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Osteitis Fibrosa Cystica Subperiosteal Resorption — ESENeph MCQ

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ModerateChronic Kidney DiseaseOsteitis Fibrosa Cystica Subperiosteal ResorptionESENeph

A 54-year-old woman with CKD G4 (eGFR 20 mL/min/1.73m2) and diabetes has a PTH of 28 pmol/L (reference 1.6-6.9 pmol/L), calcium 2.15 mmol/L, phosphate 1.9 mmol/L, 25-OH vitamin D 60 nmol/L, and alkaline phosphatase 180 U/L (elevated). X-ray of hands shows subperiosteal resorption of the radial side of the middle phalanges. What type of renal osteodystrophy does this represent?

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Correct answer: E — Osteitis fibrosa cystica (high-turnover bone disease)

Subperiosteal resorption on X-ray (particularly radial aspects of middle phalanges) is pathognomonic of osteitis fibrosa cystica — the high-turnover bone disease of secondary hyperparathyroidism. The markedly elevated PTH (28 pmol/L, >4x upper limit) drives excessive osteoclastic bone resorption. Elevated ALP confirms increased bone turnover. Vitamin D is replete, so the PTH elevation is driven by CKD-related phosphate retention, reduced 1-alpha-hydroxylase activity, and skeletal resistance to PTH. Adynamic bone disease has LOW PTH. Aluminium bone disease is associated with low PTH and aluminium exposure (now rare). Osteomalacia presents with Looser zones.

Reference: KDIGO 2024 – CKD-MBD Guideline Update; JRCPTB 2022 – Nephrology Curriculum