# Multiple Occult Fractures at Hemodialysis Initiation in a Chronic Kidney Disease Patient: Diagnostic Value of MRI and Potential Role of Zinc Deficiency

## TL;DR

A patient with kidney disease developed multiple hidden fractures after starting dialysis, which were only detected by MRI, and low zinc levels may contribute to this risk.

## Contribution

Highlights the diagnostic value of MRI over CT and X-ray for occult fractures in ESKD patients and suggests a potential role of zinc deficiency in CKD-MBD.

## Key findings

- MRI detected occult fractures in calcanei, metatarsals, and pelvis not visible on radiography or CT.
- Zinc deficiency and secondary hyperparathyroidism were observed in the patient with ESKD.
- Symptoms resolved with calcimimetics, vitamin D analogues, and zinc supplementation over 17 months.

## Abstract

We report the case of a 55-year-old man with end-stage kidney disease (ESKD) who developed multiple occult fractures within two months of hemodialysis initiation. Magnetic resonance imaging (MRI), but not radiography or computed tomography (CT), identified fractures in the calcanei, metatarsals, and pelvis. Laboratory findings revealed secondary hyperparathyroidism and hypozincemia. Treatment with calcimimetics, active vitamin D analogues, and zinc supplementation led to symptom resolution over 17 months. This case emphasizes the value of early MRI for unexplained pain at dialysis initiation and suggests that zinc deficiency may contribute to fracture risk in chronic kidney disease-mineral and bone disorder (CKD-MBD).