Biomedical subjects
Publications and source records attributed to D Kuntz.
Statistical comparison of the weight index of patients presenting arthritis of the knee with that of a control group of matching sex and age, has enabled to demonstrate a definite weight gain in the most frequent topographical varieties of knee arthritis in women: lateral femoro-patellar, medial femoro-tibial, combination of the two. In men, the excess weight was only demonstrated in medial femoro-tibial arthritis.
We report the clinical and biological picture of 34 primary hyperparathyroidism (PHT) cases, diagnosed in rheumatology. It concerned 25 women and 9 men, aged 61 + 11 years. The PHT was often asymptomatic (47 p. cent of cases) at the time of diagnosis. The clinical manifestations were dominated by asthenia (50 p. cent) and renal lithiasis (47 p. cent). We found a chondrocalcinosis in 29 p. cent of patients. No patient presented any bony manifestations of cystic osteitis; 7 out of 34 patients (including 6 women between 57 and 74 years) presented vertebral compression. The mean calcemia was 117 +/- 9 mg/l. There were no hypercalcemic attack. The dosage of PTH and cyclic AMP were elevated in 29 out of 32 and 28 out of 31 patients respectively. In all patients, the level of either of these two tests was increased. The chloremia/phosphoremia ratio was also extremely predictive of HBP, since it was increased, exceeding 3.3 in 33 out of 34 patients. The 25-hydroxyvitamin D levels (25 (OH) D) were normal. The levels of 1,25 (OH) 2D were markedly spread (37 +/- 16 pg/ml) and not significantly different from the reference group. Patients with lithiasis did not present a higher level of 1,25 (OH) 2D. A bone histomorphometry carried out in 15 patients showed a bone trabecular volume similar to that of the reference with the same age. The osteoclastic resorption was increased in all cases and was not correlated with the PTH level, but was significantly correlated with the level of 1,25 (OH) 2D (r = 0.79 p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)
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There is currently a better understanding of bony loss secondary to ageing. It involves cancellous bone as well as cortical bone. Since remodelling of cancellous bone is approximately 7 times higher than that of cortical bone, the bony loss will always be more marked in cancellous bone, especially in vertebral bodies which are essentially made of cancellous bone. In women, the total bony loss secondary to ageing is about 50 p. cent for cancellous bone and 35 p. cent for cortical bone; it is approximately 35 and 20 p. cent in men. Increased bony loss is observed in women during the 10 years following menopause. For instance, the trabecular bony loss, especially in the vertebrae, may reach 1 to 2 p. cent per year, even reaching 12 p. cent during the 2 years following ovariectomy.
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The prevalence of pathological calcifications in the menisci and articular cartilage of both knees was investigated macroscopically and radiologically in 130 consecutive autopsies. The mean age of the subjects was 72 +/- 13 years. Only 8 subjects were less than 50 years old. All had been admitted to hospital and no patient had a history of joint disorders. Half of the patients were male. Calcifications were found in 27 (20.7%) cases, all over 60 years of age. There were 15.4% males and 26.1% females affected. The incidence of intraarticular calcifications in females increased from 11.1-37.5% and in males from 20-29.4% for the 60-69 year age group and the over 80-year age group, respectively. One third of affected cases had only meniscal and 2/3 had both meniscal and chondral calcifications. Isolated meniscal calcifications were found more often in 1 and mixed meniscal and chondral calcifications were found in both knees. Severe destructive articular cartilage lesions were observed significantly more often in joints with intraarticular calcifications than in joints of age matched subjects without calcifications. Joints with calcifications showed little evidence of synovial inflammation. Similarly, no specific relationship was found between the presence of crystal and amyloid deposits in the knees examined.
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Amyloidosis in long-term haemodialysis patients mainly involves the osteo-articular system. It is held responsible for carpal tunnel syndrome, chronic arthralgia and various types of arthropathy, chronic synovitis and tenosynovitis, haemarthrosis, subacute polyarthritis and destructive arthropathies of the limbs and spine. Radiologically, amyloidosis may appear as bone cavities, particularly visible in the hips and wrists. Its frequency increases with the duration of haemodialysis. Biochemically, amyloidosis consists of beta 2-microglobulin (beta 2-M). This protein accumulates in uraemic patients under dialysis and seems to play a major role in the pathogenesis of amyloid deposits. The accumulation is due to renal impairment, being maximum in anuric patients. However, the unsatisfactory clearance of beta 2-M by dialysis methods also contributes to its retention: the production and elimination of beta 2-M seems to vary according to the extrarenal clearing technique. These data suggest that improvements in clearing techniques will eventually prevent dialysis amyloidosis.
We studied sequential bone biopsies performed at 6 to 24 month intervals from 14 untreated osteoporotic women (64 +/- 7). Subgroups were defined, respectively, by increased osteoclastic resorption surfaces and decreased osteoblastic surfaces +/- 2 S.D. Normal values were obtained from bone biopsy of 23 normal women (61 +/- 8). When patients were divided into subgroups according to the above criteria the first biopsy showed that 3 out of the 14 patients had high resorption surfaces and 6 had low osteoblastic surfaces. Eight patients spontaneously changed during the study. In 2 patients there was a change in resorption surfaces, in 3 in osteoblastic surfaces and in 3 a change in both osteoblastic and resorption surfaces was observed. Considering the first or second bone biopsy results the patient variance was higher than the control subject's variance; however the variance between the first and second bone biopsy of one patient was not different from the variance inside the group of patients. The average intraindividual variation of the parameters on sequential biopsies was of the same order as the one we previously observed on simultaneous bone biopsies of normal and hemodialyzed patients. We concluded that if osteoporosis is a heterogeneous disorder, subgroups cannot be definitively defined on the basis of cellular parameters of bone remodelling assessed on bone biopsies.
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Twenty-three uremic patients on intermittent hemodialysis for eight to eighteen years provided the material for the present pathological study. In all of them, there was evidence for dialysis related amyloidosis based on previous clinical or histological findings or both. The material examined consisted of nine skin biopsies, five abdominal fat aspirates, eight trans-iliac bone biopsies and numerous post-mortem specimens of various visceral organs from eight cases. None of the skin biopsies or fat aspirates showed amyloid deposits. In only one bone biopsy could a small Congo red positive area be recognized that showed characteristic birefringence under polarizing light. Autopsy material findings were negative except for one case: this patient had been dialyzed for 18 years. Very minute amyloid deposits with a positive immunofluorescence staining for beta 2-microglobulin (beta 2-M) were found in the walls of small vessels from her lung, heart, liver and intestine. Thus, in chronic hemodialysis patients the accumulation of beta 2-M amyloid fibrils in tissues other than joints and juxta-articular structures appears to have a low incidence, to occur lately and to be of limited size. Although extra-articular amyloid deposits may progressively occur and extend with increasing survival time on dialysis, tiny deposits such as those observed in only two of our patients will hardly lead to serious complications.
We are reporting 4 cases of unnoticed sacral fractures in osteoporotic women. Their mean age was 73 years. Only in one case the fracture was seen on a standard X-Ray. On the other hand, hyperfixation with isotopes on the sacrum formed a very characteristic H-shaped image. In two of these patients, the sacral fracture was confirmed by tomodensitometry, but this examination was unavailing in the third patient. In the 4th case, hyperfixation of the isotope was not significant. Only a guided bone biopsy and the favorable evolution of the disease enabled the diagnosis of sacral fracture.
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The progression of osteoporosis depends on an imbalance between the relative rate of bone resorption and formation leading to a decrease in bone mass. The stimulation of bone turnover, also apparently heretical, might be necessary in order to be able to make the skeletons of elderly patients become highly cellular, a prerequisite for significant restoration of bone tissue. Given the usual correlation between bone resorption and bone formation a treatment which only increases bone turnover is unlikely to increase bone mass. For this reason, it is necessary to add sequentially a drug able to block bone destruction and lead to a transient uncoupling. Forty-seven post-menopausal women with vertebral osteopenia, with one or more atraumatic spinal compression fractures were included in a double-blind randomized study in four groups. The control group (PL) (n = 9) received a placebo injection and placebo tablets. The calcitonin group (CT) (n = 15) received CT injection and placebo tablets. The phosphate group (Pi) (n = 10) received a placebo injection and phosphate tablets. The calcitonin and phosphate group (CT + Pi) (n = 13) received calcitonin injection and phosphate tablets. The duration of treatment was six months. Transiliac bone biopsies were taken before and at the end of treatment. No significant changes were noted for the (CT + Pi) group. Trabecular bone volume increased by 31% by the end of treatment. Trabecular osteoblastic surface showed a mean increase of 143% of trabecular surface. Trabecular osteoid surface showed a mean increase of 85%.(ABSTRACT TRUNCATED AT 250 WORDS)
Joint problems have been retrospectively analyzed in 10 uremic patients (mean age, 61.9 years; range, 50-70) undergoing long-term hemodialysis treatment for more than 10 years. All the patients suffered from arthralgias which were mainly localized in the shoulder region (9 patients). The arthralgias began 2-9 years after the initiation of intermittent hemodialysis. Eight out of the 10 patients had the carpal tunnel syndrome. Only three patients had evidence of marked secondary hyperparathyroidism but nine had aluminum intoxication. Juxta-articular calcium deposits were observed in 8 patients one of whom had pseudo-tumoral calcifications made of hydroxyapatite crystals. These soft tissue calcium deposits occurred 1-8 years after starting hemodialysis. Conspicuous X-ray abnormalities were found in 8 patients: destructive arthropathy in 5 cases, arthropathies of large joints in 5 cases consisting of sub-chondral lacunae and joint space narrowing or even disappearance. Prosthetic joint replacement was required in 4 patients: replacement of the hip in 3 and of the knee in 1. Massive amyloid deposits could be demonstrated in removed joints of 3 patients and in carpal tunnel of the 7 patients operated upon. They were located in the synovium, articular capsula and juxta-articular epiphyseal bone. It is probable that this is a new type of amyloidosis made of beta 2-microglobulin. The underlying pathogenetic mechanisms of these arthropathies remain to be defined by further studies.
Synovial amyloid deposits were found in 18 patients with end-stage renal failure due to various nonamyloid nephropathies, who had been treated with long-term, periodic hemodialysis (mean 116 months). All patients had carpal tunnel syndrome, which was bilateral in 14 of them; 4 patients also had finger flexor tenosynovitis. In 2 patients, destructive arthropathies required surgical replacement of the hip. Amyloid deposits were demonstrated by light microscopy in the synovium of the finger flexor tendon and/or transverse carpal ligament of all patients who had surgery for carpal tunnel syndrome, and in the synovium and capsula of the 2 surgically removed hips. Transmission electron microscopy of synovial samples from 6 patients demonstrated the characteristic fibrillar ultrastructure of amyloid deposits, the biochemical nature of which is still unknown. In addition, 9 patients had cystic radiolucencies of bone, which were interpreted as having resulted from local amyloid deposits, involving carpal bones, humeral heads, femoral heads, acetabula, or tibial plateaus. Our results show that amyloidosis is a frequent histologic finding in dialysis patients receiving surgical management of carpal tunnel syndrome, and that it can also be associated with cystic radiolucencies of bones and with destructive arthropathies.