Spectrum of Renal Osteodystrophy and Aluminum Accumulation in Egyptian CKD Patients: A Cross-Sectional Bone Biopsy Study

Spectrum of Renal Osteodystrophy and Aluminum Accumulation in Egyptian CKD Patients: A Cross-Sectional Bone Biopsy Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Spectrum of Renal Osteodystrophy and Aluminum Accumulation in Egyptian CKD Patients: A Cross-Sectional Bone Biopsy Study Nehal Elshabrawy, Mahmoud M. Sobh, Rasha T. Shemies, Mohamed M. Abdalbary, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7799852/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 20 Feb, 2026 Read the published version in BMC Nephrology → Version 1 posted 10 You are reading this latest preprint version Abstract Background : Renal osteodystrophy varies among populations. Different genetic, and environmental factors and prescription patterns may explain this variation. Egyptian Renal osteodystrophy is not sufficiently studied. Although bone biopsy is the gold standard tool, no single study reported the actual Renal osteodystrophy spectrum based on bone biopsy in Egypt nor Africa. International guidelines must consider the different patterns in developing countries. Methodology: The ISN-sistership program enabled us to create an Egyptian bone biopsy consortium that provided a nation-wide specialized CKD-MBD service. We included all CKD patients who were referred to unexplained bone pain, osteoporosis, or abnormal CKD-MBD laboratory parameters. Bone biopsy was offered for those who had clinical indications. Results: Over 2 years, 270 patients were recruited: 118 pre-dialysis, 97 on HD, 21 on PD, and 34 excluded. Non-invasive evaluation suggested that high bone turnover prevailed. Fourteen patients consented to the bone biopsy; all were on HD. Unexpectedly, various degrees of positive aluminum staining were present in 93% of biopsied patients, despite negative results in the dialysate water and nonuse of aluminum-based phosphate binders. Root cause analysis was done triggering an environmental alarm for potential sources in food, water, and drug manufacturing. Aluminum-induced suppression of bone cells was confirmed by low turnover biomarkers in patients with significant aluminum accumulation. Moreover, FGF23 was significantly higher in the same group (z=-2.082, p-value=0.037). Conclusion: To conclude, Aluminum bone disease is not extinct yet. Of the biopsied patients, 93% had variable degrees of positive aluminum staining and 57% had significant aluminum accumulation. Extra efforts are needed to eliminate this bone toxin. Renal osteodystrophy CKD-MBD Osteoporosis Metabolic bone disease Aluminum intoxication Adynamic bone disease Full Text Additional Declarations No competing interests reported. Supplementary Files Supplementarymaterial2biomarkersexactresults.xlsx Cite Share Download PDF Status: Published Journal Publication published 20 Feb, 2026 Read the published version in BMC Nephrology → Version 1 posted Editorial decision: Revision requested 03 Nov, 2025 Reviews received at journal 27 Oct, 2025 Reviews received at journal 26 Oct, 2025 Reviewers agreed at journal 17 Oct, 2025 Reviewers agreed at journal 15 Oct, 2025 Reviewers invited by journal 13 Oct, 2025 Editor invited by journal 13 Oct, 2025 Editor assigned by journal 08 Oct, 2025 Submission checks completed at journal 08 Oct, 2025 First submitted to journal 07 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7799852","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":534137938,"identity":"b78f8c1b-13b1-431c-9d51-f96b14278d1b","order_by":0,"name":"Nehal Elshabrawy","email":"data:image/png;base64,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","orcid":"","institution":"Mansoura university, faculty of medicine","correspondingAuthor":true,"prefix":"","firstName":"Nehal","middleName":"","lastName":"Elshabrawy","suffix":""},{"id":534137939,"identity":"a09bd561-4a3b-4de0-ad0e-0c963868428e","order_by":1,"name":"Mahmoud M. 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Different genetic, and environmental factors and prescription patterns may explain this variation. Egyptian Renal osteodystrophy is not sufficiently studied. Although bone biopsy is the gold standard tool, no single study reported the actual Renal osteodystrophy spectrum based on bone biopsy in Egypt nor Africa. International guidelines must consider the different patterns in developing countries.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethodology:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe ISN-sistership program enabled us to create an Egyptian bone biopsy consortium that provided a nation-wide specialized CKD-MBD service. We included all CKD patients who were referred to unexplained bone pain, osteoporosis, or abnormal CKD-MBD laboratory parameters. Bone biopsy was offered for those who had clinical indications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOver 2 years, 270 patients were recruited: 118 pre-dialysis, 97 on HD, 21 on PD, and 34 excluded. Non-invasive evaluation suggested that high bone turnover prevailed. Fourteen patients consented to the bone biopsy; all were on HD. Unexpectedly, various degrees of positive aluminum staining were present in 93% of biopsied patients, despite negative results in the dialysate water and nonuse of aluminum-based phosphate binders. Root cause analysis was done triggering an environmental alarm for potential sources in food, water, and drug manufacturing. Aluminum-induced suppression of bone cells was confirmed by low turnover biomarkers in patients with significant aluminum accumulation. Moreover, FGF23 was significantly higher in the same group (z=-2.082, p-value=0.037).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo conclude, Aluminum bone disease is not extinct yet. Of the biopsied patients, 93% had variable degrees of positive aluminum staining and 57% had significant aluminum accumulation. Extra efforts are needed to eliminate this bone toxin.\u003c/p\u003e","manuscriptTitle":"Spectrum of Renal Osteodystrophy and Aluminum Accumulation in Egyptian CKD Patients: A Cross-Sectional Bone Biopsy Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-27 14:02:17","doi":"10.21203/rs.3.rs-7799852/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-03T10:51:35+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-27T07:44:06+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-26T07:05:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"217124570251157429967923338069482020282","date":"2025-10-17T14:13:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"272470438230933703691358728462850296568","date":"2025-10-16T00:05:52+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-13T19:14:25+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-13T06:14:18+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-08T09:54:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-08T09:54:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nephrology","date":"2025-10-07T13:00:51+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnep","sideBox":"Learn more about [BMC Nephrology](http://bmcnephrol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bnep/default.aspx","title":"BMC Nephrology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"92016809-740b-4810-9ff6-ac21ecd39d83","owner":[],"postedDate":"October 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-23T16:07:05+00:00","versionOfRecord":{"articleIdentity":"rs-7799852","link":"https://doi.org/10.1186/s12882-026-04776-6","journal":{"identity":"bmc-nephrology","isVorOnly":false,"title":"BMC Nephrology"},"publishedOn":"2026-02-20 15:57:36","publishedOnDateReadable":"February 20th, 2026"},"versionCreatedAt":"2025-10-27 14:02:17","video":"","vorDoi":"10.1186/s12882-026-04776-6","vorDoiUrl":"https://doi.org/10.1186/s12882-026-04776-6","workflowStages":[]},"version":"v1","identity":"rs-7799852","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7799852","identity":"rs-7799852","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}