We report a 46-year old woman with diabetes mellitus type 1, receiving hemodialysis therapy for 7 years. In history it was indicated that she many years took aluminum hydroxide containing antacids to reveal stomach pains. On the 4 th year of that practice she suffered fractures of both heel bones. Low BMD was revealed. The patient consulted by endocrinologist and therapy with denosumab 60 mg given subcutaneously every 6 months was started. Four injections of denosumab were performed, the last one in December 2016. Lumbar spine BMD increased after first year of treatment by 7%. However bone mineral of the distal forearm decreased by 16%. The patient stopped the therapy with denosumab. In August 2017 she suffered bilateral femoral neck fracture after falling down from dialysis chair. In 6 months multiple rib and scapular fractures were revealed. Laboratory analysis showed low level of phosphates (0.42 mmol/l), 25(OH) Vit D (22 ng/ml), high level of alkaline Fig. 1. Study design. Abstracts 77 phosphatase and bone metabolites (β-isomers of CTX - 1.620 ng/ml; PINP - 1425 ng/ml. Intact PTH was 12.1 pmol/l (lab reference ranges: 0.7-5.6 pmol/l). This condition was diagnosed as hypophosphatemic osteomalacia and rebound effect of denosumab discontinuation. High doses of alfacalcidol and phosphate-rich diet were prescribed. Seven months later plasma phosphates level raised to 0.79 mmol/l, intact PTH lowered to 5.2 pmol/l, level of calcium raised slightly, but alkaline phosphatase did not change significantly. However bone resorption continued and patient suffered spontaneous fracture of the right arm. To stop this progressive, parathyroid hormone independent, bone loss we had to administer zoledronic acid. Denosumab is not contraindicated for patients with chronic kidney disease, however it should not be used in hemodialysis patients without serious reasons. If one starts therapy with denosumab, one must envisage what to do after its discontinuation.
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