extra skeletal uptake of technetium-99 m ( 99mtc ) phosphate and phosphonate radiopharmaceuticals is reported in a wide variety of conditions . in both malignant and nonmalignant conditions , extraosseous pulmonary calcification ( pc ) is found most commonly in end - stage renal disease ( esrd ) patients on chronic hemodialysis ( hd ) therapy . in our patient , pre - transplant whole body bone scan revealed lung and stomach uptake , which completely resolved in 17 months post - transplant bone scan . this case report highlights the importance of normalization of renal function and disappearance of insufficiency fractures along with the extraosseous 99mtc - methylene diphosphonate ( mdp ) uptake . a 25-year young male , chronic kidney disease ( ckd ) patient , on hd for 3 - 4 months , developed bone pains . patient had high creatinine ( 5.2 mg / dl ) and serum phosphorus , low albumin ( normal 0.8 - 1.2 ) , and normal calcium . pretransplant bone scan [ figure 1a and b ] revealed insufficiency fractures involving the medial and lateral cortices of distal shaft of both femora and medial cortex of mid shaft of bilateral tibiae with periarticular increased radiotracer . both the kidneys appeared small in size , with no definite tracer activity visualization in the bladder ; but extraosseous activity noted in both lungs and stomach . second bone scan [ figure 2 ] done 4 months later revealed no definite change . patient underwent human leukocyte antigen ( hla ) matched live donor ( mother ) renal transplantation . bone scan [ figure 3 ] performed 20 days posttransplant showed no definite interval change . on follow - up , patient developed acute graft dysfunction , serum creatinine became 3.6 mg / dl . patient complained of bone pains more in legs and thighs . a repeat bone scan ( 17 months posttransplant ) was performed which revealed [ figure 4 ] no lung or stomach uptake , resolving metabolic bone disease and resolved insufficiency fractures . patient clinically followed - up until february 2013 , asymptomatic and serum creatinine of 1.5 mg / dl , no bone scans performed . pre - transplant ( a ) whole body bone scan ( b ) static images in multiple projections shows abnormally increased periarticular radiotracer concentration . both the kidneys appear small in size and are visualized with no definite excretion of tracer in the bladder . focal increased radiotracer concentration involving the medial and lateral cortices of distal shaft of both femora and medial cortex of mid shaft of bilateral tibiae representing insufficiency fractures second pre - transplant whole body bone scan dated ( 4 months later ) on comparison with first bone scan revealed no definite new site of insufficiency fracture , insufficiency fractures involving the lateral cortices of distal shaft of both femora and medial cortex of mid shaft of bilateral tibiae were resolved , insufficiency fractures involving the medial cortex of distal shaft of both femora were significantly reduced in intensity representing healing insufficiency fracture . abnormal tracer accumulation was persistent involving both lungs and stomach immediate ( within 20 days ) post - transplant whole body bone scan , no definite interval change noted compared to the second pre - transplant bone scan whole body bone scan performed approximately 17 months post - transplant , the tracer uptake involving the lungs and stomach had completely resolved gastric uptake has been described in patients with hypercalcemia either from tumors such as myeloma and breast carcinoma , or from metabolic diseases such as renal insufficiency and milk - alkali syndrome . in both malignant and nonmalignant conditions , impaired renal function with consequent decreased phosphate excretion is a prerequisite for this phenomenon , our patient is a case of ckd with hyperphosphatemia . extraosseous pc is found most commonly in esrd patients on chronic hd therapy . in the lungs , calcium deposits have been found in the interstitium of the alveolar septum , bronchiole walls , in the large airways , and even in the walls of the pulmonary vessels . elevated stomach uptake of 99mtc - mdp can be due to free pertechnetate , to dystrophic , and to metastatic calcification . in our case , the kidneys , the lungs , and the stomach are the three main organs in the body where acids are secreted . there is a local tissue alkalinity in the region of these acid producing cells , which has been suggested to predispose these tissues to metastatic calcification . with the normalization of both calcium and phosphate metabolism and improved kidney function , new formation of 99mtc - mdp avid amorphous calcium phosphate , had ceased , we noted complete disappearance of lungs and stomach uptake in 99mtc - mdp bone scan 17 months post - transplant . in any case of elevated 99mtc - mdp uptake in the stomach and/or lungs , vitamin d intoxication should be considered , but our patient had normal vitamin d levels . insufficiency fracture is an important diagnosis to make because survival may be improved if specific management is used . this case report highlights the importance of normalization of renal function and disappearance of insufficiency fractures along with the extraosseous 99mtc - mdp uptake .
a chronic kidney disease male patient presenting with bone pains , fever , weakness , and clinically ascites was subjected to four technetium-99m - methylene diphosphonate ( tc99m - mdp ) bone scans , two before renal transplant and two after renal transplants . 
 pretransplant bone scan revealed metabolic bone disease with focal insufficiency fractures . 
 marked extraosseous activity in both lungs and stomach was also visualized . on regular hemodialysis ( hd ) after 4 months , repeat pretransplant bone scan showed persistent uptake in lungs and stomach , representing altered calcium metabolism with microcalcifications . 
 he underwent human leukocyte antigen ( hla ) matched live donor renal transplantation , started on immune - suppression and steroids . 
 posttransplant bone scan at 20 days revealed no definite interval change , but bone scan performed approximately 17 months posttransplant showed resolving metabolic bone disease and the tracer uptake in the lungs and stomach was no more visualized . 
 patient clinically followed - up until the date ( february 2013 ) is asymptomatic with serum creatinine of 1.5 mg / dl , no bone scan done .