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There is severe bilateral renal atrophy consistent with patients known history of end stage renal disease. Within the left pelvis there is a transplanted kidney demonstrating small intrarenal calculi and cysts. The spine has diffuse heterogenous osteosclerotic changes. Diffrentials include metastatic (such as prostate CA), hematological (myelofibrosis), and metabolic disorders such as renal osteodystrophy. In this case with known renal disease and abnormal lab values, renal osteodystrophy was placed first on the diffrential list.