Polypharmacy and Kidney Function in Community-Dwelling Adults Age 60 Years and Older: A Prospective Observational Study

OBJECTIVES

Information on the impact of polypharmacy on kidney function in older adults is limited. We prospectively investigated the association between intake of total number of drugs or nonsteroidal anti-inflammatory drugs (NSAIDs) and kidney function.

DESIGN

Our study is a prospective observational analysis of the 2-year Zurich Multiple Endpoint Vitamin D Trial in Knee Osteoarthritis Patients.

SETTING AND PARTICIPANTS

Of the 273 participants of the original trial, 270 participants (mean age 70.3 ± 6.4 years, 53% women) were included in this observational analysis.

METHODS

The associations between (1) total number of drugs (or NSAIDs) at baseline or (2) cumulative number of drugs (or NASAIDs) repeatedly measured over 24 months and kidney function repeatedly measured over 24 months as estimated glomerular filtration rate (eGFR) were investigated using multivariable-adjusted repeated-measures analysis.

RESULTS

Per drug at baseline, kidney function decreased by 0.64 mL/min/1.73 m² eGFR (Beta = -0.64; 95% CI -1.19 to -0.08; P = .024) over 24 months. With every additional drug taken cumulatively over 24 months, kidney function decreased by 0.39 mL/min/1.73 m² eGFR (Beta = -0.39; 95% CI -0.63 to -0.15; P = .002). In a high-risk subgroup, per NSAID taken cumulatively over 24 months, kidney function declined by 1.21 mL/min/1.73 m² eGFR (Beta = -1.21; 95% CI -2.35 to -0.07; P = .021).

CONCLUSIONS AND IMPLICATIONS

For every additional drug prescribed among older adults, our study supports an independent and immediate harmful impact on kidney function. This negative impact seems to be about 3 times greater for NSAIDs compared with an additional average drug.

Vitamin D in Relation to Incident Sarcopenia and Changes in Muscle Parameters Among Older Adults: The KORA-Age Study

Effects of low serum 25OHD on age-related changes in muscle mass and function remain unclear. Our aims were to explore associations of baseline 25OHD levels with prevalent and incident sarcopenia and changes in muscle parameters, and to examine the role of parathyroid hormone (PTH) therein. Cross-sectional (n = 975) and prospective analyses (n = 702) of older adults aged 65-93 years participating in the KORA-Age study. Sarcopenia was defined using the 2010 European Working Group on Sarcopenia in Older People (EWGSOP) criteria as low muscle mass combined with low grip strength or low physical performance. Associations with baseline 25OHD were examined in multiple regression analyses. Low vitamin D status was linked to increased odds of prevalent sarcopenia. Over three years, low baseline 25OHD < 25 vs. ≥ 50 nmol/L were associated with greater loss of muscle mass and increased time for the Timed Up and Go test. The risk for developing incident sarcopenia was not significantly elevated in individuals with low baseline 25OHD but when including death as combined outcome alongside incident sarcopenia, there was a strong positive association in multivariable analysis [OR (95% CI) 3.19 (1.54-6.57) for 25OHD < 25 vs. ≥ 50 nmol/L]. There was no evidence for a PTH-mediating effect. Low baseline 25OHD levels were associated with unfavorable changes in muscle mass and physical performance, but not with incident sarcopenia. Future randomized trials are needed to assess causality and to address the issue of competing risks such as mortality in older cohorts.

Vitamin D im Alter: Ist der Hype definitiv vorüber?

Metaanalysen zur Wirkung von Vitamin D In den Jahren 2016 bis 2018 wurden 4 Metaanalysen publiziert, um den Nutzen von Vitamin D für die Frakturprävention zu untersuchen. 2 dieser Metaanalysen konzentrierten sich auf die Primärprävention von Frakturen bei Erwachsenen ab 50 Jahren, bei denen kein Risiko für Frakturen und kein Vitamin-D-Mangel bestand. Eine weitere Metaanalyse konzentrierte sich auf die Kombination von Vitamin D plus Kalzium und die zuletzt publizierte Metaanalyse auf die individuelle Wirkung von Vitamin D ohne Kalzium. Bezogen auf die heutigen Richtlinien ist wichtig, dass sich nur 1 der 3 jüngsten Metaanalysen vorwiegend an Erwachsene ab 65 Jahren mit erhöhtem Risiko bezüglich Stürze, Frakturen und Vitamin-D-Mangel richtete.

Was können wir nun empfehlen? In Anbetracht und nach kritischer Prüfung der Metaanalysen zu Vitamin D und Frakturprävention ist eine Vitamin-D-Supplementation mit oder ohne Kalzium bei älteren Erwachsenen ab 65 Jahren mit einem erhöhten Risiko für Vitamin-D-Mangel und einem erhöhten Risiko für Frakturen weiterhin sinnvoll.

Timeline of functional recovery after hip fracture in seniors aged 65 and older: a prospective observational analysis

We investigated the timeline of functional recovery after hip fracture over 12 months in adults age ≥ 65 years using objective lower extremity function tests and subjective physical functioning. Objective functional recovery was largely complete in the first 6 months, whereas subjective recovery improved up to 9 months after hip fracture.

INTRODUCTION

Hip fractures are a major cause of loss of function among seniors. We assessed the timeline of objective and subjective functional recovery after hip fracture.

METHODS

We conducted a prospective observational secondary analysis of a 1-year clinical trial on vitamin D and home exercise treatment and complications after hip fracture among 173 patients age ≥ 65 years (mean age 84 years; 79.2% women; 77.4% community-dwelling) conducted from January 2005 through December 2007. Lower extremity function (Timed Up and Go test (TUG), knee extensor and flexor strength) and grip strength was assessed at baseline and at 6 and 12 months follow-up. Subjective physical functioning was assessed using the SF-36 questionnaire also at 3 and 9 months follow-up. Multivariable-adjusted repeated-measures models were used to assess the timeline of functional recovery in the total population and in subgroups of patients.

RESULTS

Lower extremity function including TUG (- 61.1%), knee extensor (+ 17.6%), and knee flexor (+ 11.6%) strength improved significantly in the first 6 months (P < 0.001). However, between 6 and 12 months, there was no further significant improvement for any of the functional tests. Grip strength decreased from baseline to 6 months (- 7.9%; P < 0.001) and from 6 to 12 months (- 10.8%; P < 0.001). Subjective physical functioning improved from 3 to 9 months (+ 15.2%, P < 0.001), but no longer thereafter.

CONCLUSIONS

Functional recovery after hip fracture may be largely complete in the first 6 months for objective functional tests, whereas may extend up to 9 months for subjective recovery, with oldest-old, female, institutionalized, and cognitively impaired patients recovering most poorly.

CLINICAL TRIALS REGISTRY (ORIGINAL TRIAL)

NCT00133640.

Should vitamin D administration for fracture prevention be continued? : A discussion of recent meta-analysis findings

In consideration and critical review of four recent meta-analyses on vitamin D and fracture prevention, vitamin D supplementation with or without calcium is supported among older adults age 65 years and older at risk of vitamin D deficiency and fractures if given in daily or equivalent weekly or monthly doses of 800 to 1000 IU and with good adherence. Vitamin D supplementation might not be effective in primary prevention among adults age 50 years and older without vitamin D deficiency and osteoporosis; however, clinical trials on primary prevention are limited. Notably, large annual bolus administration of vitamin D is detrimental with regard to falls and fractures among older adults at risk of fractures and should not be continued in clinical care. Larger monthly doses of 100,000 IU need further evaluation with respect to efficacy and safety.

Diagnosis, prevention, and treatment of bone fragility in people living with HIV: a position statement from the Swiss Association against Osteoporosis

Life expectancy of people living with HIV (PLWH) is reaching similar length as in the general population. Accordingly, age-related comorbidities, including osteoporosis, are increasing. Fracture risk is higher and increases approximately 10 years earlier in PLWH. Classical risk factors of bone fragility are highly prevalent in PLWH but factors specific for HIV infection itself and the type of antiretroviral therapy (ART) (triple combination antiretroviral therapy) regimen (especially tenofovir and protease inhibitors) also contribute to bone loss. The majority of bone loss occurs during virus activity and at initiation of ART (immune reconstitution) and is associated with an increase of bone resorption (upregulation RANKL). Recent data indicate that calcium and vitamin D supplements as ART initiation lower BMD loss. The reduction of tenofovir plasma concentrations with tenofovir alafenamide attenuates BMD loss but it remains unknown whether it will contribute to reduce fracture risk. Hence, special considerations for the management of bone fragility in PLWH are warranted. Based on the current state of epidemiology and pathophysiology of osteoporosis in PLWH, we provide the consensus of the Swiss Association against Osteoporosis on best practice for diagnosis, prevention, and management of osteoporosis in this population. Periodic assessment of fracture risk is indicated in all HIV patients and general preventive measures should be implemented. All postmenopausal women, men above 50 years of age, and patients with other clinical risk for fragility fractures qualify for BMD measurement. An algorithm clarifies when treatment with bisphosphonates and review of ART regimen in favour of more bone-friendly options are indicated.

Cost-benefit analysis of calcium and vitamin D supplements

If all adults with osteoporosis in the European Union (EU) and United States (US) used calcium and vitamin D supplements, it could prevent more than 500,000 fractures/year in the EU and more than 300,000/year in the US and save approximately €5.7 billion and US $3.3 billion annually.

PURPOSE

Evaluate the cost-effectiveness of calcium/vitamin D supplementation for preventing osteoporotic fractures.

METHODS

A cost-benefit analysis tool was used to estimate the net cost savings from reduced fracture-related hospital expenses if adults with osteoporosis in the EU and US used calcium/vitamin D supplements. A 14% relative risk reduction of fracture with calcium/vitamin D supplementation from a recent systematic review and meta-analysis of randomized, controlled trials was used as the basis for the benefit estimate. Other model inputs were informed by epidemiologic, clinical, and cost data (2016-2017) obtained via the medical literature or public databases. Analyses estimated the total number of avoided fractures and associated cost savings with supplement use. Net cost benefit was calculated by subtracting the supplements' market costs from those savings.

RESULTS

The > 30 million persons in the EU and nearly 11 million in US with osteoporosis experience about 3.9 million and 2.3 million fractures/year and have annual hospital costs exceeding €50 billion and $28 billion. If all persons with osteoporosis used calcium and vitamin D supplements, there would be an estimated 544,687 fewer fractures/year in the EU and 323,566 fewer in the US, saving over €6.9 billion and $3.9 billion; the net cost benefit would be €5,710,277,330 and $3,312,236,252, respectively.

CONCLUSIONS

Calcium and vitamin D supplements are highly cost-effective, and expanded use could considerably reduce fractures and related costs. Although these analyses included individuals aged ≥ 50 years, the observed effects are likely driven by benefits observed in those aged ≥ 65 years.

Effect of Monthly High-Dose Vitamin D on Mental Health in Older Adults: Secondary Analysis of a RCT

OBJECTIVES

To test the effect of monthly high-dose vitamin D supplementation on mental health in pre-frail older adults.

DESIGN

Ancillary study of a 1-year double-blind randomized clinical trial conducted in Zurich, Switzerland.

SETTING AND PARTICIPANTS

A total of 200 community-dwelling adults 70 years and older with a prior fall event in the last year. Participants were randomized to receive 24 000 IU vitamin D₃ (considered standard of care), 60 000 IU vitamin D₃ , or 24 000 IU vitamin D₃ plus 300 μg calcifediol per month.

MEASURES

The primary end point was the Mental Component Summary (MCS) of the SF-36. Secondary end points were the SF-36 Mental Health (MH) subscale and the Geriatric Depression Scale (GDS-15).

RESULTS

Participants' mean age was 78 years (67% women), and 58% were vitamin D deficient (<20 ng/mL). Over time, primary and secondary end points did not differ significantly among the three treatment groups or in subgroups by vitamin D status at baseline. Given the lack of a true placebo group, we explored in a predefined observational analysis the change in mental health scales by achieved 25(OH)D levels at 12 months. After adjusting for confounders, participants achieving the highest 25(OH)D quartile (Q) at 12 months (44.7-98.9 ng/mL) had the greatest improvements in MCS (Q4 = 0.79 vs Q1 = -2.9; p = .03) and MH scales (Q4 = 2.54 vs Q1 = -3.07; p = .03); these associations were strongest among participants who were vitamin D deficient at baseline. No association was found for GDS (p = .89).

CONCLUSIONS

For mental health, our study suggests no benefit of higher monthly doses of vitamin D₃ compared with the standard monthly dose of 24 000 IU. However, irrespective of vitamin D treatment dose, achieving higher 25(OH)D levels at 12-month follow-up was associated with a small, clinically uncertain but statistically significant improvement in mental health scores.

Physical Frailty: ICFSR International Clinical Practice Guidelines for Identification and Management

OBJECTIVE

The task force of the International Conference of Frailty and Sarcopenia Research (ICFSR) developed these clinical practice guidelines to overview the current evidence-base and to provide recommendations for the identification and management of frailty in older adults.

METHODS

These recommendations were formed using the GRADE approach, which ranked the strength and certainty (quality) of the supporting evidence behind each recommendation. Where the evidence-base was limited or of low quality, Consensus Based Recommendations (CBRs) were formulated. The recommendations focus on the clinical and practical aspects of care for older people with frailty, and promote person-centred care. Recommendations for Screening and Assessment: The task force recommends that health practitioners case identify/screen all older adults for frailty using a validated instrument suitable for the specific setting or context (strong recommendation). Ideally, the screening instrument should exclude disability as part of the screening process. For individuals screened as positive for frailty, a more comprehensive clinical assessment should be performed to identify signs and underlying mechanisms of frailty (strong recommendation). Recommendations for Management: A comprehensive care plan for frailty should address polypharmacy (whether rational or nonrational), the management of sarcopenia, the treatable causes of weight loss, and the causes of exhaustion (depression, anaemia, hypotension, hypothyroidism, and B12 deficiency) (strong recommendation). All persons with frailty should receive social support as needed to address unmet needs and encourage adherence to a comprehensive care plan (strong recommendation). First-line therapy for the management of frailty should include a multi-component physical activity programme with a resistance-based training component (strong recommendation). Protein/caloric supplementation is recommended when weight loss or undernutrition are present (conditional recommendation). No recommendation was given for systematic additional therapies such as cognitive therapy, problem-solving therapy, vitamin D supplementation, and hormone-based treatment. Pharmacological treatment as presently available is not recommended therapy for the treatment of frailty.

Effect of Monthly Vitamin D on Chronic Pain Among Community-Dwelling Seniors: A Randomized, Double-Blind Controlled Trial

OBJECTIVE

With advancing age, the prevalence of vitamin D deficiency and musculoskeletal pain increases. However, published data on the effectiveness of vitamin D supplementation in reducing chronic pain are inconclusive. The purpose of this study was to test the effect of 3 different monthly doses of vitamin D on chronic pain in seniors 70 years and older with a prior fall event.

DESIGN

1-year, double-blind randomized clinical trial.

SETTING

The trial was conducted in Zurich, Switzerland. Participants were 200 community-dwelling men and women 70 years and older with a prior fall.

INTERVENTION

Three study groups with monthly treatments were randomized to either a low-dose control group of vitamin D (24,000 IU vitamin D₃/mo), a high dose of vitamin D₃ (60,000 IU vitamin D₃/mo), or a combination of calcifediol and vitamin D₃ (24,000 IU vitamin D₃ plus 300 μg calcifediol/mo).

MEASUREMENTS

The primary endpoint was the change in the mean number of painful areas using the McGill Pain map over 12 months of follow-up. All analyses were adjusted for age, sex, body mass index, 25-hydroxyvitamin (OH)D₃ levels, and pain scores at baseline. A predefined subgroup analysis was performed by baseline 25(OH)D status (<20 vs ≥ 20 ng/mL).

RESULTS

The mean age of the participants was 78 years, 67.0% (134 of 200) were female, and 58.0% (116 of 200) were vitamin D deficient (<20 ng/mL) at baseline. Over 12 months of follow-up, the changes in the mean number of painful areas did not differ significantly among treatment groups (P = .46). However, there was a significant interaction effect between baseline vitamin levels (<20 vs ≥ 20 ng/mL) and treatment (P = .02). Among those who were vitamin D replete at baseline (n = 84), there was a significant difference between treatment groups over time (P = .04), and only seniors in the 24,000-IU vitamin D₃ group had a marginally significant decrease in their total mean pain score (-0.77; 95% CI, -1.56 to 0.01, P = .05), whereas there were no changes in the high-dose groups. Among seniors who were vitamin D deficient at baseline (n = 116), chronic pain did not differ by treatment groups over time (P = .33).

CONCLUSION

Our results suggest that both starting level of 25(OH)D₃ and monthly treatment dose of vitamin D may be important with respect to chronic pain reduction-with the only benefit seen among vitamin D-replete seniors treated with a monthly dose of 24,000 IU vitamin D₃.

Higher age is a major driver of in-hospital adverse events independent of comorbid diseases among patients with isolated mild traumatic brain injury

PURPOSE

The goal of this study was to investigate if and to what extent age, independent of comorbid diseases, is a risk factor for negative in-hospital outcome with mTBI.

METHODS

In a retrospective cohort study, we identified 1589 adult patients treated for isolated mTBI in our level-1 trauma center between 2008 and 2015. We used logistic regression analyses to assess the odds of any adverse event by age group (< 65, 65-75, 76-85, and 85+), adjusting for gender and chronic diseases.

RESULTS

The prevalence of any adverse event during in-hospital care among mTBI patients was 3.2% overall, 1.8% among those younger than age 65 years, 2.1% among those age 65-75 years, 8% among those age 75-85 years, and 19% among those age 85+ years. The odds of any adverse event were similar in patients aged 65-75 years, but increased among senior patients 4.4-fold for age 75-85 years (OR 4.4, 95%CI 2.0-9.8, p < 0.001), and 18-fold for age 85+ years (OR 18.0, 95%CI 8.7-37, p < 0.001). Additionally, chronic alcohol abuse (OR 7.0, 95%CI 3.2-15, p < 0.001), diseases of the musculoskeletal system (OR 4.3, 95%CI 1.5-13, p = 0.008), and diabetes mellitus (OR 2.7, 95%CI 1.2-6.5, p = 0.023) increased the odds of any adverse events independent of age and all other covariates.

CONCLUSIONS

The odds of sustaining an adverse event increased exponentially after age 75 independent of gender and any comorbid diseases. Our data support international efforts to manage senior patients in interdisciplinary geriatric trauma units.

Which Method of Fall Ascertainment Captures the Most Falls in Prefrail and Frail Seniors?

There is no consensus on the most reliable method of ascertaining falls among the elderly. Therefore, we investigated which method captured the most falls among prefrail and frail seniors from 2 randomized controlled trials conducted in Zurich, Switzerland: an 18-month trial (2009-2010) including 200 community-dwelling prefrail seniors with a prior fall and a 12-month trial (2005-2008) including 173 frail seniors with acute hip fracture. Both trials included the same methods of fall ascertainment: monthly active asking, daily self-report diary entries, and a call-in hotline. We compared numbers of falls reported and estimated overall and positive percent agreement between methods. Prefrail seniors reported 499 falls (fall rate = 2.5/year) and frail seniors reported 205 falls (fall rate = 1.4/year). Most falls (81% of falls in prefrail seniors and 78% in frail seniors) were reported via active asking. Among prefrail seniors, diaries captured an additional 19% of falls, while the hotline added none. Among frail seniors, the hotline added 16% of falls, while diaries added 6%. The positive percent agreement between active asking and diary entries was 100% among prefrail seniors and 88% among frail seniors. While monthly active asking captures most falls in both groups, this method alone missed 19% of falls in prefrail seniors and 22% in frail seniors. Thus, a combination of active asking and diaries for prefrail seniors and a combination of active asking and a hotline for frail seniors is warranted.

Vitamin D status and risk of infections after liver transplantation in the Swiss Transplant Cohort Study

Increasing evidence indicates a role of vitamin D in the immune system affecting response to infections. We aimed to characterize the role of vitamin D status, i.e. deficiency [25-OH vitamin D (25-OHD) <50 nmol/l] and no deficiency (25-OHD ≥50 nmol/l) in incident infections after liver transplantation. In 135 liver transplant recipients, blood samples drawn at time of liver transplantation and 6 months afterwards were used to determine 25-OHD levels. Incident infections episodes were prospectively collected within the Swiss Transplant Cohort Study database. Poisson regression was applied to address associations between vitamin D status and incident infections. Vitamin D deficiency was common at time of transplantation and 6 months afterwards without a significant change in median 25-OHD levels. In univariable analyses, vitamin D deficiency was a risk factor for incident infections in the first 6 months post-transplant incidence rate ratio (IRR 1.52, 95% CI 1.08-2.15, P = 0.018) and for bacterial infections occurring after 6 up to 30 months post-transplant (IRR 2.29, 95% CI 1.06-4.94, P = 0.034). These associations were not detectable in multivariable analysis with adjustment for multiple confounders. Efforts to optimize vitamin D supplementation in liver transplant recipients are needed. Our data question the role of vitamin D deficiency in incident infections.

Treatment of non-alcoholic steatohepatitis patients with vitamin D: a double-blinded, randomized, placebo-controlled pilot study

BACKGROUND

Non-alcoholic steatohepatitis (NASH) is defined by liver inflammation and consecutive fibrotic damage caused by a deposition of fat in the liver. No licensed medical treatments exist and lifestyle modification is difficult to incorporate into everyday life. We investigated the efficacy and safety of a 48-week treatment with vitamin D3 in NASH patients.

METHODS

Histologically determined NASH patients with elevated alanine aminotransferase (ALT) and decreased 25-OH vitamin D level at baseline received vitamin D3 or placebo orally over a 48-week period. The primary endpoint of this study was the change in ALT from baseline to the end-of-treatment. Steatohepatitis was categorized according to the Steatosis, Activity and Fibrosis Score and disease activity was assessed using the NAFLD activity score.

RESULTS

Serum 25-OH vitamin D levels significantly increased only in the vitamin D3 group over the 48-week treatment phase indicating compliance. In contrast to placebo, patients in the vitamin D group had markedly decreased ALT levels after the end-of-treatment phase. A significant decrease during treatment with vitamin D was also observed for cytokeratin-18 fragments compared with placebo. The study was not powered to detect changes in histological score, hence only descriptive results for histopathological characteristics are available.

CONCLUSIONS

Treatment with 2100 IE vitamin D q.d. over 48 weeks was well tolerated and led to a significant improvement of serum ALT levels in patients with hypovitaminosis D and histology-proven NASH as the primary endpoint together with a trend toward reduction of hepatic steatosis, which was not significant due to a small number of available biopsy specimens.

Issues of trial selection and subgroup considerations in the recent meta-analysis of Zhao and colleagues on fracture reduction by calcium and vitamin D supplementation in community-dwelling older adults

Zhao and colleagues are addressing an important question about the efficacy of calcium and vitamin D on fracture risk reduction among community-dwelling adults age 50+. However, we are concerned about four aspects of their approach, which may affect the validity of their conclusions and implications for public health.

INTRODUCTION

We discuss the recent meta-analysis by Zhao and colleagues on the primary prevention of fractures of calcium and vitamin D as well as their combination among community-dwelling adults age 50+.

METHODS

Zhao and colleagues included 33 trials that recruited a total of 51,145 community-dwelling participants age 50 years and older, including any randomized clinical trial with a placebo or no treatment in the control group.

RESULTS

The authors found no significant association of calcium and/or vitamin D with risk of hip fracture compared with placebo or no treatment and concluded that the routine use of calcium, vitamin D, and the combination in community-dwelling older people is not supported by their findings. We discuss four concerns regarding this meta-analysis, including the target population, the selection of trials with regard to blinding and duration of follow-up, and the lack of adjustment for adherence to the interventions and subgroup analysis by bolus versus daily dosing for vitamin D.

CONCLUSION

Based on the four concerns raised in this letter and the fact that there will be a manyfold increase in the data on vitamin D supplementation in community-dwelling senior adults from large ongoing trials, we believe that it is too early to recommend the cessation of vitamin D with or without calcium for the prevention of fractures among community-dwelling adults.

Recovery after unilateral knee replacement due to severe osteoarthritis and progression in the contralateral knee: a randomised clinical trial comparing daily 2000 IU versus 800 IU vitamin D

Objective

To test whether daily high-dose vitamin D improves recovery after unilateral total knee replacement.

Methods

Data come from a 24-month randomised, double-blind clinical trial. Adults aged 60 and older undergoing unilateral joint replacement due to severe knee osteoarthritis were 6-8 weeks after surgery randomly assigned to receive daily high-dose (2000 IU) or standard-dose (800 IU) vitamin D₃. The primary endpoints were symptoms (Western Ontario and McMaster Universities Arthritis Index pain and function scores) assessed at baseline, 6, 12, 18 and 24 months in both knees, and the rate of falls over 24 months. The secondary outcomes were sit-to-stand performance, gait speed, physical activity and radiographic progression in the contralateral knee.

Results

We recruited 273 participants, 137 were randomised to receive 2000 IU and 136 were randomised to receive 800 IU vitamin D per day. 2000 IU vitamin D increased 25-hydroxyvitamin D levels to 45.6 ng/mL and 800 IU vitamin D to 37.1 ng/mL at month 24 (p<0.0001). While symptoms improved significantly in the operated knee and remained stable in the contralateral knee over time, none of the primary or secondary endpoints differed by treatment group over time. The rate of falls over 24 months was 1.05 with 2000 IU and 1.07 with 800 IU (p=0.84). 30.5% of participants in the 2000 IU and 31.3% of participants in the 800 IU group had radiographic progression in the contralateral knee over 24 months (p=0.88).

Conclusions

Our findings suggest that a 24-month treatment with daily 2000 IU vitamin D did not show greater benefits or harm than a daily standard dose of 800 IU among older adults undergoing unilateral total knee replacement.

[The Influence of Protein on the Prevention of Fragility Fractures Among Senior Adults]

The Influence of Protein on the Prevention of Fragility Fractures Among Senior Adults Abstract. The aim of this review article is to discuss protein intake in senior adults at risk for fragility fractures as a modifiable factor for fracture prevention. Proteins are building blocks of the bone matrix and the muscles. This dual function fits in with the concept of prevention of fragility fractures in senior adults aimed at reducing both bone loss and falls. In older adults, a protein-rich diet could be another simple and effective way to promote bone and muscle health, in addition to the established recommendations for adequate vitamin D and calcium intake.

Milk and other dairy foods and risk of hip fracture in men and women

The role of dairy foods for hip fracture prevention remains controversial. In this study, among US men and women, a glass of milk per day was associated with an 8% lower risk of hip fracture. This contrasts with a reported increased risk with higher milk intake in Swedish women.

INTRODUCTION

The purpose of this study was to examine whether higher milk and dairy food consumption are associated with risk of hip fracture in older adults following a report of an increased risk for milk in Swedish women.

METHODS

In two US cohorts, 80,600 postmenopausal women and 43,306 men over 50 years of age were followed for up to 32 years. Cox proportional hazards models were used to calculate the relative risks (RR) of hip fracture per daily serving of milk (240 mL) and other dairy foods that were assessed every 4 years, controlling for other dietary intakes, BMI, height, smoking, activity, medications, and disease diagnoses.

RESULTS

Two thousand one hundred thirty-eight incident hip fractures were identified in women and 694 in men. Each serving of milk per day was associated with a significant 8% lower risk of hip fracture in men and women combined (RR = 0.92, 95% confidence interval (CI) 0.87 to 0.97). A suggestive inverse association was found for cheese in women only (RR = 0.91, CI 0.81 to 1.02). Yogurt consumption was low and not associated with risk. Total dairy food intake, of which milk contributed about half, was associated with a significant 6% lower risk of hip fracture per daily serving in men and women (RR = 0.94, CI 0.90 to 0.98). Calcium, vitamin D, and protein from non-dairy sources did not modify the association between milk and hip fracture, nor was it explained by contributions of these nutrients from milk.

CONCLUSIONS

In this group of older US adults, higher milk consumption was associated with a lower risk of hip fracture.

Bone metabolism dynamics in the early post-transplant period following kidney and liver transplantation

Bone disease contributes to relevant morbidity after solid organ transplantation. Vitamin D has a crucial role for bone metabolism. Activation of vitamin D depends on the endocrine function of both, liver and kidney. Our study assessed key markers of bone metabolism at time of transplantation and 6 months after transplantation among 70 kidney and 70 liver recipients. In 70 kidney recipients 25-OH vitamin D levels did not differ significantly between peri-transplant (median 32.5nmol/l) and 6 months post-transplant (median 41.9nmol/l; P = 0.272). Six months post-transplant median 1, 25-(OH)₂ vitamin D levels increased by >300% (from 9.1 to 36.5ng/l; P<0.001) and median intact parathyroid hormone levels decreased by 68.4% (from 208.7 to 66.0 ng/l; P<0.001). Median β-Crosslaps (CTx) and total procollagen type 1 amino-terminal propeptide (P1NP) decreased by 65.1% (from 1.32 to 0.46ng/ml; P<0.001) and 60.6% (from 158.2 to 62.3ng/ml; P<0.001), respectively. Kidney recipients with incident fractures had significantly lower levels of 1, 25-(OH)₂ vitamin D at time of transplantation and of intact parathyroid hormone 6 months post-transplant. Among 70 liver recipients, 25-OH vitamin D, 1, 25-(OH)₂ vitamin D and intact parathyroid hormone levels were not significantly altered between peri-transplant and 6 months post-transplant. Contrary to kidney recipients, median CTx increased by 60.0% (from 0.45 to 0.72 ng/ml; P = 0.002) and P1NP by 49.3% (from 84.0 to 125.4ng/ml; P = 0.001) in the longitudinal course. Assessed biomarkers didn’t differ between liver recipients with and without fractures. To conclude, the assessed panel of biomarkers proved highly dynamic after liver as well as kidney transplantation in the early post-transplant period. After kidney transplantation a significant gain in 1, 25-(OH)₂ vitamin D combined with a decline in iPTH, CTx and P1NP, whereas after liver transplantation an increase in CTx and P1NP were characteristic.