Evaluation of bone turnover in postmenopause, vertebral fracture, and hip fracture using biochemical markers for bone formation and resorption

Longitudinal Changes in Serum Markers of Bone Metabolism and Bone Material Strength in Premenopausal Women with Distal Radial Fracture

BACKGROUND

Markers of bone metabolism (MBM) play an important role in fracture evaluation, and changes have been associated with increased fracture risk. The purpose of the present study was to describe changes in MBM in premenopausal women with distal radial fractures.

METHODS

Premenopausal women with distal radial fractures (n = 34) and without fractures (controls) (n = 39) were recruited. Serum MBM in patients with distal radial fractures were obtained at the time of the initial presentation, 6 weeks, and 3, 6, and 12 months. MBM included 25(OH) vitamin D, PTH, osteocalcin, P1NP, BSAP, CTX, sclerostin, DKK1, periostin, and TRAP5b. Areal bone mineral density (aBMD) was assessed with dual x-ray absorptiometry, and the bone material strength index (BMSi) was assessed with microindentation.

RESULTS

Most MBM reached peak levels at 6 weeks after the injury, including osteocalcin (+17.7%), sclerostin (+23.5%), and DKK1 (12.6%). Sclerostin was lower (-27.4%) and DKK1 was higher (+22.2%) at 1 year after the fracture. CTX declined below baseline levels at 6 and 12 months, whereas TRAP5b, BSAP, and periostin did not significantly change. At 12 months, sclerostin was lower (p = 0.003) and DKK1 was higher (p = 0.03) in the distal radial fracture group than in the control group. Greater fracture severity was associated with greater increases in P1NP and BSAP. aBMD and BMSi were not associated with fracture.

CONCLUSIONS

Distal radial fractures caused increases in several MBM, which typically peaked at 6 weeks after injury and gradually decreased over 6 months. Sclerostin and DKK1 remained below and above baseline at 1 year, respectively. Increasing fracture severity resulted in larger changes in MBM. aBMD and BMSi did not discriminate between patients with distal radial fractures and controls. Continued efforts to identify markers of skeletal fragility in young women are warranted to mitigate future fracture risk.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Analysis of Combined Indicators for Risk of Osteoporotic Hip Fracture in Elderly Women

Objective

To compare the accuracy of combined independent risk factors in assessing the risk of hip fractures in elderly women.

Methods

Ninety elderly females who sustained hip fractures (including femoral neck fractures and intertrochanteric fractures) and 110 female outpatients without a hip fracture were included in our cross‐sectional study from 24 November 2017 to 20 May 2019. The age of subjects in the present study was ≥65 years, with the mean age of 78.73 ± 7.77 and 78.09 ± 5.03 years for women with and without elderly hip fractures, respectively. Bone mineral density (BMD), Beta‐carboxy terminal telopeptide (β‐CTX), N‐terminal/mid region (N‐MID), and 25(OH)D levels were analyzed. A novel evaluation model was established to evaluate combined indicators in assessing hip fractures in elderly women.

Results

Compared with the control group, taller height (155.68 ± 6.40 vs 150.97 ± 6.23, P < 0.01), higher levels of β‐CTX (525.91 ± 307.38 vs 330.94 ± 289.71, P < 0.01), and lower levels of total hip BMD (0.662 ± 0.117 vs 0.699 ± 0.111, P = 0.022), femoral neck BMD (0.598 ± 0.106 vs 0.637 ± 0.100, P = 0.009), and 25(OH)D (15.67 ± 7.23 vs 29.53 ± 10.57, P < 0.01) were found in the facture group. After adjustment for confounding factors, logistic regression analysis revealed that 25(OH)D (adjusted OR 0.837 [95% CI 0.790–0.886]; P < 0.01), femoral neck BMD (adjusted OR 0.009 [95% CI 0.000–0.969]; P = 0.048) and height (adjusted OR 1.207 [95% CI 1.116–1.306]; P < 0.01) remained risk factors for hip fractures in elderly women. Then a model including independent risk factors was established. A DeLong test showed the area under the receiver operator characteristic (ROC) (Area under the curve [AUC]) of 25(OH)D was significantly greater than that for femoral neck BMD (P < 0.01) and height (P < 0.01). The AUC of model including 25(OH)D and height was significantly greater than that of other combinations (P < 0.01).

Conclusion

25(OH)D, femoral neck BMD and height were associated with the occurrence of hip fractures in elderly women even after adjustment for confounding factors, and a model including 25(OH)D and height could provide better associated power than other combinations in the assessment of elderly hip fractures.

Energy Deficiency Suppresses Bone Turnover in Exercising Women With Menstrual Disturbances

CONTEXT

In exercising women, energy deficiency can disrupt the balance of bone formation and resorption, resulting in bone loss and an altered rate of bone turnover, which may influence future bone mineral density and fracture risk.

OBJECTIVE

To assess the effects of energy status and estrogen status on bone turnover.

DESIGN

Cross-sectional.

SETTING

The Women's Health and Exercise Laboratory at Pennsylvania State University.

PARTICIPANTS

Exercising women (n = 109) operationally defined as energy deficient or replete based on total triiodothyronine concentration and as estrogen deficient or replete based on menstrual cycle history and reproductive hormone metabolites.

MAIN OUTCOME MEASURES

Bone formation index [procollagen type I N-terminal propeptide (P1NP) concentration corrected for average P1NP concentration in healthy reference group, i.e., [P1NP]i/median [P1NP]ref], bone resorption index [serum C-terminal telopeptide (sCTx) concentration corrected for average sCTx concentration in healthy reference group, i.e., [sCTx]i/median [sCTx]ref], bone balance (ratio of bone formation index to bone resorption index to indicate which process predominates), and bone turnover rate (collective magnitude of bone formation index and bone resorption index to indicate overall amount of bone turnover).

RESULTS

The combination of energy and estrogen deficiency resulted in less bone formation and a lower rate of bone turnover compared with women who were estrogen deficient but energy replete. Regardless of estrogen status, energy deficiency was associated with decreased bone resorption as well. No main effects of estrogen status were observed.

CONCLUSIONS

The results highlight the critical role that adequate energy plays in the regulation of bone turnover, especially bone formation, in exercising women with menstrual disturbances.

Bone Turnover Markers Are Not Associated With Hip Fracture Risk: A Case-Control Study in the Women's Health Initiative

Current guidelines recommend that serum C-terminal telopeptide of type I collagen (CTX) and serum procollagen type 1 aminoterminal propeptide (PINP), measured by standardized assays, be used as reference markers in observational and interventional studies. However, there are limited data to determine whether serum CTX and PINP are associated with hip fracture risk among postmenopausal women. We determined the associations of serum CTX and serum PINP with hip fracture risk among postmenopausal women aged 50 to 79 years at baseline. We performed a prospective case-control study (400 cases, 400 controls) nested in the Women's Health Initiative Observational Study, which enrolled participants at 40 US clinical centers. Cases were women with incident hip fracture not taking osteoporosis medication; hip fractures were confirmed using medical records. Untreated controls were matched by age, race/ethnicity, and date of blood sampling. Serum CTX and serum PINP were analyzed on 12-hour fasting blood samples. The main outcome measure was incident hip fracture risk (mean follow-up 7.13 years). After adjustment for body mass index, smoking, frequency of falls, history of fracture, calcium and vitamin D intake, and other relevant covariates, neither serum CTX level nor serum PINP level was statistically significantly associated with hip fracture risk (CTX p_trend  = 0.22, PINP p_trend  = 0.53). Our results do not support the utility of serum CTX level or PINP level to predict hip fracture risk in women in this age group. These results will inform future guidelines regarding the potential utility of these markers in fracture prediction. © 2018 American Society for Bone and Mineral Research.

Roles of chemokine receptor CX3CR1 in maintaining murine bone homeostasis through the regulation of both osteoblasts and osteoclasts

Chemokines have recently been reported to be involved in pathological bone destruction. However, the physiological roles of chemokines in bone metabolism in vivo have not been well documented. We analyzed the bone phenotypes in Cx3cr1-deficient mice. The mice exhibited slight but significant increases in trabecular and cortical thickness, reduced numbers of osteoclasts and increased rates of osteoid formation. Although the morphometric parameters showed marginal differences, the Cx3cr1-deficient bones showed an elevated expression of Osterix/SP7, which encodes an essential transcriptional factor for osteoblasts, whereas the gene Osteocalcin/Bglap, which encodes a late marker, was downregulated. The levels of transcripts for various osteoclastic markers, such as receptor activator of NF-κB (RANK)/TNFRSF11A, receptor activator of NF-κB ligand (RANKL)/TNFSF11, tartrate-resistant acid phosphatase 5b (TRAP5B)/ACP5B, Cathepsin K(CTSK), MMP3 and MMP13, were significantly decreased in the Cx3cr1-deficient bones. Cultured Cx3cr1-deficient osteoblastic cells showed inverse temporal patterns of osteoblastic marker expression and reduced calcium deposition. Furthermore, in vitro studies and immunofluorescence staining against CX3CR1 and CX3CL1 suggested a role for the CX3CR1-CX3CL1 axis in an early stage of osteoblast differentiation, possibly through their trans and cis interactions. Cultured Cx3cr1-deficient pre-osteoclasts showed impaired differentiation, mainly due to a deficiency of the CD115(+)CD11b(lo) osteoclastogenic population of myeloid-lineage precursors. The treatment of bone-marrow-derived osteoclastic cultures with recombinant CX3CL1 at different time points suggested that the CX3CR1-CX3CL1 axis favors the maintenance of osteoclastic precursors, but not differentiated osteoclasts. These observations uncovered novel roles of the CX3CR1-CX3CL1 axis in the differentiation of both osteoblasts and osteoclasts.

Deficiency of chemokine receptor CCR1 causes osteopenia due to impaired functions of osteoclasts and osteoblasts

Chemokines are characterized by the homing activity of leukocytes to targeted inflammation sites. Recent research indicates that chemokines play more divergent roles in various phases of pathogenesis as well as immune reactions. The chemokine receptor, CCR1, and its ligands are thought to be involved in inflammatory bone destruction, but their physiological roles in the bone metabolism in vivo have not yet been elucidated. In the present study, we investigated the roles of CCR1 in bone metabolism using CCR1-deficient mice. Ccr1(-/-) mice have fewer and thinner trabecular bones and low mineral bone density in cancellous bones. The lack of CCR1 affects the differentiation and function of osteoblasts. Runx2, Atf4, Osteopontin, and Osteonectin were significantly up-regulated in Ccr1(-/-) mice despite sustained expression of Osterix and reduced expression of Osteocalcin, suggesting a lower potential for differentiation into mature osteoblasts. In addition, mineralized nodule formation was markedly disrupted in cultured osteoblastic cells isolated from Ccr1(-/-) mice. Osteoclastogenesis induced from cultured Ccr1(-/-) bone marrow cells yielded fewer and smaller osteoclasts due to the abrogated cell-fusion. Ccr1(-/-) osteoclasts exerted no osteolytic activity concomitant with reduced expressions of Rank and its downstream targets, implying that the defective osteoclastogenesis is involved in the bone phenotype in Ccr1(-/-) mice. The co-culture of wild-type osteoclast precursors with Ccr1(-/-) osteoblasts failed to facilitate osteoclastogenesis. This finding is most likely due to a reduction in Rankl expression. These observations suggest that the axis of CCR1 and its ligands are likely to be involved in cross-talk between osteoclasts and osteoblasts by modulating the RANK-RANKL-mediated interaction.

Bone mineral density after concurrent chemoradiation in patients with uterine cervical cancer

OBJECTIVE

The aim of this study was to examine the bone mineral density (BMD) of women with cervical cancer treated with chemoradiation and to compare the outcomes with those of women with myomas treated by hysterectomy.

METHODS

The BMDs of 43 women with cervical cancer treated with concurrent chemoradiation (CCRT) were measured by dual-energy x-ray absorptiometry (L-spine and proximal femur) and compared with those of 43 matched control women with the same age distribution and body mass index. Medical records were reviewed retrospectively. Both women with cervical cancer and control women had reached menopause or had a history of bilateral salpingo-oophorectomy.

RESULTS

The lowest T scores for BMD were significantly lower in the women with cervical cancer treated with CCRT compared with the control women (P = 0.017). The serum total alkaline phosphatase was significantly higher in women with cervical cancer treated with CCRT (P = 0.027). There was no correlation between total alkaline phosphatase and BMD (L-spine and proximal femur; r = 0.089, P = 0.416). The BMDs of both the greater trochanter of the femur (P = 0.013) and L4 (P = 0.011) were significantly lower in women with cervical cancer than in the control women.

CONCLUSIONS

The results of this study suggest that postmenopausal women with uterine cervical cancer treated with CCRT have a lower BMD and are at risk for osteoporosis.

The treatment of osteoporosis in patients with rheumatoid arthritis receiving glucocorticoids: a comparison of alendronate and intranasal salmon calcitonin

OBJECTIVE

The purpose of this study was to assess the effects of alendronate and intranasal salmon calcitonin (sCT) treatments on bone mineral density and bone turnover in postmenopausal osteoporotic women with rheumatoid arthritis (RA) receiving low-dose glucocorticoids.

METHODS

Fifty osteoporotic postmenopausal women with RA, who had been treated with low-dose corticosteroids for at least 6 months, were randomized to receive alendronate 10 mg/day or sCT 200 IU/day for a period of 24 months. All patients received calcium supplementation 1,000 mg and vitamin D 400 IU daily. Bone mineral density (BMD) of the lumbar spine, femoral neck, and trochanter was measured annually using dual-energy X-ray absorptiometry. Bone metabolism measurements included urinary deoxypyridinoline (DPD), serum bone alkaline phosphatase (BAP), and serum osteocalcin (OC).

RESULTS

Over 2 years, the lumbar spine (4.34%, P < 0.001), femoral neck (2.52%, P < 0.05), and trochanteric (1.29%, P < 0.05) BMD in the alendronate group increased significantly. The sCT treatment increased lumbar spine BMD (1.75%, P < 0.05), whereas a significant bone loss occurred at the femoral neck at month 24 (-3.76%, P < 0.01). A nonsignificant decrease in the trochanteric region was observed in the sCT group (-0.81%). The difference between the groups with respect to the femoral neck and trochanteric BMD was statistically significant ( P < 0.001 and P < 0.05, respectively). The decreases in urinary DPD (-21.87%, P < 0.001), serum BAP (-10.60%, P < 0.01), and OC (-19.59%, P < 0.05) values were statistically significant in the alendronate group, whereas nonsignificant decreases were observed in the sCT group (-5.77%, -1.96%, and -4.31%, respectively). A significant difference was found in the DPD and BAP levels between the two treatment groups in favor of the alendronate group at all time points ( P = 0.001 and P < 0.05, respectively).

CONCLUSION

The results of this study demonstrated that alendronate treatment produced significantly greater increases in the femoral neck BMD and greater decreases in bone turnover than intranasal sCT in RA patients receiving low dose glucocorticoids.

Prostaglandin E2 receptor (EP4) selective agonist (ONO-4819.CD) accelerates bone repair of femoral cortex after drill-hole injury associated with local upregulation of bone turnover in mature rats

Prostaglandin E(2) (PGE(2)) is essential for fracture healing. Systemic administration of EP4 ligands such as PGE(2) and other synthetic EP4 agonists appears to transduce anabolic signals by binding to receptor EP4. Therefore, the present study was designed to test whether administration of EP4 agonist accelerates the healing of drill-hole injury in the femoral diaphysis. After surgery, a total of 128 Wistar rats, at the age of 12 weeks, were assigned to basal control (n = 8), and three groups with respective doses of 0 (vehicle control), 10 (low-dose), and 30 (high-dose) microg/kg body weight of the agent were subcutaneously injected twice a day. Femoral specimens were obtained at 0, 5, 7, 14, 21, and 28 days. In EP4 agonist-treated groups, the total bone volume of the regenerating bone in the defect did not significantly differ, but the regenerated cortical bone volume measured by histomorphometry and cortical bone mineral content (Ct. BMC) by pQCT dose-dependently increased at 14 and 21 days compared to the control. In the high-dose group, the value of osteoclast surface significantly increased compared with that in the control at 14 days. Expression levels of osteocalcin and TRAP mRNAs in the injured tissue increased at 14 days. Expression levels of EP4, BMP-2, and RANKL mRNAs increased at 7 days in the high-dose group. The bone mineral values of the lumbar bone at 28 days, measured by DXA, did not differ in the three groups. These data indicated that systemic administration of EP4 agonist ONO-4819.CD accelerated cortical bone healing after drill-hole injury by upregulating the local turnover of the regenerating bone.

Comparison of biochemical markers of bone turnover and bone mineral density between hip fracture and vertebral fracture

Bone density and the biochemical markers of bone turnover were compared between 26 hip-fracture patients and 41 vertebral-fracture patients after age adjustment to investigate whether or not type of osteoporosis differs between hip fracture and vertebral fracture. C-Terminal propepides of type I collagen (PIPC) was lower in hip fracture than vertebral fracture. The other bone formation markers (bone-specific alkaline phosphatase [ALP], osteocalcin) tended to be lower, and bone resorption markers (deoxypyridinoline, C-telopeptide crosslinking of type I collagen [CTX] tended to be higher in hip fracture compared to vertebral fracture. Mean of Z-scores of spine bone mineral density (BMD) in hip fracture and vertebral fracture were -0.461 and -0.919, respectively. Mean of Z-scores of femoral neck BMD in hip fracture and vertebral fracture were -0.994 and -0.361, respectively. All Z-scores were negative values, which means reduction of BMD compared to decade-matched controls. Z-scores of bone formation markers, such as bone-specific ALP, osteocalcin, and PIPC, were positive values in vertebral fracture, which means an increase against decade-matched controls, whereas those were negative values in hip fracture. Z-scores of bone resorption markers, such as deoxypyridinoline and CTX, were greater in hip fracture than in vertebral fracture. To express bone balance between formation and resorption in hip fracture and vertebral fracture, we calculated an uncoupling status index (USI) by the values of biochemical markers. USI of hip fracture showed a great negative value (-1.29), which indicates excess of bone resorption over formation, whereas that of vertebral fracture showed a small positive value (0.23). In conclusion, bone formation markers increase in vertebral fractures, but decrease in hip fracture. Bone resorption markers increase in both fracture, but greater increase in hip fracture.

Comparison of serum and urinary C-terminal telopeptide of type I collagen in aging, menopause and osteoporosis

BACKGROUND

Urinary C-terminal telopeptide of type I collagen (u-CTx) has been reported to be a sensitive biochemical marker of bone turnover. There have been two assays for urinary CTx, which are alpha-CTx and beta-CTx. A newly developed immunoassay for serum CTx (s-CTx) is now available for assessment of bone resorption. We evaluated the effects of aging, menopause, and osteoporosis on the measurements of serum CTx and compared them to urinary CTx assays.

METHODS

In 79 premenopausal healthy women, 80 postmenopausal healthy women, 61 osteoporotic patients with vertebral fractures and 34 osteoporotic patients with hip fractures, s-CTx and urinary beta-CTx (u-betaCTx) were measured by ELISAs, and urinary alpha-CTx (u-alphaCTx) was measured by an RIA.

RESULTS

In all subjects, s-CTx significantly correlated with both u-alphaCTx (r=0.54) and u-betaCTx (r=0.51). There was no significant difference among s-CTx, u-alphaCTx and u-betaCTx in the T-scores of the postmenopausal group over the premenopausal group. These findings indicate that the value of s-CTx, as well as urinary CTxs, reflected the increase of bone resorption associated with menopause with a high degree of sensitivity. Patients with vertebral fractures had moderately increased concentrations of bone resorption markers compared to age-matched healthy postmenopausal women (T-score; s-CTx: 0.8, u-alphaCTx: 0.9, u-betaCTx: 0.7), whereas bone resorption markers in hip fracture patients were greatly increased compared to healthy postmenopausal women (T-score; s-CTx: 1.1, u-alphaCTx: 1.3 u-betaCTx: 1.3). The T-scores of u-CTxs against the postmenopausal group in vertebral fracture group and in hip fracture group were not significantly different from those of s-CTx.

CONCLUSIONS

s-CTx, as well as urinary CTxs, reflects the increase of bone resorption in patients with vertebral fractures and hip fractures.

Biochemical markers and bone mineral density in patients with hip fractures in men

The purpose of this study was to determine whether males with hip fractures have associated decreased gonadal function. Second void urine and serum samples were obtained from 25 male hip fracture patients (mean age+/-SD, 78.5+/-5.9 years) and 19 age- and gender-matched controls (77.6+/-6.2 years). Serum levels of luteinizing hormone (LH), total testosterone (Te), total estradiol (E2), dehydroepiandrosterone sulfate (DHEAS), 1,25(OH)2D3, N-mid osteocalcin (OC(N-mid)), type I collagen degradation products (S-CTx) and urinary levels of pyridinoline (Pyr), deoxypyridinoline (Dpyr) and type I collagen degradation products (U-CTx) were measured. Bone mineral density (BMD) of the L2-4 spine, femoral neck, trochanter, Ward's triangle, distal one third portion of the radius and ultradistal radius were also measured in the fracture group. Serum levels of LH, E2, Te, DHEAS, 1,25(OH)2D3 and OCN-mid in the fracture group were not statistically different from those in the control group. Levels of urinary Pyr, CTx and S-CTx in the fracture group increased significantly compared with those in the control group. In the fracture group, serum levels of Te correlated positively with distal one third portion of the radius BMD and ultradistal radius BMD. U-CTx and S-CTx correlated negatively with all the BMD measurement sites in the hip region and with the radius BMD. An imbalance between bone resorption and bone formation was evident in male hip fracture patients. However, male patients with hip fractures did not show associated decreased gonadal function in this study.

Biochemical markers of bone turnover do not decline after menopause in healthy women

OBJECTIVES

To investigate the duration of high bone turnover after menopause in normal healthy women.

DESIGN

Study recruited from three screening studies for health care in the elderly held in the area of Hamamatsu city.

SETTING

Department of Orthopaedic Surgery, Hospital at Hamamatsu University School of Medicine, Hamamatsu.

PARTICIPANTS

Ninety-two healthy postmenopausal women aged 47-81 years and 18 premenopausal women.

MAIN OUTCOME MEASURES

Bone mass was determined by densitometry of the spine and the os calcis, or by ultrasound of the os calcis. Biochemical markers of bone turnover were measured including total and bone-specific alkaline phosphatase, osteocalcin, C-terminal propeptide of type I procollagen, free deoxypyridinoline and urinary degredation products of type I collagen.

RESULTS

All markers except the C-terminal propeptide of type I procollagen were significantly higher in early postmenopausal women than in premenopausal women. Postmenopausal women were divided into four groups according to years since menopause. There was no difference in biochemical markers among those women in whom years since menopause were 1 to 5, 6 to 15, 16 to 25 and >26. There were no correlations between biochemical markers and age in postmenopausal women. When the postmenopausal women were divided into three groups according to t-scores of bone mass, there was no significant difference in the biochemical markers among the groups.

CONCLUSIONS

High bone turnover occuring after menopause lasts for >25 years during the postmenopausal period.