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

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).