title: Osteomalacia complicating renal tubular acidosis in association with Sjogren's syndrome.
abstract: Renal involvement in Sjogren's syndrome (SS) is not uncommon and may precede other complaints. Tubulointerstitial nephritis is the most common renal disease in SS and may lead to renal tubular acidosis (RTA), which in turn may cause osteomalacia. Nevertheless, osteomalacia rarely occurs as the first manifestation of a renal tubule disorder due to SS. We herewith describe a 43-year-old woman who was admitted to our hospital for weakness, lumbago and inability to walk. X-ray of the long bones showed extensive demineralization of the bones. Laboratory investigations revealed chronic kidney disease with serum creatinine of 2.3 mg/dL and creatinine clearance of 40 mL/min, hypokalemia (3.2 mmol/L), hypophosphatemia (0.4 mmol/L), hypocalcemia (2.14 mmol/L) and hyperchloremic metabolic acidosis (chlorine: 114 mmol/L; alkaline reserve: 14 mmol/L). The serum alkaline phosphatase levels were elevated. The serum levels of 25-hydroxyvitamin D and 1,25-dihydroxy vitamin D were low and borderline low, respectively, and the parathyroid hormone level was 70 pg/L. Urinalysis showed inappropriate alkaline urine (urinary PH: 7), glycosuria with normal blood glucose, phosphaturia and uricosuria. These values indicated the presence of both distal and proximal RTA. Our patient reported dryness of the mouth and eyes and Schirmer's test showed xerophthalmia. An accessory salivary gland biopsy showed changes corresponding to stage IV of Chisholm and Masson score. Kidney biopsy showed diffuse and severe tubulo-interstitial nephritis with dense lymphoplasmocyte infiltrates. Sicca syndrome and renal interstitial infiltrates indicated SS as the underlying cause of the RTA and osteomalacia. The patient received alkalinization, vitamin D (Sterogyl ®), calcium supplements and steroids in an initial dose of 1 mg/kg/day, tapered to 10 mg daily. The prognosis was favorable and the serum creatinine level was 1.7 mg/dL, calcium was 2.2 mmol/L and serum phosphate was 0.9 mmol/L.
authors.forename: Zohra
authors.initials: Z
authors.lastname: El Ati
authors.affiliation: Nephrology Department, La Rabta Hospital, Tunis, Tunisia.
authors.forename: Lilia Ben
authors.initials: LB
authors.lastname: Fatma
authors.forename: Ghada
authors.initials: G
authors.lastname: Boulahya
authors.forename: Lamia
authors.initials: L
authors.lastname: Rais
authors.forename: Madiha
authors.initials: M
authors.lastname: Krid
authors.forename: Wided
authors.initials: W
authors.lastname: Smaoui
authors.forename: Hedi Ben
authors.initials: HB
authors.lastname: Maiz
authors.forename: Soumaya
authors.initials: S
authors.lastname: Beji
authors.forename: Karim
authors.initials: K
authors.lastname: Zouaghi
authors.forename: Fatma Ben
authors.initials: FB
authors.lastname: Moussa
mesh_terms: D000141:Acidosis, Renal Tubular / Q000175:diagnosis / Q000188:drug therapy / Q000209:etiology*; D000328:Adult; D015415:Biomarkers / Q000097:blood / Q000652:urine; D001706:Biopsy; D015519:Bone Density; D002118:Calcium / Q000627:therapeutic use; D019587:Dietary Supplements; D005260:Female; D006801:Humans; D010018:Osteomalacia / Q000175:diagnosis / Q000188:drug therapy / Q000209:etiology*; D012859:Sjogren's Syndrome / Q000150:complications* / Q000175:diagnosis / Q000188:drug therapy; D013256:Steroids / Q000627:therapeutic use; D016896:Treatment Outcome; D014807:Vitamin D / Q000627:therapeutic use
chemical_list: D015415:Biomarkers; D013256:Steroids; D014807:Vitamin D; D002118:Calcium