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Journal of Peking University (Health Sciences) ›› 2020, Vol. 52 ›› Issue (5): 975-979. doi: 10.19723/j.issn.1671-167X.2020.05.031

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Low-dose adefovir-induced Fanconi syndrome and hypophosphatemic osteomalacia: A case report and literature review

Wen SUN1,Ang LI2,∆(),Jun-qing ZHANG2,Zhen-fang YUAN2   

  1. 1. Department of Pulmonary and Critical Care Medicine, Peking University First Hospital, Beijing, Beijing 100034, China
    2. Department of Endocrinology, Peking University First Hospital, Beijing 100034, China
  • Received:2018-06-14 Online:2020-10-18 Published:2020-10-15
  • Contact: Ang LI E-mail:liang850513@hotmail.com

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Abstract:

A young male patient with a clear diagnosis of chronic hepatitis B, had taken long-term adefovir dipivoxil and lamivudine antiviral therapy. Osteomalacia related symptoms, such as bone pain and walking difficulties appeared 10 months ago. Renal damage related symptoms, such as urine volume change and increased urinary foam appeared 7 months ago. The examination showed signs of osteomalacia after admission, such as duck step, osteoarticular tenderness, thoracic and pelvic compression sign positive. Relevant examinations showed that hypophosphatemic osteomalacia related signs, such as hypophosphatemia, normal blood calcium, elevated blood alkaline phosphatase, no significant decline in active vitamin D3 and intact parathyroid hormone (iPTH). In bone mineral density test, bone fracture line could be noted. Bone scan suggested multiple metabolic lesions. At the same time, there were Fanconi syndrome related performances, such as elevated serum creatinine, decreased blood uric acid, urine glucose positive, elevated urinary and uric acid, urinary protein positive with mainly small molecule proteins, increased renal tubular damage indicators, and the clearance test suggested a decrease in renal tubular reabsorption of phosphorus. Kidney stones could be seen in urinary ultrasound. Therefore, combined with the patient’s clinical manifestations, past history and examinations, we definitely considered his diagnosis was adefovir dipivoxil related renal injury. Adefovir has been widely used for the treatment of chronic hepatitis B. Some studies confirmed that the nephrotoxicity of adefovir, including Fanconi syndrome and hypophosphatemic osteomalacia, was dose-dependent. A daily high-dose of 60-120 mg/d adefovir was concluded in the treatment of human immunodeficiency virus (HIV) infection, inducing nearly 1/2 patients of renal injury. A daily moderate-dose of 30 mg/d adefovir was used for patients in chronic hepatitis B, with nearly 1/3 patients of renal injury. Long-term low-dose adefovir (10 mg/d) used for chronic hepatitis B patients was found to be responsible for renal injury, but the incidence was significantly reduced. We studied this patient and related literature to analyze the pathogenesis, clinical characteristics and treatment outcomes in low-dose adefovir-induced Fanconi syndrome and hypophosphatemic osteomalacia.

Key words: Adefovir, Kidney injury, Fanconi syndrome, Osteomalacia

CLC Number: 

  • R692.3

Figure 1

Dual-energy X-ray bone mineral density: severe decrease of bone density in the vertebrae,double hips, and double femoral necks in the patient L, lumbar vertebra. "

Table 1

Dual-energy X-ray bone mineral density: patient’s Z-score of vertebrae, double hips,and double femoral necks were all below -2.5, suggesting osteoporosis"

Region Area/m2 Bone mineral contents/g Bone mineral density/(g/cm2) Z-score
Lumbar spine 57.44 28.26 0.492 -5.4
Left neck of femur 4.75 1.74 0.366 -4.0
Left hip joint 33.95 16.23 0.478 -3.6
Right neck of femur 4.95 1.81 0.365 -4.0
Right hip joint 34.30 15.82 0.461 -3.7

Figure 2

Whole body bone scan: bilateral multiple ribs and left mandibular have the abundant blood supply, with multiple metabolic lesions;bilateral lower sacroiliac joints have the mild abundant blood supply; accordance with the performance of hypophosphatemic osteomalacia"

Figure 3

Urinary ultrasound: a strong echo was seen at the end of right renal calices, 0.37 cm in diameter, with a weak acoustic shadow behind (A); a strong echo was seen at the end of the left renal calices, 0.63 cm in diameter, followed by an acoustic shadow (B) "

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