1
|
Raimundo A, Charrua Z, Batalha N, Pereira C, Parraca J, Tomas-Carus P. High Levels of Physical Activity May Promote a Reduction in Bone Mineral Density in Peritoneal Dialysis. MEDICINA (KAUNAS, LITHUANIA) 2020; 56:E464. [PMID: 32932809 PMCID: PMC7558793 DOI: 10.3390/medicina56090464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 09/08/2020] [Accepted: 09/08/2020] [Indexed: 12/26/2022]
Abstract
Background and objectives: Peritoneal dialysis (PD) patients are expected to present lower levels of physical activity, unhealthy changes at the body composition level, and low levels of strength. Firstly, this study aimed to report the sex differences in physical activity, body composition and muscle strength and the relations among these variables. Secondly, we analyze the relationship between physical activity and biochemical parameters. Materials and Methods: Thirty-four patients (13 women and 21 men) participated in this study. Body composition was assessed by bioimpedance and dual-energy X-ray absorptiometry (DXA), and maximum isokinetic unilateral strength, analytical parameters and physical activity levels were evaluated. Results: The men showed higher values for weight, height, lean body mass, bone mineral content, bone mineral density (BMD) and total body water, while women showed higher values for the percentage of fat mass and hydration of lean body mass (p < 0.05). No differences between the sexes were found in different levels of physical activity; however, males registered significantly higher values for isokinetic strength variables except for knee extensor strength. BMD was positively related to sedentary activity and negatively related to moderate and vigorous activity (r = 0.383 and r = -0.404, respectively). Light physical activity was negatively correlated with albumin (r = -0.393) and total protein (r = -0.410) levels, while moderate/vigorous activity was positively correlated with urea distribution volume (r = 0.446) and creatinine clearance (r = 0.359) and negatively correlated with the triglyceride level (r = -0.455). Conclusions: PD patients with higher levels of physical activity present better results in terms of body composition and biochemical parameters. Additional studies should be conducted to clarify the relation between physical activity level and BMD.
Collapse
Affiliation(s)
- Armando Raimundo
- Departamento de Desporto e Saúde, Escola de Ciência e Tecnologia, Universidade de Évora, 7000 Évora, Portugal; (Z.C.); (N.B.); (C.P.); (J.P.); (P.T.-C.)
- Comprehensive Health Research Center (CHRC), University of Évora, 7000 Évora, Portugal
| | - Zelinda Charrua
- Departamento de Desporto e Saúde, Escola de Ciência e Tecnologia, Universidade de Évora, 7000 Évora, Portugal; (Z.C.); (N.B.); (C.P.); (J.P.); (P.T.-C.)
| | - Nuno Batalha
- Departamento de Desporto e Saúde, Escola de Ciência e Tecnologia, Universidade de Évora, 7000 Évora, Portugal; (Z.C.); (N.B.); (C.P.); (J.P.); (P.T.-C.)
- Comprehensive Health Research Center (CHRC), University of Évora, 7000 Évora, Portugal
| | - Catarina Pereira
- Departamento de Desporto e Saúde, Escola de Ciência e Tecnologia, Universidade de Évora, 7000 Évora, Portugal; (Z.C.); (N.B.); (C.P.); (J.P.); (P.T.-C.)
- Comprehensive Health Research Center (CHRC), University of Évora, 7000 Évora, Portugal
| | - Jose Parraca
- Departamento de Desporto e Saúde, Escola de Ciência e Tecnologia, Universidade de Évora, 7000 Évora, Portugal; (Z.C.); (N.B.); (C.P.); (J.P.); (P.T.-C.)
- Comprehensive Health Research Center (CHRC), University of Évora, 7000 Évora, Portugal
| | - Pablo Tomas-Carus
- Departamento de Desporto e Saúde, Escola de Ciência e Tecnologia, Universidade de Évora, 7000 Évora, Portugal; (Z.C.); (N.B.); (C.P.); (J.P.); (P.T.-C.)
- Comprehensive Health Research Center (CHRC), University of Évora, 7000 Évora, Portugal
| |
Collapse
|
2
|
Boonpheng B, Thongprayoon C, Mao MA, Wijarnpreecha K, Bathini T, Kaewput W, Ungprasert P, Cheungpasitporn W. Risk of hip fracture in patients on hemodialysis versus peritoneal dialysis: A meta-analysis of observational studies. J Evid Based Med 2019; 12:98-104. [PMID: 30701673 DOI: 10.1111/jebm.12341] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 12/31/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Bone and mineral metabolism disorders are common among end-stage renal disease (ESRD) patients, which could lead to hip fracture. It is unclear whether the hip fracture risk is different among patients on hemodialysis (HD) versus peritoneal dialysis (PD). This meta-analysis was conducted to evaluate the hip fracture risk in ESRD patients on HD, when compared to PD. METHODS A literature review was conducted in EMBASE, MEDLINE, and Cochrane databases through January 31, 2018 to identify studies that appraised the rate or risk of hip fracture among patients on HD, when compared to PD. Effect estimates from the individual studies were derived and consolidated utilizing random-effect, generic inverse variance approach of DerSimonian and Laird. RESULTS Five cohort studies with 1 276 677 ESRD patients were enrolled. HD status was associated with a significantly higher risk of hip fracture with the pooled odds ratio (OR) of 1.61 (95% confidence interval [CI] 1.50-1.73, I2 = 10.0%), compared with PD. When the analysis was limited to studies with confounder-adjusted analysis, the pooled OR of hip fracture among HD patients was 1.57 (95% CI 1.43-1.72, I2 = 13.6%). Funnel plots and Egger's regression test demonstrated no significant publication bias in our meta-analysis. CONCLUSIONS Among ESRD patients, HD status is associated with a 61% higher risk of hip fracture compared to PD.
Collapse
Affiliation(s)
- Boonphiphop Boonpheng
- Department of Internal Medicine, East Tennessee State University, Johnson City, Tennessee
| | - Charat Thongprayoon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Michael A Mao
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Karn Wijarnpreecha
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Jacksonville, Florida
| | - Tarun Bathini
- Department of Internal Medicine, University of Arizona, Tucson, Arizona
| | - Wisit Kaewput
- Department of Military and Community Medicine, Phramongkutklao College of Medicine, Bangkok, Thailand
| | - Patompong Ungprasert
- Clinical Epidemiology Unit, Department of Research and Development, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Wisit Cheungpasitporn
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| |
Collapse
|
3
|
Rroji M, Seferi S, Cafka M, Petrela E, Likaj E, Barbullushi M, Thereska N, Spasovski G. Is residual renal function and better phosphate control in peritoneal dialysis an answer for the lower prevalence of valve calcification compared to hemodialysis patients? Int Urol Nephrol 2013; 46:175-82. [PMID: 23591721 DOI: 10.1007/s11255-013-0438-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Accepted: 04/02/2013] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Cardiac valve calcification (CVC) has long been regarded as a consequence of abnormal calcium-phosphate metabolism in uremic patient associated with increased cardiovascular mortality in this population. We evaluated the association between residual renal function (RRF), phosphate level and valve calcification in peritoneal dialysis (PD) and hemodialysis (HD) patients. METHODS We studied 30 stable PD patients (60 % males; mean age 57 ± 12.36 years) and 34 HD patients (58.8 % males; mean age 50.8 ± 10.4 years) on renal replacement therapy (RRT) from 6 up to 36 months. The presence of CVC was assessed by standard bi-dimensional echocardiography. RRF was calculated by standard technique. RESULTS Valve calcification was more frequently found in HD compared to PD patients (70.6 vs 29.4 %, p = 0.007). Significantly lower phosphate [1.38 ± 0.41 versus 1.99 ± 0.35 mmol/L (p < 0.0001)], a higher RRF [4.09 ± 2.09 ml/min vs 0.62 ± 0.89 ml/min (p < 0.0001)], and older age [57 ± 12.36 years vs 50.8 ± 10.4 years (p = 0.033)] were observed in PD as compared to HD patients. The logistic regression analysis for the presence of valve calcification when adjusted for age and diabetes, with type of therapy, serum phosphate, RRF, CRP, and serum albumin as variables in the model, revealed significant association between the presence of valve calcification and age and RRF. The correlation between phosphate levels and RRF was even stronger in PD patients than in HD patients (r = -0.704; p = 0.0001) vs (r = -0.502; p = 0.02). CONCLUSIONS Our study shows that the residual renal function in PD patients contributes significantly to the maintenance of phosphate balance and may explain the lower prevalence of valve calcification in PD patients compared with HD patients in the period up to first 3 years under renal replacement therapy.
Collapse
Affiliation(s)
- Merita Rroji
- Department of Nephrology-Dialysis-Transplantation, UHC "Mother Teresa", Dibra Street Nr 370, Tirana, Albania,
| | | | | | | | | | | | | | | |
Collapse
|
4
|
Avila M, Prado C, Ventura MDJ, Mora C, Briones D, Valdez H, Hurtado ME, Lindholm B, Qureshi A, Castillo-Henkel C, Paniagua R. Vitamin D receptor gene, biochemical bone markers and bone mineral density in Mexican women on dialysis. Nephrol Dial Transplant 2010; 25:2259-65. [PMID: 20124547 DOI: 10.1093/ndt/gfq019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The influence of the Bsm1 polymorphism of the vitamin D receptor (VDR) gene on mineral and bone disorders in chronic kidney disease (CKD) is still under discussion. The aim of this study was to analyse the relationship between VDR polymorphism, bone mineral density (BMD), biochemical bone markers and clinical factors in women on peritoneal dialysis (PD) and haemodialysis (HD). METHODS In a cross-sectional study, 197 women (42 +/- 10 years; 25% with diabetes mellitus (DM); body mass index (BMI) 25.26 +/- 4.77 kg/m(2)) treated by PD (72%) or HD (28%) underwent measurements of BMD (measured at the calcaneus by quantitative ultrasound; expressed as T- and Z-scores) and plasma total calcium (tCa), intact parathyroid hormone 1-84 (iPTH), phosphorus, albumin, glucose, osteoprotegerin (OPG), fetuin-A, intact osteocalcin-49 and N-MID fragment 1-43 aa (N-MID osteocalcin) N-terminal propeptide of type 1 procollagen (PINP) and C-terminal telopeptide-beta aspartic acid (BCL). DNA was extracted from peripheral blood. PCR products were digested with Bsm1 to analyse VDR polymorphism. RESULTS The Z-score of BMD was -1.1 +/- 1.03. According to the values of osteopenia (T-score = -1.0), patients with higher BMD were younger, had lower frequency of amenorrhoea and diabetes and had higher serum creatinine and fetuin levels as well as lower levels of PINP. In a stepwise multivariate logistics analysis, osteopenia was associated with presence of genotype BB+Bb (OR = 3.26, P < or = 0.003) and age (OR = 0.95, P = 0.050). According to the B allele, bb: n = 126 (64%) and BB+Bb: n = 71(36%), group bb had significantly higher mean Z-scores (-0.97 +/- 1.0 vs -1.3+/-0.92; P < or = 0.021). CONCLUSIONS The high frequency of osteopenia observed in female CKD patients on dialysis is associated with age and genetic predisposition as revealed by its association to the Bsm1 VDR polymorphism.
Collapse
Affiliation(s)
- Marcela Avila
- Unidad de Investigación Médica en Enfermedades Nefrológicas, Hospital de Especialidades, CMN SXXI, Instituto Mexicano del Seguro Social, México City, México.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
5
|
Ambrus C, Marton A, Nemeth ZK, Mucsi I. Bone mineral density in patients on maintenance dialysis. Int Urol Nephrol 2009; 42:723-39. [DOI: 10.1007/s11255-009-9666-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2009] [Accepted: 10/13/2009] [Indexed: 01/09/2023]
|
6
|
|
7
|
Popp AW, Senn C, Franta O, Krieg MA, Perrelet R, Lippuner K. Tibial or hip BMD predict clinical fracture risk equally well: results from a prospective study in 700 elderly Swiss women. Osteoporos Int 2009; 20:1393-9. [PMID: 19096747 DOI: 10.1007/s00198-008-0808-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2008] [Accepted: 11/07/2008] [Indexed: 12/24/2022]
Abstract
SUMMARY In a randomly selected cohort of Swiss community-dwelling elderly women prospectively followed up for 2.8 +/- 0.6 years, clinical fractures were assessed twice yearly. Bone mineral density (BMD) measured at tibial diaphysis (T-DIA) and tibial epiphysis (T-EPI) using dual-energy X-ray absorptiometry (DXA) was shown to be a valid alternative to lumbar spine or hip BMD in predicting fractures. INTRODUCTION A study was carried out to determine whether BMD measurement at the distal tibia sites of T-EPI and T-DIA is predictive of clinical fracture risk. METHODS In a predefined representative cohort of Swiss community-dwelling elderly women aged 70-80 years included in the prospective, multi-centre Swiss Evaluation of the Methods of Measurement of Osteoporotic Fracture risk (SEMOF) study, fracture risk profile was assessed and BMD measured at the lumbar spine (LS), hip (HIP) and tibia (T-DIA and T-EPI) using DXA. Thereafter, clinical fractures were reported in a bi-yearly questionnaire. RESULTS During 1,786 women-years of follow-up, 68 clinical fragility fractures occurred in 61 women. Older age and previous fracture were identified as risk factors for the present fractures. A decrease of 1 standard deviation in BMD values yielded a 1.5-fold (HIP) to 1.8-fold (T-EPI) significant increase in clinical fragility fracture hazard ratio (adjusted for age and previous fracture). All measured sites had comparable performance for fracture prediction (area under the curve range from 0.63 [LS] to 0.68 [T-EPI]). CONCLUSION Fracture risk prediction with BMD measurements at T-DIA and T-EPI is a valid alternative to BMD measurements at LS or HIP for patients in whom these sites cannot be accessed for clinical, technical or practical reasons.
Collapse
Affiliation(s)
- A W Popp
- Osteoporosis Policlinic, Inselspital, Bern University Hospital and University of Bern, CH-3010 Bern, Switzerland
| | | | | | | | | | | |
Collapse
|
8
|
|
9
|
OTT SUSANM. Review article: Bone density in patients with chronic kidney disease stages 4-5. Nephrology (Carlton) 2009; 14:395-403. [DOI: 10.1111/j.1440-1797.2009.01159.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
10
|
Levy R, Gal-Moscovici A. Renal Osteodystrophy in Peritoneal Dialysis: Special Considerations. Perit Dial Int 2008. [DOI: 10.1177/089686080802802s03] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Bone disease is one of the most challenging complications in patients with chronic kidney disease. Today, it is considered to be part of a complex systemic disorder manifested by disturbances of mineral metabolism and vascular calcifications called chronic kidney disease – mineral bone disorder (CKD-MBD). The term renal osteodystrophy is reserved to define the specific bone lesion in CKD-MBD, whose spectrum ranges from high turnover to low turnover disease. Phosphate retention, decreased serum calcium, and 1,25-dihydroxy vitamin D synthesis are involved in the pathogenesis of high bone turnover. However, the various therapeutic approaches (calcium supplements, phosphate binders, and vitamin D metabolites, among others), the renal replacement modality (hemodialysis or continuous ambulatory peritoneal dialysis), and the types of patients to whom dialysis is offered (more patients who are diabetic or older, or both) may influence the evolution of the bone disorder. As a result, recent studies have reported a greater prevalence of adynamic forms of renal osteodystrophy, especially in diabetic and peritoneal dialysis patients. The present article reviews, for patients treated with peritoneal dialysis, the pathophysiologic mechanisms involved in the evolution and perpetuation of this bone disease and the therapeutic modalities for treating and preventing adynamic bone.
Collapse
Affiliation(s)
- Ronen Levy
- Division of Nephrology and Hypertension and Department of Medicine, Hadassah Medical Organization, Hebrew University, Ein-Karem, Jerusalem, Israel
| | - Anca Gal-Moscovici
- Division of Nephrology and Hypertension and Department of Medicine, Hadassah Medical Organization, Hebrew University, Ein-Karem, Jerusalem, Israel
| |
Collapse
|
11
|
Wehrli FW, Leonard MB, Saha PK, Gomberg BR. Quantitative high-resolution magnetic resonance imaging reveals structural implications of renal osteodystrophy on trabecular and cortical bone. J Magn Reson Imaging 2004; 20:83-9. [PMID: 15221812 DOI: 10.1002/jmri.20085] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To explore the potential role of micro-magnetic resonance imaging (micro-MRI) for quantifying trabecular and cortical bone structural parameters in renal osteodystrophy (ROD), a multifactorial disorder of bone metabolism, traditionally evaluated by bone biopsy. MATERIALS AND METHODS Seventeen hemodialysis patients (average PTH level = 502 +/- 415 microg/liter) were compared with 17 age-, gender-, and body mass index (BMI)-matched control subjects. The average dialysis duration for the patients was 5.5 years (range = 0.96-18.2 years). Three-dimensional (3D) fast large-angle spin-echo (FLASE) MR images of the distal tibia (voxel size = 137 x 137 x 410 microm(3)) were processed to yield bone volume fraction (BV/TV). From a skeletonized representation of the trabecular bone network, the topology of each bone voxel was determined providing surface and curve voxel densities (SURF and CURV) and the topological erosion index (EI). Further, high-resolution two-dimensional (2D) spin-echo images were collected at the tibial midshaft for measurement of cortical bone cross-sectional area (CCA), relative CCA expressed as a percentage of total bone area (RCA), and mean cortical thickness (MCT). RESULTS The data show both RCA and MCT to be lower in the patients (61.2 vs. 69.1%, P = 0.008, and 4.53 vs. 5.19 mm, P = 0.01). BV/TV and SURF were lower, while EI was increased in the patients, although these differences were not quite significant (P = 0.06-0.09). All of the cortical and trabecular findings are consistent with increased bone fragility. CONCLUSION The data suggest that micro-MRI may have potential to characterize the structural implications of metabolic bone disease, potentially providing a noninvasive tool for the evaluation of therapies for ROD.
Collapse
Affiliation(s)
- Felix W Wehrli
- Laboratory for Structural NMR Imaging, Department of Radiology, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania 19104, USA.
| | | | | | | |
Collapse
|
12
|
Mareš J, Opatrná S, Ferda J, Opatrný K, Tomšu M, Šefrna F, Kreuzberg B, Topolcan O. Computed Tomography-Based Assessment of Bone Mineral Density in Patients Treated with Peritoneal Dialysis. Perit Dial Int 2003. [DOI: 10.1177/089686080302300617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Jan Mareš
- Departments of Internal Medicine I, Charles University Medical School Pilsen, Czech Republic
| | - Sylvie Opatrná
- Departments of Internal Medicine I, Charles University Medical School Pilsen, Czech Republic
| | - Jirí Ferda
- Department of Diagnostic Radiology Charles University Medical School Pilsen, Czech Republic
| | - Karel Opatrný
- Departments of Internal Medicine I, Charles University Medical School Pilsen, Czech Republic
| | - Martina Tomšu
- Departments of Internal Medicine I, Charles University Medical School Pilsen, Czech Republic
| | - František Šefrna
- Departments of Internal Medicine I, Charles University Medical School Pilsen, Czech Republic
| | - Boris Kreuzberg
- Department of Diagnostic Radiology Charles University Medical School Pilsen, Czech Republic
| | - Ondrej Topolcan
- II, Charles University Medical School Pilsen, Czech Republic
| |
Collapse
|
13
|
Hidaka H, Nakao T. Preservation of residual renal function and factors affecting its decline in patients on peritoneal dialysis. Nephrology (Carlton) 2003; 8:184-91. [PMID: 15012719 DOI: 10.1046/j.1440-1797.2003.00156.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The decline of residual renal function (RRF) in peritoneal dialysis (PD) patients was analysed and assessed, and risk factors affecting its decline were identified. Residual glomerular filtration rate (GFR) was calculated from averaging the urea and creatinine clearance by 24-h urine collection, and peritoneal solute removal was evaluated by creatinine clearance calculated from 24-h effluent collection. Both GFR and peritoneal solute removal were chronologically examined in 34 PD patients from the time of initiation, and risk factors associated with rapid GFR decline were investigated. The RRF contributed to 43.1 +/- 17.6% of total (peritoneal and renal) weekly creatinine clearance at 1 month after initiation of PD. Residual GFR, however, declined continuously with time (-0.19 +/- 0.14 mL/min per month), and the reduction rate was high with a higher GFR, higher normalized dietary protein intake, higher urine volume and higher urine protein excretion at the initiation of PD. Other factors related to the rapid decline of GFR were: being older than 60 years of age, automated peritoneal dialysis (APD) rather than continuous ambulatory peritoneal dialysis, mean blood pressure higher than 110 mmHg, and serum human atrial natriuretic peptide level higher being than 60 pg/dL. These data suggest that while RRF plays an important role in the removal of uraemic solute in PD patients, they show a significant decrease over 2 years. The factors related to the rapid decline of GFR corresponded to older age, modality of PD (APD), higher GFR and higher amount of urine protein at initiation, higher dietary protein intake, and inadequate control of hypertension and body fluid volume.
Collapse
Affiliation(s)
- Hiromi Hidaka
- Department of Nephrology, Tokyo Medical University, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo 160-0023, Japan
| | | |
Collapse
|
14
|
Affiliation(s)
- A M Parfitt
- Division of Endocrinology and Metabolism and Center for Osteoporosis and Metabolic Bone Disease, University of Arkansas for Medical Sciences, Little Rock 72205-7199, USA
| |
Collapse
|