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Rytz CL, Kochaksaraei GS, Skeith L, Ronksley PE, Dumanski SM, Robert M, Ahmed SB. Menstrual Abnormalities and Reproductive Lifespan in Females with CKD: A Systematic Review and Meta-Analysis. Clin J Am Soc Nephrol 2022; 17:1742-1753. [PMID: 36418040 PMCID: PMC9718020 DOI: 10.2215/cjn.07100622] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 10/16/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Menstrual abnormalities and shortened reproductive lifespan are associated with shorter life expectancy and higher cardiovascular and osteoporosis risk in the general population, although the magnitude of these reproductive factor irregularities in females with CKD is unclear. This systematic review and meta-analysis aimed to summarize the current knowledge regarding menstrual abnormalities and reproductive lifespan among females with CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A comprehensive bibliographic search (MEDLINE, Embase, and Cumulative Index to Nursing and Allied Health Literature [CINAHL]) was completed from database inception to February 2022 to identify all original articles reporting on females of reproductive age with nondialysis-dependent/nonkidney transplant CKD, dialysis-dependent CKD, or kidney transplantation and menstruation patterns, age of menarche, and/or menopause. Data extraction and study quality assessment were completed in duplicate. Random effects meta-analyses were used to derive pooled proportions estimates. RESULTS Forty-six studies were identified, and 35 were meta-analyzed, stratified by KRT modality and reported outcome. Menstrual abnormalities were present in 19%-47% of patients on hemodialysis and 75% of patients on peritoneal dialysis. Kidney transplantation was associated with a 7%-30% decrease in menstrual abnormalities. Reproductive lifespan was 32 years (95% confidence interval, 30 to 34 years). Although significant heterogeneity was present, study quality ranged from fair to good, and no evidence of publication bias was noted. CONCLUSIONS Menstrual abnormalities and shorter reproductive lifespan are common in females with CKD, although kidney transplantation may improve menstrual health.
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Affiliation(s)
- Chantal L. Rytz
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Leslie Skeith
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
- Alberta Kidney Disease Network, Calgary, Alberta, Canada
| | - Paul E. Ronksley
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
- Alberta Kidney Disease Network, Calgary, Alberta, Canada
| | - Sandra M. Dumanski
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
- Alberta Kidney Disease Network, Calgary, Alberta, Canada
| | - Magali Robert
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada
| | - Sofia B. Ahmed
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
- Alberta Kidney Disease Network, Calgary, Alberta, Canada
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Khelifi N, Desbiens L, Sidibé A, Mac‐Way F. Vitamin D Analogues and Fracture Risk in Chronic Kidney Disease: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. JBMR Plus 2022; 6:e10611. [PMID: 35434454 PMCID: PMC9009117 DOI: 10.1002/jbm4.10611] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 01/25/2022] [Indexed: 11/15/2022] Open
Abstract
Vitamin D receptor agonists (VDRAs) are commonly prescribed in chronic kidney disease (CKD). However, their protective effects on bone remain controversial. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the effect of VDRAs on fracture risk and bone mineral density (BMD) in adult patients with CKD. We searched MEDLINE, EMBASE, CENTRAL, ClinicalTrials.gov, and the WHO's International Clinical Trials Registry Platform databases from inception to June 19, 2021. We included RCTs comparing VDRAs, to placebo or another medication, in adults with CKD requiring or not dialysis. Conference abstracts and trials involving kidney transplant recipients and/or comparing VDRAs to antiresorptive or anabolic bone therapy were excluded. Primary outcome was fracture at any anatomical site. Secondary outcomes were BMD at femoral neck, lumbar spine, and/or total hip. Prespecified subgroup analyses were conducted according to baseline demographics, overall risk of bias, and follow-up time. From 6868 references retrieved, eight RCTs were eligible: five reported fracture, two reported BMD, and one reported both outcomes. As comparator, one study used no VDRAs, one used nutritional intervention and no medication, and six used placebo. In meta-analysis, VDRAs were not associated with a significant reduction in total fractures in overall (risk ratio = 0.79, 95% confidence interval 0.38-1.65, I2 = 0%, six trials, 1507 participants, 27 fractures) or in prespecified subgroup analyses. Three trials reported BMD at different sites and with different BMD measurements; thus, a meta-analysis could not be performed. Two RCTs were at high risk of bias, notably because of deviations from the intended interventions. As limitation, we have to mention the low total number of fractures included in our meta-analysis. In conclusion, current evidence from RCTs is insufficient to associate VDRAs with bone protection in CKD. Further large and long-term studies specifically designed to evaluate the efficacy of VDRAs on bone outcomes are thus required. © 2022 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Nada Khelifi
- CHU de Québec Research Center, Division of NephrologyEndocrinology and Nephrology AxisQuebec CityCanada
- Faculty and Department of MedicineUniversité LavalQuebec CityCanada
| | - Louis‐Charles Desbiens
- CHU de Québec Research Center, Division of NephrologyEndocrinology and Nephrology AxisQuebec CityCanada
- Faculty and Department of MedicineUniversité LavalQuebec CityCanada
| | - Aboubacar Sidibé
- CHU de Québec Research Center, Division of NephrologyEndocrinology and Nephrology AxisQuebec CityCanada
- Faculty of Medicine, Department of Social and Preventive MedicineUniversité LavalQuebec CityCanada
| | - Fabrice Mac‐Way
- CHU de Québec Research Center, Division of NephrologyEndocrinology and Nephrology AxisQuebec CityCanada
- Faculty and Department of MedicineUniversité LavalQuebec CityCanada
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Li M, Cheng J, Zhao J, Xue W, Bao H, Song Y, Qin L. Relationship between intact parathyroid hormone and all-cause death, cardiovascular events, and ectopic calcification in patients with diabetic kidney disease: A retrospective study. Diabetes Res Clin Pract 2021; 177:108926. [PMID: 34161808 DOI: 10.1016/j.diabres.2021.108926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 06/11/2021] [Accepted: 06/17/2021] [Indexed: 11/29/2022]
Abstract
AIM We aimed to investigate the relationship between intact parathyroid hormone (iPTH) levels and all-cause death, cardiovascular events, and ectopic calcification in patients with diabetic kidney disease (DKD). METHODS In this retrospective cohort study, we collected the clinical data of 508 patients with clinically diagnosed DKD. The primary and secondary outcomes were all-cause death or cardiovascular events and ectopic calcification, respectively. We used different regression methods to analyze the relationship between various clinical parameters and the two clinical outcomes. RESULTS We found that iPTH was a risk factor for all-cause death and cardiovascular events (hazards ration [HR]: 2.817, 95% confidence interval [CI]: 1.045-6.562, P = 0.016). Meanwhile, diabetes duration (HR: 1.090, 95% CI: 1.045-1.138, P < 0.0001), triglycerides (TG) (HR: 1.254, 95% CI: 1.049-1.499, P = 0.013), and iPTH (HR: 1.954, 95% CI: 1.001-3.813, P = 0.049) were independent risk factors for ectopic calcification. In contrast to patients with lower iPTH levels (iPTH < 31.7 pg/mL), patients with higher iPTH levels (iPTH ≥ 31.7 pg/mL) had increased ectopic calcification rate (P = 0.002) and decreased survival time (P < 0.001). CONCLUSION In patients with DKD, higher iPTH levels were significantly related to worsen clinical outcomes.
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Affiliation(s)
- Mengyuan Li
- Department of Nephrology & Rheumatology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301, Middle Yanchang Road, Shanghai 200072, China
| | - Jiafen Cheng
- Department of Nephrology & Rheumatology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301, Middle Yanchang Road, Shanghai 200072, China
| | - Jian Zhao
- Department of Nephrology & Rheumatology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301, Middle Yanchang Road, Shanghai 200072, China
| | - Wen Xue
- Department of Nephrology & Rheumatology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301, Middle Yanchang Road, Shanghai 200072, China
| | - Hui Bao
- Department of Nephrology & Rheumatology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301, Middle Yanchang Road, Shanghai 200072, China
| | - Yaxiang Song
- Department of Nephrology & Rheumatology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301, Middle Yanchang Road, Shanghai 200072, China.
| | - Ling Qin
- Department of Nephrology & Rheumatology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301, Middle Yanchang Road, Shanghai 200072, China.
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McKee H, Ioannidis G, Lau A, Treleaven D, Gangji A, Ribic C, Wong-Pack M, Papaioannou A, Adachi JD. Comparison of the clinical effectiveness and safety between the use of denosumab vs bisphosphonates in renal transplant patients. Osteoporos Int 2020; 31:973-980. [PMID: 31900542 DOI: 10.1007/s00198-019-05267-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 12/15/2019] [Indexed: 12/29/2022]
Abstract
UNLABELLED A retrospective chart review was conducted on 85 renal transplant patients aged 19-88 years, treated with denosumab or bisphosphonate therapy. Bone densitometry measures were compared between treatment groups at baseline; at years 1, 2, and 3; and at final follow-up (average of 3.4 years). Both bisphosphonate and denosumab treatments increased lumbar spine bone density; however, the effect of denosumab was greater compared with that of bisphosphonate treatment. Denosumab treatment increased femoral neck BMD, whereas bisphosphonate treatment had a mean decrease in femoral neck BMD at final follow-up. Thus, our study provides evidence for the efficacy of denosumab treatment in renal transplant patients. Caution around hypocalcemia is warranted. We recommend more prospective studies to analyze the effects of long-term antiresorptive therapy in patients with a renal transplant. INTRODUCTION To compare the clinical effectiveness and safety between the use of denosumab and bisphosphonates on bone density and incidence of adverse events in renal transplant patients. METHODS A retrospective chart review was conducted on 85 renal transplant patients aged 19-88 years, treated with denosumab or bisphosphonate therapy. Bone densitometry measures were compared between treatment groups at baseline; years 1, 2, and 3; and at final follow-up (average of 3.4 years). RESULTS Absolute change in lumbar spine and femoral neck BMD over the treatment period was 0.029 ± 0.075 g/cm2 and - 0.003 ± 0.064 g/cm2, respectively, in the bisphosphonate group. Absolute change in lumbar spine and femoral neck BMD at final follow-up was 0.072 ± 0.094 g/cm2 and 0.025 ± 0.063 g/cm2, respectively, in the denosumab group. Denosumab resulted in significantly greater increases in lumbar spine BMD (0.045 g/cm2 greater in the denosumab group). Similarly, the absolute change in BMD at the femoral neck was 0.022 g/cm2 greater in the denosumab group as compared with the bisphosphonate group. The denosumab group had one event of severe hypocalcemia following first injection and one report of hospitalized pneumonia. No serious adverse events were reported in the bisphosphonate group. CONCLUSIONS Both treatments increased lumbar spine BMD; however, the effect of denosumab was greater compared with that of bisphosphonate treatment. Our study provides evidence for the efficacy of denosumab treatment in renal transplant patients. Caution around hypocalcemia is warranted. We recommend more prospective studies to analyze the effects of long-term antiresorptive therapy in patients with a renal transplant.
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Affiliation(s)
- H McKee
- McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada.
| | - G Ioannidis
- McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - A Lau
- McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - D Treleaven
- McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - A Gangji
- McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - C Ribic
- McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - M Wong-Pack
- McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - A Papaioannou
- McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - J D Adachi
- McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
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Geng S, Kuang Z, Peissig PL, Page D, Maursetter L, Hansen KE. Parathyroid hormone independently predicts fracture, vascular events, and death in patients with stage 3 and 4 chronic kidney disease. Osteoporos Int 2019; 30:2019-2025. [PMID: 31190122 DOI: 10.1007/s00198-019-05033-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 05/22/2019] [Indexed: 12/18/2022]
Abstract
UNLABELLED Doctors do not know whether treatment of high parathyroid hormone levels is linked to better outcomes in their patients with kidney disease. In this study, lower parathyroid hormone levels at baseline were linked to lower risk of fracture, vascular events, and death in people with kidney disease. PURPOSE Chronic kidney disease (CKD) affects ~ 20% of older adults, and secondary hyperparathyroidism (HPT) is a common condition in these patients. To what degree HPT predicts fractures, vascular events, and mortality in pre-dialysis CKD patients is debated. In stage 3 and 4 CKD patients, we assessed relationships between baseline serum PTH levels and subsequent 10-year probabilities of clinical fractures, vascular events, and death. METHODS We used Marshfield Clinic Health System electronic health records to analyze data from adult CKD patients receiving care between 1985 and 2013, and whose PTH was measured using a second-generation assay. Covariates included PTH, age, gender, tobacco use, vascular disease, diabetes, hypertension, hyperlipidemia, obesity, GFR, and use of osteoporosis medications. RESULTS Five thousand one hundred eight subjects had a mean age of 68 ± 17 years, 48% were men, and mean follow-up was 23 ± 10 years. Fractures, vascular events, and death occurred in 18%, 71%, and 56% of the cohort, respectively. In univariate and multivariate models, PTH was an independent predictor of fracture, vascular events, and death. The hazards of fracture, vascular events and death were minimized at a baseline PTH of 0, 69, and 58 pg/mL, respectively. CONCLUSIONS We found that among individuals with stage 3 and 4 CKD, PTH was an independent predictor of fractures, vascular events, and death. Additional epidemiologic studies are needed to confirm these findings. If a target PTH range can be confirmed, then randomized placebo-controlled trials will be needed to confirm that treating HPT reduces the risk of fracture, vascular events, and death.
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Affiliation(s)
- S Geng
- Department of Computer Science, Princeton University, Princeton, NJ, USA
| | - Z Kuang
- Computer Science Department, Stanford University, Stanford, CA, USA
| | - P L Peissig
- Center for Computational and Biomedical Informatics, Marshfield Clinic Research Institute, Marshfield, WI, USA
| | - D Page
- Department of Biostatistics and Medical Informatics, Department of Computer Sciences, University of Wisconsin-Madison, Madison, WI, USA
| | - L Maursetter
- Department of Medicine, University of Wisconsin School of Medicine & Public Health, Mailbox 4124, Medical Foundation Centennial Building, 1685 Highland Avenue, Madison, WI, 53705-2281, USA
| | - K E Hansen
- Department of Medicine, University of Wisconsin School of Medicine & Public Health, Mailbox 4124, Medical Foundation Centennial Building, 1685 Highland Avenue, Madison, WI, 53705-2281, USA.
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6
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Aggarwal HK, Jain D, Yadav S, Kaverappa V. Bone mineral density in patients with predialysis chronic kidney disease. Ren Fail 2013; 35:1105-11. [DOI: 10.3109/0886022x.2013.815102] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Choi SW, Kim HY, Ahn HR, Lee YH, Kweon SS, Choi JS, Rhee JA, Nam HS, Jeong SK, Park KS, Ryu SY, Song HR, Shin MH. Association of bone mineral density with albuminuria and estimated glomerular filtration rate: the Dong-gu Study. Kidney Blood Press Res 2013; 37:132-41. [PMID: 23615166 DOI: 10.1159/000350067] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Kidney dysfunction and albuminuria may be associated with BMD. However, little evidence has been reported on relationships between BMD and eGFR and albuminuria. METHODS A total of 8,992 subjects aged 50 years or older participated in a survey conducted. Participants had their lumbar spine and femoral neck BMD measured by a Lunar Prodigy bone densitometer (GE, Madison, WI). Kidney function was assessed using MDRD eGFR and diagnosis of albuminuria was based on albumin-creatinine ratio. RESULTS ACR was negatively associated with lumbar spine and femur neck BMD in females (lumbar spine: 1.001, 0.988, 0.974 and 0.979 g/cm(2), p < 0.001; femur neck: 0.796, 0.790, 0.783 and 0.782 g/cm(2), p = 0.002), but not in males, after adjusting for covariates. Additionally, eGFR was shown to be negatively associated with lumbar spine BMD after adjusting for covariates (male: 1.181, 1.166, 1.152 and 1.149 g/cm(2), p = 0.001; female: 0.997, 0.980, 0.979 and 0.982 g/cm(2), p = 0.005), but demonstrated no association with femur BMD. CONCLUSIONS ACR in females was negatively associated with lumbar spine and femur neck BMD, but not in males. eGFR was negatively associated with lumbar spine BMD in both males and females.
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Affiliation(s)
- Seong-Woo Choi
- Department of Preventive Medicine, Chosun University Medical School, 375, Seosuk-dong, Gwangju 501-759, Republic of Korea
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Christoforidis A, Printza N, Gkogka C, Siomou E, Challa A, Kazantzidou E, Kollios K, Papachristou F. Comparative study of quantitative ultrasonography and dual-energy X-ray absorptiometry for evaluating renal osteodystrophy in children with chronic kidney disease. J Bone Miner Metab 2011; 29:321-7. [PMID: 20845051 DOI: 10.1007/s00774-010-0220-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2010] [Accepted: 07/29/2010] [Indexed: 10/19/2022]
Abstract
Our aim was to assess bone parameters in children with chronic kidney disease (CKD) with both dual-energy X-ray absorptiometry (DXA) and quantitative ultrasonography (QUS) and additionally with biochemical markers of bone turnover. Twenty children (12 boys and 8 girls) with CKD and a mean decimal age of 9.47 ± 4.44 years were included in the study where anthropometric parameters (height and weight), pubertal status, bone mineral density (BMD) at lumbar spine, speed of sound (SOS) measured by QUS at radius and at tibia, and biochemical markers of bone metabolism were measured. Six patients (30%) had tibial SOS Z score <-1, and 52.7% had radial SOS Z score <-1, whereas only 16.67% had BMD Z score <-1. Patients had significantly increased levels of serum intact parathormone (p < 0.001), serum bone alkaline phosphatase (BAP) (p < 0.001) and serum N-terminal-mid fragment (aminoacids 1-43) of osteocalcin (p < 0.001) compared to controls, whereas serum osteoprotegerin was significantly decreased in patients compared to controls (p = 0.001). SOS was significantly correlated to BAP (r = -0.586, p = 0.013 and r = -0.709, p = 0.001, respectively, for radius and tibia). In conclusion no association between DXA and QUS measurements was documented in our study, whereas QUS was better correlated to biochemical indices of ROD.
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Affiliation(s)
- Athanasios Christoforidis
- 1st Paediatric Department, Aristotle University, 49, Konstantinoupoleos str., 54642 Thessaloniki, Greece.
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Kim HL, Park IY, Choi JM, Hwang SM, Kim HS, Lim JS, Kim M, Son MJ. A decline in renal function is associated with loss of bone mass in Korean postmenopausal women with mild renal dysfunction. J Korean Med Sci 2011; 26:392-8. [PMID: 21394308 PMCID: PMC3051087 DOI: 10.3346/jkms.2011.26.3.392] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2010] [Accepted: 12/14/2010] [Indexed: 01/15/2023] Open
Abstract
This study was conducted to assess the relationship between estimated glomerular filtration rate (eGFR) and bone mineral density (BMD) in Korean postmenopausal women with mild renal dysfunction. A total of 328 postmenopausal women who underwent BMD measurement during health check-up was investigated. BMD was measured in lumbar spine (L1-L4), femoral neck, total proximal femur and femoral trochanteric areas by dual energy radiography absorptiometry and renal function was estimated by eGFR using Cockcroft-Gault equation. Of the 328 subjects, 317 (96.6%) had an eGFR ≥60 mL/min/1.73 m(2). By using simple linear regression analysis, age, height, weight and eGFR were significantly associated with BMD for the 4 aforementioned anatomic sites, while serum levels of creatinine and blood urea nitrogen did not influence BMD. When multiple regression analyses were applied, age and body weight still had significant associations with BMD at 4 different anatomic sites (P < 0.001). A significant association of eGFR with BMD remained in the lumbar spine, femoral neck and proximal total femur (P < 0.05) but not in the trochanteric area (P = 0.300). Our study suggests that a decline of renal function is associated with lower BMD in the lumbar spine, femoral neck and total proximal femur areas in Korean menopausal women with mild renal dysfunction.
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Affiliation(s)
- Hack-Lyoung Kim
- Armed Forces Seoul Hospital, Seoul, Korea
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | | | | | - Se-Min Hwang
- Department of Preventive Medicine, The Armed Forces Medical Commands, Seongnam, Korea
| | - Hyo Sang Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | | | - Min Kim
- Armed Forces Seoul Hospital, Seoul, Korea
| | - Min-Jeong Son
- Division of Nephrology, Department of Internal Medicine, The Armed Forces Capital Hospital, Seongnam, Korea
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Gupta R, Mohammed AM, Alenizi EK, Ben Nekhi A. Bone mineral density in Kuwaiti patients with end-stage renal disease. Med Princ Pract 2011; 20:156-8. [PMID: 21252572 DOI: 10.1159/000319775] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2009] [Accepted: 05/09/2010] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE This study compared an ethnically uniform group of end-stage renal disease (ESRD) Kuwaiti patients with a control group of healthy Kuwaiti subjects, in terms of their bone mineral density (BMD) and anthropometric measurements. SUBJECTS AND METHODS Included in the study were 94 males and 129 females with a mean age of 48 ± 10 years. Forty-five males and 53 females had ESRD. The remaining 49 males and 26 females were the control subjects. BMD was measured at total lumbar spine (L1-L4) and total left hip, using dual energy X-ray absorptiometry (HOLOGIC, QRS series, Europe, Belgium). The data were analyzed using SPSS, version 15 (SPSS Inc., Chicago, Ill., USA). The difference in BMD and the anthropometric measurements between the ESRD patients and the controls was assessed. Multivariate linear regression models were used to examine independent effects of ESRD on BMD while adjusting for relevant covariates. RESULTS The ESRD patients had a lower BMD than the controls at the hip (0.81 ± 0.11 vs. 0.92 ± 0.16) and the spine (0.84 ± 0.12 vs. 0.92 ± 0.16), p < 0.001. They also had a lower body mass index (27.80 ± 6.03 vs. 30.85 ± 6.54; p < 0.001) and were taller (162.56 ± 15.31 vs. 156.94 cm ± 10.03; p < 0.01). The reduced BMD persisted after controlling for confounding effects of sex, age and anthropometric measurements (p < 0.001). CONCLUSION Kuwaiti patients with ESRD had a lower BMD and, therefore, an increased risk of osteoporosis and bone fractures.
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Affiliation(s)
- Renu Gupta
- Department of Radiology, Kuwait University, Jabriya, Kuwait. renu @ hsc.edu.kw
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Kirkpantur A, Altun B, Arici M, Turgan C. Proton pump inhibitor omeprazole use is associated with low bone mineral density in maintenance haemodialysis patients. Int J Clin Pract 2009; 63:261-8. [PMID: 19196364 DOI: 10.1111/j.1742-1241.2008.01883.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Limited studies have shown that proton pump inhibitor (PPI) therapy may decrease bone density or insoluble calcium reabsorption through induction of hypochlorhydria. However, PPI therapy may also reduce bone resorption via inhibition of osteoclastic vacuolar proton pumps. The aim of this study was to determine whether the opposing effects of PPI therapy may cause clinically important alterations in bone mineral densitometry (BMD) parameters in maintenance haemodialysis patients. METHODS Sixty-eight maintenance haemodialysis patients were enrolled in this study. Patients were classified into two groups involving users of PPI therapy (omeprazole 20 mg/day, group 1, n = 36 patients) and non-users of acid suppression drugs (group 2, n = 32 patients). Patients had radius, hip and spine BMD assessed by dual-energy X-ray absorptiometry. RESULTS The mean duration of PPI therapy with omeprazole was 27 +/- 5 months. The users of PPI therapy had lower values of bone mineral density and T-scores at the anatomical regions than non-users of acid suppression drugs. Serum calcium and phosphate levels, calcium-phosphate product and serum intact parathormone levels and the ratio of users of vitamin D therapy were similar among groups. A mutivariable adjusted odds ratio for lower bone density associated with more than 18 months of omeprazole, when all the potential confounders were considered, was 1.31 in the proximal radius, 0.982 in the femur neck, 0.939 in the trochanter and 1.192 in the lumbal spine. CONCLUSION The present data suggest that PPI therapy should be cautiously prescribed in maintenance haemodialysis patients, especially with lower BMD values.
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Affiliation(s)
- A Kirkpantur
- Nephrology Unit, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey.
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12
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Ishani A, Paudel M, Taylor BC, Barrett-Connor E, Jamal S, Canales M, Steffes M, Fink HA, Orwoll E, Cummings SR, Ensrud KE. Renal function and rate of hip bone loss in older men: the Osteoporotic Fractures in Men Study. Osteoporos Int 2008; 19:1549-56. [PMID: 18392664 DOI: 10.1007/s00198-008-0608-0] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2007] [Accepted: 01/15/2008] [Indexed: 10/22/2022]
Abstract
UNLABELLED Older men with reduced renal function are at increased risk of hip bone loss. Given the robustness of this association across different measures and a growing body of literature, our findings indicate that clinicians should take into account renal function when evaluating older men for osteoporosis risk and bone loss. Future randomized controlled trials should test whether interventions in this high risk population are effective in preventing bone loss and decreasing fracture incidence. INTRODUCTION Studies examining whether kidney impairment, not requiring dialysis, is associated with osteoporosis have reported conflicting results. METHODS We tested the hypothesis that reduced renal function in older men as manifested by higher concentrations of cystatin C or lower levels of estimated glomerular filtration rate (eGFR) is associated with higher rates of bone loss. We measured serum cystatin C, serum creatinine and total hip bone mineral density (BMD) at baseline in a cohort of 404 older men enrolled in the Osteoporotic Fractures in Men (MrOS) Study and followed them prospectively for an average of 4.4 years for changes in BMD. Associations between renal function and change in hip BMD were examined using linear regression. RESULTS In multivariable analysis, the mean rate of decline in total hip BMD showed an increase in magnitude with higher cystatin C concentration (mean annualized percent change -0.29, -0.34, -0.37 and -0.65% for quartiles 1 to 4; p for trend=0.004). Similarly, adjusted rates of hip bone loss were higher among men with lower eGFR as defined by the modification of diet in renal disease formula (mean annualized percent change -0.58, -0.39, -0.37, and -0.31 for quartiles 1 to 4; p for trend=0.02), but not among men with lower eGFR as defined by the Cockcroft-Gault formula (mean annualized percent change -0.47, -0.44, -0.31 and -0.43 for quartiles 1 to 4; p for trend=0.48). CONCLUSIONS Older men with reduced renal function are at increased risk of hip bone loss. Our findings suggest that health care providers should consider renal function when evaluating older men for risk factors for bone loss and osteoporosis.
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Affiliation(s)
- A Ishani
- Center for Chronic Disease Outcomes Research, Veterans Affairs Medical Center, Minneapolis, MN, USA.
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13
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Stavroulopoulos A, Porter CJ, Roe SD, Hosking DJ, Cassidy MJD. Relationship between vitamin D status, parathyroid hormone levels and bone mineral density in patients with chronic kidney disease stages 3 and 4. Nephrology (Carlton) 2008; 13:63-7. [PMID: 18199106 DOI: 10.1111/j.1440-1797.2007.00860.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM Low vitamin D status is associated with secondary hyperparathyroidism and increased bone turnover in the general population and can aggravate the hyperparathyroidism of chronic kidney disease (CKD) patients. It is also correlated to low bone mineral density (BMD), but this correlation is less clear in CKD patients. Aims of our study were to investigate these associations in CKD stages 3 and 4 patients, and to identify significant predictors of BMD in this population. METHODS Serum 25-hydroxyvitamin D (25OHD) levels, BMD at the femur and radius, and bone mineral metabolism parameters were measured in 89 CKD stages 3 and 4 patients. Vitamin D status was defined according to the NKF/KDOQI guidelines. RESULTS Mean 25OHD levels were 53.8+/-32.1 nmol/L and correlated to the severity of proteinuria. Thirty-five patients (39%) had vitamin D insufficiency, 29 (33%) had vitamin D deficiency and five (6%) had severe deficiency. Of the 89 patients, two had osteoporosis and 31 had osteopenia either at femur or radius. Independent predictors for the total femur BMD were the intact parathyroid hormone (iPTH) levels and the body mass index (BMI). For the total radius BMD, independent predictor was only the BMI. Serum 25OHD levels were not directly associated with BMD, but they were independent predictors of iPTH. CONCLUSION Vitamin D insufficiency and deficiency are very common in CKD stages 3 and 4 population and may indirectly affect, via effects on iPTH, the BMD of these patients.
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Ishani A, Blackwell T, Jamal SA, Cummings SR, Ensrud KE. The effect of raloxifene treatment in postmenopausal women with CKD. J Am Soc Nephrol 2008; 19:1430-8. [PMID: 18400939 DOI: 10.1681/asn.2007050555] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
It is unknown whether treatment for osteoporosis with raloxifene is safe or effective in those with chronic kidney disease (CKD). With data from a multicenter, randomized, placebo-controlled trial of 7705 postmenopausal women with osteoporosis, the effect of raloxifene on rate of change of bone mineral density (BMD), incidence of fractures, and adverse events by stage of CKD was examined over 3 yr. Baseline serum creatinine values were available for 7316 women, and these values were used to assign a category of creatinine clearance (CrCl) using the Cockcroft-Gault formula (CrCl < 45, 45 to 59, and > or = 60 ml/min). BMD was measured at baseline and annually by dual x-ray absorptiometry. Within the placebo group, lower baseline CrCl was associated with a trend for higher annual losses of BMD at the femoral neck; however, within the raloxifene group, lower baseline CrCl was associated with greater increases in femoral neck BMD. This interaction between category of CrCl and treatment assignment was significant for rate of change of BMD at the hip. Irrespective of kidney function, raloxifene treatment was associated with a greater increase in spine BMD, a reduction in vertebral fractures, and no effect on nonvertebral fractures compared with placebo. Within each category of kidney function, adverse events were similar between the raloxifene and placebo groups. In conclusion, raloxifene increases BMD at both the hip and the spine and reduces the risk for vertebral fractures among individuals with CKD. The effect ofraloxifene on hip BMD is greater among those with mild to moderate CKD.
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Affiliation(s)
- Areef Ishani
- Center for Chronic Disease Outcomes Research, Veterans Affairs Medical Center, and Department of Medicine and Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN 55417, USA.
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Tillmann FP, Jäger M, Blondin D, Oels M, Rump LC, Grabensee B, Hetzel GR. Post-transplant distal limb syndrome: clinical diagnosis and long-term outcome in 37 renal transplant recipients. Transpl Int 2008; 21:547-53. [PMID: 18373640 DOI: 10.1111/j.1432-2277.2008.00668.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
After the introduction of steroid sparing immunosuppressive protocols, osteonecrosis of the hip has become a rare entity in renal transplantation. Instead, an elusive bilateral pain syndrome of the distal extremities has gained more clinical attention. Because of the typical presentation, it is sometimes referred to as 'post-transplant distal limb syndrome' (PTDLS). The syndrome typically manifests during the first year after transplantation and may lead to significant morbidity because of pain induced immobilization. On MRI-scans, a characteristic bilateral patchy osteoedema can be demonstrated. The etiology of PTDLS has not been determined definitely so far. Over the last 8 years, we have seen the syndrome in 37 out of 639 renal transplant patients (5.8%). There was no association to steroid-medication, age, gender, PTH levels or delayed graft function. As an important finding, we saw a significant rise in alkaline phosphatase from 160 +/- 54 to 271 +/- 108 U/l (P = 0.001) and calcium from 2.46 +/- 0.18 to 2.58 +/- 0.18 mmol/l (P = 0.013) preceding the onset of pain by several weeks. Mean duration of clinical symptoms was 5.1 +/- 3.1 months; however, all patients experienced remission without signs of chronic damage on long-term follow up.
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Affiliation(s)
- Frank-Peter Tillmann
- Department of Nephrology, Heinrich Heine University Medical Center, Düsseldorf, Germany.
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Doumouchtsis KK, Kostakis AI, Doumouchtsis SK, Tziamalis MP, Stathakis CP, Diamanti-Kandarakis E, Dimitroulis D, Perrea DN. Associations between osteoprotegerin and femoral neck BMD in hemodialysis patients. J Bone Miner Metab 2008; 26:66-72. [PMID: 18095066 DOI: 10.1007/s00774-007-0785-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2007] [Accepted: 06/21/2007] [Indexed: 11/29/2022]
Abstract
Numerous humoral factors are involved in the development of renal osteodystrophy, causing perturbations in bone mineral density (BMD) in patients with end-stage renal disease (ESRD). The RANKL/OPG cytokine system appears to mediate the effects of many of these factors on bone turnover, contributing to the pathogenesis of renal bone disease. The aim of this study was to evaluate the clinical and biochemical correlations of BMD measurements in patients on chronic hemodialysis. Fifty-four hemodialysis patients underwent measurement of BMD at the proximal femur and the lumbar spine (L2-L4). Intact parathyroid hormone (PTH), osteoprotegerin (OPG), sRANKL, and main bone biochemical markers were also measured in serum samples of all patients. BMD of the femoral neck was negatively correlated with OPG levels (r = 0.333, P = 0.014). OPG levels were significantly different among normal, osteopenic, and osteoporotic tertiles defined according to BMD of the femoral neck. The highest OPG levels were measured in the lowest T-score (osteoporotic) tertile and were higher than in the osteopenic and normal tertiles (P < 0.05). A threshold level for OPG at 21.5 pmol/l enabled the detection of osteoporotic patients with 76.5% sensitivity and 62.2% specificity. BMD values of trabecular bone-rich sites of the skeleton such as lumbar spine (L2-L4), trochanter, and Ward' s triangle were inversely correlated with total ALP levels (P < 0.05). Hemodialysis patients with low BMD of the femoral neck demonstrated higher OPG levels than patients with normal BMD. Those with lumbar spine (L2-L4), trochanteric, and Ward's triangle BMDs below the normal range presented higher total ALP levels. These results suggest that OPG and total ALP may be clinically useful markers in the detection of significant femoral neck and trabecular bone mineral deficit in hemodialysis patients, warranting further investigations.
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Affiliation(s)
- Konstantinos K Doumouchtsis
- Laboratory for Experimental Surgery and Surgical Research, Athens University, 15B Saint Thomas Street, Athens 11527, Greece.
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17
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18
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Waller S, Ridout D, Rees L. Bone mineral density in children with chronic renal failure. Pediatr Nephrol 2007; 22:121-7. [PMID: 16977474 DOI: 10.1007/s00467-006-0292-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2006] [Revised: 07/03/2006] [Accepted: 07/06/2006] [Indexed: 10/24/2022]
Abstract
Bone mineral density (BMD) is important in children and adolescents because of its relationship to long-term skeletal health, and because, in adults with chronic renal failure (CRF), a relationship between low BMD and vascular calcification has been suggested. To investigate the relationship between BMD and manipulable factors that might affect it, i.e. plasma calcium, phosphate and parathyroid hormone (PTH), 64 patients with a median glomerular filtration rate (GFR) of 31 (range 7-60) ml min(-1) 1.73 m(-2) and median age of 10.0 (4.1-16.9) years were followed over 1.3 (0.7-1.7) years at an average of 5 (3-14) clinic visits. At one visit, BMD of the lumbar spine was measured by dual energy X-ray absorptiometry. The mean BMD Z-score was normal (=0.0). Overall mean calcium, phosphate and PTH levels were in their respective normal ranges. The majority of the patients (72%) were treated with calcium carbonate, mean dose 65 mg kg(-1) day(-1); prescription was positively related to serum calcium levels and calcium-phosphate product (P=0.012 and P<0.01 respectively). Almost all patients (98%) were treated with alfacalcidol, mean dose 12 ng kg(-1) day(-1); prescription was not related to investigated factors. Patients grew well; there was no change in height standard deviation score (DeltaHtSDS=0.0). Normal BMD Z-score for age and sex can be achieved in children with CRF managed with the aim of maintaining normal PTH levels by dietary phosphate restriction, calcium-based phosphate binders and small doses of alfacalcidol. Further investigation of the underlying bone by the use of biopsy and histomorphometry is required to determine actual bone health.
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Affiliation(s)
- Simon Waller
- Department of Nephro-Urology, Institute of Child Health and the Great Ormond Street Hospital for Children NHS Trust, Great Ormond Street, London, WC1N 3JH, UK.
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Guglielmi G, de Terlizzi F, Aucella F, Scillitani A. Quantitative ultrasound technique at the phalanges in discriminating between uremic and osteoporotic patients. Eur J Radiol 2006; 60:108-14. [PMID: 16750341 DOI: 10.1016/j.ejrad.2006.05.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2005] [Revised: 03/09/2006] [Accepted: 05/02/2006] [Indexed: 11/29/2022]
Abstract
This study was conducted to test the ability of quantitative ultrasound technique (QUS) at the phalanges to discriminate between uremic and osteoporotic patients. Three groups of subjects (38 dialytic women, 16 osteoporotic women with vertebral fractures, 19 non-dialytic and non-fractured women) were recruited at the Department of Radiology at "Casa Sollievo della Sofferenza" Hospital, San Giovanni Rotondo, Italy. The groups were matched for age and body mass index (BMI). On all subjects the following measurements were performed: spinal BMD by QCT and by DXA, Femoral BMD by DXA, phalangeal QUS. For QUS measurements, the DBM Sonic (IGEA, Carpi, Italy) was applied to the metaphysis of the proximal phalanges of the last four fingers of the hand. Osteoporotic women with vertebral fractures showed significantly lower values of spinal BMD by QCT and DXA and Ward's Triangle BMD with respect to hemodialytic patients (p<0.005). All QUS values, except for BTT and SoS, showed lower values in osteoporotic women with respect to hemodialytic patients (p<0.05). Control group showed higher values of AD-SoS, BTT and SoS than hemodialytic patients (p<0.005) while the two groups did not differ for BMD values measured with both QCT and DXA. UBPI and FWA data showed a similar behaviour to DXA and QCT results, whereas BTT and SoS showed a completely different behaviour. AD-SoS was the only parameter that could effectively discriminate among the three groups (ANOVA, p<0.0001). We conclude that phalangeal QUS can discriminate between hemodialysed patients and controls with similar bone mineral density, and can also discriminate between hemodialysed and osteoporotic subjects with vertebral fractures. Different characteristics of ultrasound signal can be ascribed to each bone tissue condition, enabling a clear differentiation of bone tissue changes occurring in menopause, osteoporosis and renal osteodystrophy.
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Affiliation(s)
- G Guglielmi
- Department of Radiology, Scientific Institute Hospital, Casa Sollievo della Sofferenza, Viale Cappuccini 1, San Giovanni Rotondo, Italy.
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20
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Pluskiewicz W, Przedlacki J, Drozdzowska B, Włodarczyk D, Matuszkiewicz-Rowińska J, Adamczyk P. Quantitative ultrasound in monitoring of skeletal status in adults with end-stage renal disease. ULTRASOUND IN MEDICINE & BIOLOGY 2006; 32:1521-7. [PMID: 17045873 DOI: 10.1016/j.ultrasmedbio.2006.06.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2006] [Revised: 05/23/2006] [Accepted: 06/08/2006] [Indexed: 05/12/2023]
Abstract
The aim of the longitudinal study was to assess skeletal status in 29 subjects (18 males and 11 females) with end-stage renal disease (ESRD) being on regular hemodialysis. Control group consisted of 494 healthy subjects (305 males and 189 females). Skeletal status was evaluated by quantitative ultrasound measurements at the hand phalanges using DBM Sonic 1200 (IGEA, Carpi, Italy), which measures amplitude-dependent speed of sound (Ad-SoS, in m/s), performed three times: at the baseline, six and 12 months later. A precision expressed in root mean square-CV% was 0.72% in males and 0.43% in females. The values of Ad-SoS, T-score and Z-score at the baseline were significantly lower than in controls (p < 0.05). The mean values of Ad-SoS decreased over a period of observation; in the whole group from 1979 +/- 106 m/s to 1928 +/- 105 m/s, p < 0.0001, in males from 2003 +/- 93 m/s to 1949 +/- 111 m/s, p < 0.001 and in females from 1940 +/- 121 m/s to 1894 +/- 108 m/s, p < 0.05. Ad-SoS Z-scores dropped significantly over a period of the study in whole group (-1.14 +/- 1.64 to -2.08 +/- 2.26, p < 0.01), in males (-0.63 +/- 1.44 to -1.74 +/- 2.29, p < 0.0001) and in females nonsignificant decrease was observed. Using the least significant change (LSC) values for skeletal measurement, a decrease in Ad-SoS was noted in 15 subjects (52%). The values of PTH were over a normal limit. In the whole group main factors negatively influencing current Ad-SoS values were duration of dialysis, age and PTH. The skeletal status in subjects with ESRD on hemodialysis was seriously affected, and longitudinal measurements showed its aggravation over a time of the study.
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Affiliation(s)
- Wojciech Pluskiewicz
- Metabolic Bone Diseases Unit, Dept. and Clinic of Internal Diseases, Diabetology and Nephrology, Silesian School of Medicine, Katowice, Poland.
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Mehrotra R. Disordered Mineral Metabolism and Vascular Calcification in Nondialyzed Chronic Kidney Disease Patients. J Ren Nutr 2006; 16:100-18. [PMID: 16567266 DOI: 10.1053/j.jrn.2006.01.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2005] [Indexed: 01/18/2023] Open
Abstract
It is well established that abnormalities in mineral metabolism are apparent early in the course of chronic kidney disease (CKD) and result in clinically relevant consequences such as renal osteodystrophy. Furthermore, there is emerging evidence linking some of these abnormalities (hyperphosphatemia) to the high cardiovascular morbidity and mortality experienced by nondialyzed patients with CKD. Most studies have evaluated vascular calcification in patients with stage 5 CKD. Reports published over the last 2 years show that the process begins rather early in CKD and is particularly severe among elderly and type 2 diabetic patients. Furthermore, "calcium begets calcium", such that the calcification burden in early CKD is an important predictor of subsequent progression, including the rapid increase seen in stage 5 CKD. There is an increasing body of evidence that supports the thesis that elevated serum levels of phosphorus and calcium and deficiency of inhibitors of calcification (for example, fetuin-A) are important in the progression of vascular calcification in patients with end-stage renal disease. However, the concentrations of calcium and phosphorus shown to induce mineralization in cell culture studies are not observed in most patients until late in stage 4 or stage 5 CKD. Cross-sectional and longitudinal studies have also been unable to show a correlation between serum levels of markers of disordered mineral metabolism and severity of vascular calcification. Future studies should evaluate the pathogenetic role of phosphorus retention, which occurs early in the course of CKD, in the induction and/or progression of vascular calcification. Finally, there is a need to identify alternative pathogenetic mechanisms that may be important causes of the high calcification burden observed early in CKD.
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Affiliation(s)
- Rajnish Mehrotra
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute, Harbor-UCLA, Torrance, CA, USA.
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Abstract
Chronic kidney disease is commonly accompanied by disturbances in the hypothalamic-pituitary-gonadal axis. Such disturbances in men give rise to hypogonadism and low circulating testosterone levels. The deficiency in testosterone can contribute to clinical outcomes such as sexual dysfunction, decreased bone mineralization, malnutrition and decreased muscle mass, and anemia. The administration of androgens to nonuremic hypogonadal men is usually effective in treating such outcomes. By contrast, the response to therapy in uremic men tends to be much less predictable. This variability in response is not surprising, because these same clinical outcomes can be the result of other aspects of the uremic state or the comorbid conditions that are frequently present in men with chronic kidney disease. Although further studies are needed, testosterone therapy may prove most useful as an adjunct to other more general therapies designed to address the uremic state.
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Pluskiewicz W, Adamczyk P, Drozdzowska B, Szprynger K, Szczepańska M, Halaba Z, Karasek D. Skeletal status in adolescents with end-stage renal failure: a longitudinal study. Osteoporos Int 2005; 16:289-95. [PMID: 15221204 DOI: 10.1007/s00198-004-1672-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2003] [Accepted: 05/10/2004] [Indexed: 11/30/2022]
Abstract
In a longitudinal study, bone status was assessed in adolescents and young adults aged 15.3+/-3.4 years at the onset of the study with end-stage renal failure (ESRF). The group consisted of 18 subjects (11 females and seven males), of whom nine patients were on hemodialysis and nine patients on peritoneal dialysis. Six patients were previous or current glucocorticoid (GCS) users. Renal failure was recognized before 6.1+/-4.1 years, and dialysis was performed for 3.0+/-2.0 years. Follow-up took placed 8.6+/-0.8 and 21.7+/-2.5 months later, and the following data were collected: bone mineral density (BMD) at the spine (s-BMD) and total body (TB-BMD) using DPX-L (Lunar, USA); quantitative ultrasound by DBM 1200 (IGEA, Italy) at the hand phalanges (Amplitude-dependent Speed of Sound, Ad-SoS), serum concentration of i-PTH, total calcium, ionized calcium and phosphate. Tanner stages were also evaluated. The mean values of BMD measurements and Ad-SoS were stable during a period of observation, and a mean Z-score for TB-BMD was significantly lower at the third versus baseline value (-1.87+/-1.75 versus -1.49+/-1.53, P<0.05). Z-scores for s-BMD and Ad-SoS decreased non-significantly. Changes in s-BMD and TB-BMD Z-scores were influenced by changes in body size and changes in biochemical parameters, and a change in Ad-SoS Z-score was not dependent on these factors. The values of second (P<0.05) and third (P<0.01) s-BMD Z-score were significantly lower in GCS treated subjects, and longitudinal change in spine Z-score was greater in GCS treated patients versus others (P<0.05). Duration of ESRF, duration and type of dialysis and gender did not influence skeletal variables. Skeletal measurements correlated significantly with Tanner stages (besides the correlation with Ad-SoS in the first measurement, r ranged from 0.5 to 0.72, P<0.05), and changes in Tanner stages observed over a period of observation did not correlate with changes in skeletal variables. Among laboratory variables, the following non-significant tendencies to change were observed: serum concentration of i-PTH and phosphate increased, and total and ionized calcium decreased. In conclusion, adolescent subjects with ESRF treated with dialysis showed stable mean values of skeletal measurements, and these were expressed as Z-scores, a tendency to drop was observed. The lack of an increase observed in normal healthy subjects of the same age, and low values in Z-scores, indicates that skeletal status is seriously affected in subjects with ESRF.
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Affiliation(s)
- Wojciech Pluskiewicz
- Department and Clinic of Internal Diseases, Diabetology and Nephrology, Metabolic Bone Diseases Unit Zabrze, Silesian School of Medicine in Katowice, 3 Maja 13/15 Street, 41-807 Zabrze, Poland.
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Rix M, Eskildsen P, Olgaard K. Effect of 18 months of treatment with alfacalcidol on bone in patients with mild to moderate chronic renal failure. Nephrol Dial Transplant 2004; 19:870-6. [PMID: 15031343 DOI: 10.1093/ndt/gfg595] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The bone abnormalities that lead to symptomatic renal osteodystrophy commence early in the course of renal failure, but the optimal time to start treatment needs clarifying. The present study examined the effect of alfacalcidol treatment on bone metabolism and bone density in patients with pre-dialysis chronic renal failure (CRF) in a prospective, randomized, placebo-controlled double blind design. METHODS Repetitive measures of bone mineral density (BMD) estimated by dual energy X-ray absorptiometry and plasma levels of biochemical markers of bone turnover [osteocalcin, bone alkaline phosphatase, propeptide of type-I collagen (PICP) and telopeptide of type-I collagen] and parameters of calcium homeostasis were performed in 36 patients with a glomerular filtration rate (GFR) of 6-60 ml/min. RESULTS A significant difference in BMD between the treatment groups in favour of the alfacalcidol-treated patients was found in the spine (4.2%), the femoral neck (4.9%) and the total femur (3.0%) (P<0.05). In the alfacalcidol group, plasma levels of parathyroid hormone 1-84 decreased from baseline values by 47+/-9%, and p-osteocalcin and bone alkaline phosphatase decreased by 24+/-9% and 48+/-8%, respectively (P<0.05). In the placebo group, PICP increased by 32+/-26% (P<0.05). No significant changes were found in plasma levels of vitamin D metabolites. GFR decreased significantly from baseline values in the alfacalcidol group (by 28+/-4 ml/min) and in the placebo group (by 26+/-5 ml/min) (P<0.05), with no difference being detected between the groups. CONCLUSIONS Long-term treatment with alfacalcidol is safe and might be beneficial for the preservation of bone mass in the pre-dialysis stages of CRF, most likely through a reduction in bone turnover as estimated from the changes of the biochemical bone markers.
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Affiliation(s)
- Marianne Rix
- Nephrological Dept P 2132, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark.
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25
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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.
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Affiliation(s)
- Felix W Wehrli
- Laboratory for Structural NMR Imaging, Department of Radiology, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania 19104, USA.
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Zayour D, Daouk M, Medawar W, Salamoun M, El-Hajj Fuleihan G. Predictors of bone mineral density in patients on hemodialysis. Transplant Proc 2004; 36:1297-301. [PMID: 15251316 DOI: 10.1016/j.transproceed.2004.05.069] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Renal osteodystrophy is a universal complication of uremia. Renal failure patients are at risk for low bone mineral density (BMD) and fractures. Parathyroid hormone (PTH) plays a pivotal role in the pathophysiology of uremic bone disease. Histomorphometric studies suggest that the maintenance of PTH levels between two and four times the upper limit of normal is associated with the lowest prevalence of two common forms of osteodystrophy: osteitis fibrosa cystica and adynamic bone disease. The purpose of this study was to investigate whether the above recommendation for PTH levels in dialysis patients corresponds to a more optimal BMD with a special emphasis on diabetic versus nondiabetic subjects. Twenty-eight patients with chronic renal failure on hemodialysis underwent measurement of PTH levels, as well as BMD at the lumbar spine, hip, and forearm. They were divided into three groups based on the mean PTH level over the 5 years prior to having BMD measured. Osteoporosis was diagnosed in 55% of men and 87% of women on dialysis. Predictors of BMD were gender, duration on hemodialysis, and diabetes. Our study supports the histomorphometry-based studies suggesting that the maintenance of intact PTH levels two to four times the upper limit of normal may be associated with better skeletal health in uremic patients on hemodialysis, and that the diabetic subgroup is at particular risk for low BMD.
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Affiliation(s)
- D Zayour
- Calcium Metabolism and Osteoporosis Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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Pluskiewicz W, Przedlacki J, Drozdzowska B, Włodarczyk D, Matuszkiewicz-Rowinska J, Adamczyk P. Quantitative ultrasound at hand phalanges in adults with end-stage renal failure. ULTRASOUND IN MEDICINE & BIOLOGY 2004; 30:455-459. [PMID: 15121247 DOI: 10.1016/j.ultrasmedbio.2004.01.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2003] [Revised: 01/07/2004] [Accepted: 01/15/2004] [Indexed: 05/24/2023]
Abstract
The aim of this study was to assess bone status in 220 subjects with end-stage renal failure (ESRF) (146 men, mean age 53.0 +/- 13.9 years and 74 women, mean age 48.1 +/- 14.3 years). The duration of hemodialysis (durHD) and duration of renal insufficiency (durRI) were, in men, 2.6 +/- 3.8 years and 7.7 +/- 8.0 years, and, in women, 2.8 +/- 3.4 years and 9.1 +/- 7.6 years, respectively. ESRF was caused by the following reasons: chronic glomerulonephritis in 92 patients, diabetes in 52, chronic pyelonephritis in 37, polycystic kidney disease in 19, amyloidosis in 5, hypertension in 4 and unknown cause in 11. The control group consisted of 1615 normal healthy subjects (1216 women, mean age 48.1 +/- 12.1 years and 399 men, mean age 52.9 +/- 14.8 years). Mean age did not differ between patients and controls. Skeletal status was evaluated by quantitative ultrasound (US) measurements at the hand phalanges using DBM 1200 (IGEA, Italy) which measures amplitude-dependent speed of sound (Ad-SoS, m/s). The mean value of Ad-SoS in male patients was 1981 +/- 88 m/s, T-score -l2.03 +/- 1.26, Z-score -0.53 +/- 1.7 and, in female patients, 1967 +/- 96 m/s, -2.23 +/- 1.37, -1.41 +/- 1.56, respectively. Respective values in male controls were 2008 +/- 81 m/s, -1.66 +/- 1.16, -0.01 +/- 0.98 and, in female controls, 2026 +/- 81 m/s, -1.4 +/- 1.15, -0.74 +/- 0.86, and were significantly higher than in male (p < 0.001) and female (p < 0.0000001) patients. A correlation analysis of Ad-SoS with durHD and durRI showed that only in males did both factors significantly influence parameters measured (r = -0.26, p < 0.01). Multiple stepwise regression analysis of Ad-SoS on age, durHD, durRI, weight and height was possible to perform only in males and the following equation was established: Ad-SoS = 2545 m/s - 3.09 x age (years) - 5.68 x durHD (years) - 2.15 x height (cm) - 0.99 x durRI (years), p < 0.000001, r = 0.55, SEE = 69.6. Concluding, in subjects with ESRF treated with hemodialysis, skeletal status assessed with the use of quantitative US was affected.
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Affiliation(s)
- W Pluskiewicz
- Metabolic Bone Diseases Unit, Dept. and Clinic of Internal Diseases, Diabetology and Nephrology, Silesian School of Medicine in Katowice, Poland
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28
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Lima EM, Goodman WG, Kuizon BD, Gales B, Emerick A, Goldin J, Salusky IB. Bone density measurements in pediatric patients with renal osteodystrophy. Pediatr Nephrol 2003; 18:554-9. [PMID: 12712376 DOI: 10.1007/s00467-002-1041-9] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2001] [Revised: 12/21/2001] [Accepted: 10/15/2002] [Indexed: 10/25/2022]
Abstract
Peripheral quantitative computed tomography (pQCT) can selectively measure the densities of cortical and trabecular bone, but there is limited information about its use in patients with renal osteodystrophy. Thus pQCT (Norland XCT-2000, Stratec, Pforzheim, Germany) was performed at the ultradistal radius in 21 patients aged 16+/-3.6 (SD) years on continuous cycling peritoneal dialysis. Trabecular bone density (TBD) was higher in patients, 206+/-16 mg/cm(3), than in controls, 182.7+/-24.8 mg/cm(3) ( P<0.0001), whereas cortical bone density (CBD) was lower in patients, 946.5+/-147.5 mg/cm(3), than in controls, 1,153+/-25.4 mg/cm(3) ( P<0.001). TBD was inversely correlated with age ( r=-0.59, P=0.05), height ( r=-0.59, P<0.01), and weight ( r=-0.51, P<0.05). In contrast, CBD was positively correlated with age ( r=0.53, P<0.05), height ( r=0.56, P<0.05), and weight ( r=0.53, P<0.05). CBD was inversely related to serum alkaline phosphatase ( r=-0.71, P<0.001) and parathyroid hormone levels ( r=-0.50, P<0.05). In patients with adynamic bone, TBD was less, 192+/-9 mg/cm(3), than in those with high-turnover lesions, 215+/-13 mg/cm(3), P<0.001. CBD, however, was lower in patients with high-turnover lesions, 900+/-151 mg/cm(3), than in those with low turnover, 1,022+/-111 mg/cm(3), P<0.05. Compared with controls, in patients with high-turnover lesions, CBD was lower ( P<0.0001) and TBD higher ( P<0.0001). These findings suggest that pQCT may be an additional tool in the assessment of renal osteodystrophy.
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Affiliation(s)
- Eleonora M Lima
- Division of Pediatric Nephrology, Department of Pediatrics, UCLA School of Medicine, Los Angeles, California 90095, USA
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29
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Pluskiewicz W, Adamczyk P, Drozdzowska B, Szprynger K, Szczepańska M, Halaba Z, Karasek D. Skeletal status in children and adolescents with chronic renal failure before onset of dialysis or on dialysis. Osteoporos Int 2003; 14:283-8. [PMID: 12730774 DOI: 10.1007/s00198-002-1335-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2002] [Accepted: 10/04/2002] [Indexed: 11/28/2022]
Abstract
Bone status was assessed in 15 children and adolescents with predialysis chronic renal failure (CRF) and in 25 subjects with end-stage renal failure (ESRF). The mean age in the whole group was 14.6+/-3.2 years and CRF had been recognized 5.8+/-4.0 years earlier. The mean age, body size, duration of the disease and Tanner stages did not differ significantly between patients with predialysis CRF and ESRF. The control group consisted of 890 healthy subjects matched with patients for age. Bone mineral density (BMD) was measured by DPX-L (Lunar, Madison, WI) at the spine (s-BMD) and total body (TB-BMD); quantitative ultrasound (QUS) was performed by DBM 1200 (IGEA, Italy) at the hand phalanges (Ad-SoS). Laboratory investigations included the evaluation of intact parathyroid hormone (i-PTH), total and ionized serum calcium, and serum phosphate. In the whole group of patients the following mean values were obtained: Ad-SoS 1952+/-79 m/s (significantly lower than in controls, who had Ad-SoS 2022+/-85 m/s, p<0.05; the difference remained significant after adjusting for body mass index), s-BMD 0.87+/-0.22 g/cm2 ( Z-score -1.6), TB-BMD 0.92+/-0.12 g/cm2 ( Z-score -1.44), i-PTH 276+/-300 pg/ml, total calcium 2.46+/-0.19 mmol/l, ionized calcium 1.14+/-0.08 mmol/l, phosphate 1.68+/-0.61 mmol/l. Skeletal measurements correlated significantly with age, body size and Tanner stages (also after adjusting for age), while significant correlations of these parameters with the duration of CRF and laboratory investigations (except of correlations of i-PTH with Ad-SoS and with TB-BMD in predialysis patients) were not observed. None of the studied variables differed significantly between predialysis and dialysis patients. In conclusion, both predialysis and dialysis children and adolescents showed a decrease in BMD and quantitative ultrasound measurements. The severity of skeletal alterations was similar in the early phase (predialysis patients) and end stage (dialysis patients) of the disease and did not show a tendency to progress with CRF duration.
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Affiliation(s)
- W Pluskiewicz
- Department and Clinic of Internal Diseases, Diabetology and Nephrology, Metabolic Bone Diseases Unit, Silesian School of Medicine in Katowice, 3 Maja 13/15 Street, 41-800, Zabrze, Poland.
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30
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Abstract
Bone disease is common after renal transplantation. The main syndromes are bone loss with a consequent fracture rate of 3% per year, osteonecrosis of the hip, and bone pain. The causes of disease include preexisting uremic osteodystrophy (hyperparathyroidism, aluminum osteomalacia, beta2-associated amyloidosis, and diabetic osteopathy), postoperative glucocorticoid therapy, poor renal function, and ongoing hyperparathyroidism, as the result of either autonomous transformation of the parathyroid gland or ongoing physiologic stimuli. Cyclosporine A treatment, hyperphosphaturia, and a pathogenic vitamin D allele have also been implicated. Bone loss is particularly pronounced during the first year after operation, amounting to up to 9% of bone mass. The clinical and biochemical picture is consistent with a high turnover bone disease, but histomorphometric studies do not completely support this. Principal prophylactic options include preoperative osteodystrophy prophylaxis; postoperative calcium, vitamin D, or calcitriol therapy; estrogen therapy for postmenopausal women; and parathyroidectomy for medically intractable hyperparathyroidism. Recently, prophylactic biphosphonate treatment has shown promise, but the exact indications for treatment remain to be determined.
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Affiliation(s)
- James G Heaf
- Department of Nephrology B, Copenhagen University Hospital in Herlev, Denmark.
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31
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Abstract
Bone disease is observed in 75-100% of patients with chronic renal failure as the glomerular filtration rate (GFR) falls below 60 ml/minute. Hyperparathyroid (high turnover) bone disease is found most frequently followed by mixed osteodystrophy, low-turnover bone disease, and osteomalacia. With advancing renal impairment, "skeletal resistance" to parathyroid hormone (PTH) occurs. To maintain bone turnover, intact PTH (iPTH) targets from two to four times the upper normal range have been suggested, but whole PTH(1-84) assays indicate that amino-terminally truncated fragments, which accumulate in end-stage renal disease (ESRD), account for up to one-half of the measured iPTH. PTH levels and bone-specific alkaline phosphatase (BSAP) provide some information on bone involvement but bone biopsy and histomorphometry remains the gold standard. Calcitriol and calcium salts can be used to suppress PTH and improve osteomalacia but there is growing concern that these agents predispose to the development of vascular calcification, cardiovascular morbidity, low-turnover bone disease and fracture. Newer therapeutic options include less calcemic vitamin D analogues, calcimimetics and bisphosphonates for hyperparathyroidism, and sevelamer for phosphate control. Calcitriol and hormone-replacement therapy (HRT) have been shown to maintain bone mineral density (BMD) in certain patients with end-stage renal disease (ESRD). After renal transplantation, renal osteodystrophy generally improves but BMD often worsens. Bisphosphonate therapy may be appropriate for some patients at risk of fracture. When renal bone disease is assessed using a combination of biochemical markers, histology and bone densitometry, early intervention and the careful use of an increasing number of effective therapies can reduce the morbidity associated with this common problem.
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Affiliation(s)
- Grahame Elder
- Garvan Institute of Medical Research, Sydney, NSW, Australia
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32
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Abstract
Bone disease develops relatively early in the development of chronic renal failure. Much of what is known about the evaluation and management of renal osteodystrophy in chronic renal failure is based on knowledge obtained in the dialysis population. The classic bone lesion found in the dialysis population is osteitis fibrosa, the high turnover lesion of secondary hyperparathyroidism. Clearly, hypocalcemia, hyperphosphatemia, and calcitriol deficiency play major roles in the development and maintenance of the high turnover disease. Interestingly, in both the dialysis and nondialysis patients, the incidence of adynamic bone disease, a low turnover lesion, is increasing. It is postulated that the aggressive use of calcium-containing phosphate binders and the use of calcitriol and other vitamin D analogs to treat secondary hyperparathyroidism may contribute to this shift in bone lesions. Treatment in the nondialysis kidney disease patient remains aggressive correction of hypocalcemia and hyperphosphatemia. The use of calcitriol and other agents to maintain serum calcium and to suppress elevated parathyroid hormone remains well supported. However, the increase in extraskeletal calcifications and incidence of adynamic bone disease in these patients raises concern about current management techniques.
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Affiliation(s)
- L Tammy Ho
- Division of Nephrology, Evanston Northwestern Healthcare, Northwestern University Feinberg School of Medicine, Evanston, IL 60201, USA
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33
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Hsu CY, Cummings SR, McCulloch CE, Chertow GM. Bone mineral density is not diminished by mild to moderate chronic renal insufficiency. Kidney Int 2002; 61:1814-20. [PMID: 11967032 DOI: 10.1046/j.1523-1755.2002.00306.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Persons with end-stage renal disease are at higher risk for osteopenia and hip fracture relative to the age-matched general population. Persons with mild to moderate chronic renal insufficiency (CRI) may have reduced bone mineral density (BMD) as a result of abnormalities in acid-base and vitamin D-parathyroid hormone homeostasis. METHODS We analyzed data on 13,848 adults aged 20 and above from the Third National Health and Nutrition Examination Survey (NHANES III; 1988-1994). Regression models were used to determine the relationship between femoral BMD and renal function, the latter assessed using serum creatinine, blood urea nitrogen or Cockcroft-Gault creatinine clearance. To control for confounding, we fit sex-stratified models that adjusted for age, weight, height, race-ethnicity, menopausal status, estrogen use, activity level, family history of osteoporosis, diuretic use, and dietary intake of calcium and alcohol. RESULTS Although subjects with reduced renal function had significantly lower femoral BMD in unadjusted analysis, the association between CRI and bone mineral density was extinguished after adjustment in the multivariate models. In fact, controlling for only sex, age and weight was sufficient to extinguish any negative association between decreased renal function and decreased bone mineral density. CONCLUSION Although subjects with worse renal function have significantly lower femoral BMD, this association can be explained by confounding, principally by sex, age and weight. After taking into account the facts that women, older individuals and smaller individuals have less renal function and lower BMD, renal function itself is not independently associated with BMD.
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Affiliation(s)
- Chi-yuan Hsu
- Division of Nephrology, Prevention Science Group, University of California, San Francisco, San Francisco, California 94143-0532, USA.
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34
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Alon US. Preservation of bone mass in pediatric dialysis and transplant patients. ADVANCES IN RENAL REPLACEMENT THERAPY 2001; 8:191-205. [PMID: 11533920 DOI: 10.1053/jarr.2001.26352] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Renal osteodystrophy continues to be a major challenge to the physician treating the child with end-stage renal disease (ESRD). The gold standard for the assessment of bone status is bone histomorphometry, which divides bone pathology into 3 main types; high-turnover, low-turnover, and mixed disease. The high-turnover disease, related to hyperparathyroidism, has been the one most extensively investigated; however, optimal therapy, especially in the growing child, is yet unclear. Overzealous treatment might result in adynamic bone disease (an extreme example of low-turnover disease), and further interference with statural growth. Pre-existent bone disease after kidney transplantation seems to worsen immediately, probably because of the high dose of corticosteroids used. In children who attain normal kidney function in the allograft, bone status seems to improve over time. Little is known about bone in transplanted patients with reduced glomerular filtration rate (GFR). The correlation between bone histology and its main surrogates, bone remodeling markers and bone mineral density, is yet unclear, but it might serve to follow the progress of an individual patient. New therapeutic modalities aimed at suppressing hyperparathyroidism, and consequently bone resorption, as well as agents directly attenuating bone resorption, should be further investigated for their effect on bone in patients with ESRD or after transplantation. Similarly, agents stimulating bone formation, particularly growth hormone, require further attention for their potential to improve bone status. Bone health and the child's somatic growth at ESRD or after kidney transplantation are closely related, and therapy should be aimed at achieving optimal results for both.
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Affiliation(s)
- U S Alon
- Section of Pediatric Nephrology and Bone and Mineral Disorders Clinic, The Children's Mercy Hospital, University of Missouri at Kansas City, Kansas City, MO 64108, USA.
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35
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Rix M, Andreassen H, Eskildsen P, Langdahl B, Olgaard K. Bone mineral density and biochemical markers of bone turnover in patients with predialysis chronic renal failure. Kidney Int 1999; 56:1084-93. [PMID: 10469378 DOI: 10.1046/j.1523-1755.1999.00617.x] [Citation(s) in RCA: 237] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Metabolic bone disease might commence early in the course of renal failure. This study therefore examined the frequency and severity of the skeletal changes in predialysis chronic renal failure by measurements of bone mineral density (BMD), biochemical markers of bone turnover (osteocalcin, bone-specific alkaline phosphatase, carboxy terminal propeptide of type I collagen, and carboxy-terminal telopeptide of type I collagen), parathyroid hormone (PTH), ionized calcium (Ca++), phosphate (P), and vitamin D metabolites. METHODS The study was performed in 113 patients (male/female: 82/31) with chronic renal diseases [mean glomerular filtration rate (GFR) of 37 ml/min] and in 89 matched, normal control subjects. RESULTS The patients had significantly (P<0.05) reduced BMD in the spine (-6.3%), the femur (-12.1%), the forearm (-5.7%), and the total body (-4.2%) as compared with the control subjects. Dividing the patients into quartiles according to GFR revealed that BMD decreased with the gradual decline in renal function at all the measured skeletal sites, but was most pronounced in the femur: 0.63+/-0.03, 0.74+/-0.02, 0.77+/-0.02, and 0.82+/-0.03 g/cm2 in each quartile from lowest to highest GFR compared with 0.82+/-0.02 g/cm2 in the control group (P<0.0001). All of the measured bone markers showed increasing plasma levels with the more advanced stages of renal failure. Serum PTH and serum P levels increased, whereas serum Ca++ and 1,25-dihydroxyvitamin D decreased. BMD Z-scores of the femur and of the forearm correlated to the biochemical markers and to PTH (P<0.05 to P<0.0001). The biochemical markers all showed strong correlations to PTH, also when corrected for the effect of the decline in GFR (r = 0.40 to 0.92, P<0.01 to P< 0.0001). CONCLUSION Skeletal changes are initiated at an early stage of chronic renal failure, as estimated from reduced BMD and elevated levels of PTH and from the biochemical markers of both bone formation and bone resorption.
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Affiliation(s)
- M Rix
- Medical Department C, Roskilde County Hospital Koge, Denmark.
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36
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Montagnani A, Gonnelli S, Cepollaro C, Martini S, Finato V, Di Paolo N, Bellucci G, Gennari C. Quantitative ultrasound in the assessment of skeletal status in uremic patients. J Clin Densitom 1999; 2:389-95. [PMID: 10677792 DOI: 10.1016/s1094-6950(06)60404-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/1999] [Revised: 04/09/1999] [Accepted: 05/13/1999] [Indexed: 10/24/2022]
Abstract
Renal osteodystrophy (ROD) can be characterized by both high (HT) and low (LT) bone turnover states. Although bone biopsy remains the "gold standard" to diagnose ROD, noninvasive tools for the diagnosis and follow-up of such bone disease are desirable. Recently, ultrasound (US) techniques, proposed to assess skeletal status, have been shown to be correlated not only with bone density but also with bone quality. We have investigated 98 patients on chronic hemodyalisis (HD) and 98 healthy, sex- and age-matched subjects. Amplitude-dependent speed of sound (AD-SOS) and ultrasound bone profile score (UBPS) at phalanxes and speed of sound (SOS), broadband ultrasound attenuation (BUA), and a quantitative ultrasound index (QUI/stiffness) at the heel were performed in both groups. In all subjects intact parathyroid hormone (PTH), total alkaline phosphatase (T-ALP), bone isoenzyme alkaline phosphatase (B-ALP), and carboxy-terminal telopeptide of type I collagen (ICTP) were assessed. All US parameters were significantly lower in the hemodialysis group than in control subjects. Moreover, among US parameters only AD-SOS and UBPS showed a significant correlation with PTH, T-ALP, and B-ALP. Dialytic age showed a modest, but significant correlation only with US parameters at the phalanxes. On the basis of bone biochemical markers, we considered a group with high and a group with normal to low bone turnover. AD-SOS and UBPS, but not SOS, BUA, and stiffness were significantly (p < 0.01) lower in the high bone turnover than in low bone turnover group. Furthermore, in the high bone turnover group, parameters of the US phalanxes strongly correlated with B-ALP. Our results seem to demonstrate that US parameters are a useful tool in the assessment of skeletal status in patients on maintenance dialysis.
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Affiliation(s)
- A Montagnani
- Institute of Internal Medicine, University of Siena, Italy.
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37
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Boot AM, Nauta J, de Jong MC, Groothoff JW, Lilien MR, van Wijk JA, Kist-van Holthe JE, Hokken-Koelega AC, Pols HA, de Muinck Keizer-Schrama SM. Bone mineral density, bone metabolism and body composition of children with chronic renal failure, with and without growth hormone treatment. Clin Endocrinol (Oxf) 1998; 49:665-72. [PMID: 10197084 DOI: 10.1046/j.1365-2265.1998.00593.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Osteopenia has been reported in adult patients with chronic renal failure (CRF). Only a few studies have been performed in children. The objective of this study was to evaluate bone mineral density (BMD), bone turnover, body composition in children with CRF and to study the effect of GH on these variables. DESIGN Two groups were identified: patients with growth retardation who received GH (GH-group) and patients most of whom were not growth retarded who did not receive GH (no-GH-group). After an observation period of 6 months, the patients in the GH-group started GH treatment. Patients were studied every 6 months during 18 months. PATIENTS Thirty-six prepubertal patients (27 boys and 9 girls), mean age 7.9 years, with CRF participated in the study. The GH-group consisted of 17 patients of whom 14 completed one year treatment. The no-GH-group consisted of 19 patients, of whom 16 were followed for 6 months, 14 for 12 months and 13 for 18 months. MEASUREMENTS Lumbar spine BMD, total body BMD and body composition were assessed by dual energy X-ray absorptiometry, compared to age-and sex-matched reference values of the same population and expressed as standard deviation scores (SDS). BMD of appendicular bone was measured by quantitative microdensitometry (QMD). Blood samples were obtained to assess bone metabolism and growth factors. RESULTS Baseline mean lumbar spine and total body BMD SDS of all patients were not significantly different from normal. Mean lumbar spine and total body BMD SDS did not change significantly in the GH-group during GH treatment. The change of QMD at the midshaft during the first 6 months of GH treatment was significantly smaller than during the observation period (P < 0.01). Height SDS and biochemical markers of both bone formation and bone resorption increased significantly during GH treatment; 1,25-dihydroxyvitamin D remained stable. Lean tissue mass increased (P < 0.001) and percentage body fat decreased (P < 0.01) during GH treatment. BMD, the biochemical markers of bone turnover which are independent of renal function, and body composition remained stable in the no-GH-group. CONCLUSIONS Mean lumbar spine and total body BMD of children with chronic renal failure did not differ from healthy controls. The lack of a GH-induced increase in 1,25-dihydroxyvitamin D levels, probably due to treatment with alpha-calcidol, might be linked to the absence of a response in BMD during GH treatment in children with chronic renal failure.
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Affiliation(s)
- A M Boot
- Department of Paediatrics, Sophia Children's Hospital, Rotterdam, The Netherlands.
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38
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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
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39
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Boling EP, Primavera C, Friedman G, King M, Bosserman L, Schulz EE, Goodman WG. Non-invasive measurements of bone mass in adult renal osteodystrophy. Bone 1993; 14:409-13. [PMID: 8363886 DOI: 10.1016/8756-3282(93)90172-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- E P Boling
- Department of Radiology and Medicine, UCLA School of Medicine
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