rats; Strontium Radioisotopes; Tetracycline; Time Factors

Topics: Adrenal Cortex Hormones; Adult; Aged; Biopsy; Bone Resorption; Female; Femur Head Necrosis; Humans; Ilium; Male; Middle Aged; Ossification, Heterotopic; Osteomalacia; Staining and Labeling; Tetracycline

Topics: Adult; Age Factors; Aged; Biopsy; Bone and Bones; Bone Development; Bone Resorption; Female; Humans; Ilium; Male; Middle Aged; Osteoblasts; Osteomalacia; Osteoporosis; Tetracycline

Topics: Acidosis; Acute Kidney Injury; Animals; Bone Diseases; Bone Regeneration; Bone Resorption; Chronic Kidney Disease-Mineral and Bone Disorder; Hyperplasia; Male; Nephrectomy; Osteoclasts; Osteomalacia; Parathyroid Glands; Rats; Tetracycline; Tibia; Time Factors; Uremia

Topics: Biopsy; Birefringence; Bone and Bones; Bone Diseases; Collagen; Hand; Haversian System; Humans; Knee; Male; Microscopy, Fluorescence; Microscopy, Polarization; Middle Aged; Osteoblasts; Osteoclasts; Osteomalacia; Radiography; Ribs; Tetracycline

Topics: Alkaline Phosphatase; Blood; Bone and Bones; Bone Development; Calcium; Calcium, Dietary; Drug Therapy; Humans; Metabolic Diseases; Minerals; Osteomalacia; Parathyroid Glands; Phosphorus; Postoperative Complications; Surgical Procedures, Operative; Tetracycline; Urine; Vitamin D; Vitamins