Lower back pain in a patient on long-term haemodialysis.

To cite: Callus R, Pullicino R, Buhagiar L, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2014205110 DESCRIPTION A 60-year-old woman with end-stage renal disease secondary to adult polycystic kidney disease, presented with a 6-month history of worsening sacral and rectal pain. She reported anorexia and significant weight loss. She was on haemodialysis for 5 years prior to receiving a renal transplant, which failed after 8 years. She was then recommenced haemodialysis for another 4 years to date. She underwent bilateral nephrectomy of her native kidneys prior to transplantation. Clinical examination showed cachexia, hepatomegaly and a right iliac fossa graft. Rectal examination was normal. Passive movements of both lower limbs were painful; however, there was no neurological deficit. Investigations showed a chronic normocytic anaemia despite high doses of erythropoeitin and adequate iron stores. Secondary hyperparathyroidism progressed despite treatment with alfacalcidol and phosphate binders. Serum calcium was 2.40 mmol/L (normal 2.05–2.55 mmol/L); phosphate 1.63 mmol/L (normal 0.87–1.45 mmol/L); alkaline phosphatase 503 U/L (normal 40–104 U/L) and parathyroid hormone 2053 pg/mL (target 150– 300 pg/mL). CT imaging revealed a sacral mass (figures 1–3). Brown tumours are more common in primary compared with secondary hyperparathyroidism. In this case the severe hyperparathyroidism was attributed to a long history of advanced chronic kidney disease, as well as poor phosphate control. Thirty-seven cases of brown tumours affecting the spine have been reported in the literature, all presenting with symptoms and signs of cord compression. The thoracic spine was affected in 58.3% of cases. Treatment options include decompression surgery and/or parathyroidectomy. Osteoclastomas may be prevented by prompt diagnosis and treatment of hyperparathyroidism in chronic kidney disease as well as in renal transplant patients.