PMC9995371_01
(A) Intact PTH trend during kidney graft dysfunction period and during hemodialysis period. (B) Alkaline Phosphatase trend during kidney graft dysfunction period and during hemodialysis period.
fmed-09-1050062-g001.jpg
PMC9995371_01_fmed-09-1050062-g001.jpg
F1
The laboratory changes over time are shown in Figure 1. Intact PTH (iPTH) increased to 4500 pg/mL (Figure 1A) with a parallel rise in alkaline phosphatase > 600 UI/L (Figure 1B). During the following months, while on a 7 5 mg dose of Etalcalcetide, there was a gradual reduction in iPTH (Figure 1A) and serum alkaline phosphatase (Figure 1B), up to 500 pg/dl and 200 IU/L, respectively.
(A) Osteo-thickening areas affecting the entire spine. (B) Osteo-thickening areas in the pelvis.
fmed-09-1050062-g002.jpg
PMC9995371_01_fmed-09-1050062-g002.jpg
F2
A Computed Tomography scan showed multiple bone-thickening lesions (Figure 2). At 6 months, bone marrow histology showed variable reduction of marrow fibrosis (Figure 3D, grade 2 on the left side and grade 3 on the right) improvement of osteosclerosis (Figure 3E) and only residual decreased myelopoiesis (Figure 3F).
(A) First bone marrow biopsy: silver impregnation staining (x10) shows diffuse severe (grade 3) fibrosis. (B) First bone marrow biopsy: Hematoxylin Eosin (x10) shows depleted cellularity and frank osteosclerosis with bone thickening and remodeling. (C) First bone marrow biopsy: Hematoxylin Eosin (x10) shows residual decreased myelopoiesis. (D) Second bone marrow biopsy: silver impregnation staining (x10) shows variability of marrow fibrosis (severe 3 on the right side; moderate on the left side). (E) Second bone marrow biopsy: Hematoxylin Eosin (x10) shows mild improvement of the osteosclerosis. (F) Second bone marrow biopsy: Hematoxylin Eosin (x10) shows residual decreased myelopoiesis. (G) Third bone marrow biopsy: silver impregnation staining (x10) shows almost normalization of marrow fibrosis. (H) Third bone marrow biopsy: Hematoxylin Eosin (x10) shows clear-cut improvement of the osteosclerosis with normal appearing bone trabeculae. (I) Third bone marrow biopsy: Hematoxylin Eosin (x10) shows regular cellularity and myelopoiesis.
fmed-09-1050062-g003.jpg
PMC9995371_01_fmed-09-1050062-g003.jpg
F3
Bone marrow histology showed diffuse severe grade 3 fibrosis (Figure 3A), depleted cellularity and osteosclerosis with bone thickening and remodeling (Figure 3B), and residual decreased myelopoiesis (Figure 3C). Blood samples for mutations in JAK-2, CALR, and MPL and BCR-ABL rearrangement were negative. At 6 months, bone marrow histology showed variable reduction of marrow fibrosis (Figure 3D, grade 2 on the left side and grade 3 on the right) improvement of osteosclerosis (Figure 3E) and only residual decreased myelopoiesis (Figure 3F). A bone marrow biopsy was repeated at 12 months and showed near normalization of marrow reticulin (fibrosis) (Figure 3G), clear-cut improvement of the osteosclerosis with normal appearance of bone trabeculae (Figure 3H), and regular cellularity and myelopoiesis (Figure 3I).