Elevated IGFBP-1 cause high bone turnover in growth-restricted monochorionic twins with discordant birth weight

Age-related bone loss is associated with FGF21 but not IGFBP1 in healthy adults

What is the central question of this study? Fibroblast growth factor 21 (FGF21) plays important therapeutic roles in metabolic diseases but is associated with bone loss, through insulin-like growth factor binding protein 1 (IGFBP1), in animals. However, the effect of the FGF21-IGFBP1 axis on age-related bone loss has not been explored in humans. What is the main finding and its importance? Using 'genetically linked' parent and child family pairs, we show that the FGF21 concentration, but not the IGFBP1 concentration, is higher in older than in younger adults. Our results suggest that age-associated decline in bone mineral density is associated with FGF21 and increased bone turnover but not likely to involve IGFBP1 in healthy humans. ABSTRACT: Bone fragility increases with age. The fibroblast growth factor 21 (FGF21)-insulin-like growth factor binding protein 1 (IGFBP1) axis regulates bone loss in animals. However, the role of FGF21 in mediating age-associated bone fragility in humans remains unknown. The purpose of this study was to explore the FGF21-regulatory axis in bone turnover and the age-related decline in bone mineral density (BMD). Twenty 'genetically linked' family (parent and child) pairs were recruited. Younger adults were 22-39 years old and older adults 60-71 years old. The BMD and serum concentrations of FGF21, IGFBP1, receptor activator of nuclear factor-κB ligand (RANKL), tartrate-resistant acid phosphatase 5b (TRAP5b) and bone-specific alkaline phosphatase (BAP) were measured. Older adults had 10-18% lower BMD at the hip and spine (P < 0.008) and a twofold higher FGF21 concentration (P < 0.001). The IGFBP1 concentration was similar in younger and older adults (P = 0.961). The RANKL concentration was 44% lower (P = 0.006), whereas TRAP5b and BAP concentrations were 36 and 31% higher (P = 0.01 and P = 0.004), respectively, in older adults than in younger adults. Adjusting for sex did not affect these results. The FGF21 concentration was negatively correlated with BMD at the spine (r = -0.460, P = 0.003), but not with the IGFBP1 concentration (r = -0.144, P = 0.374). The IGFBP1 concentration was not correlated with BMD at the hip or spine (all P > 0.05). In humans, FGF21 might be involved in the age-associated decline in BMD, especially at the spine, through increased bone turnover. IGFBP1 is unlikely to be the downstream effector of FGF21 in driving the age-associated decline in BMD and in RANKL-associated osteoclast differentiation.

Early prognostic factors of outcomes in monochorionic twin pregnancy: systematic review and meta-analysis

BACKGROUND

Monochorionic twin pregnancies are high-risk, however at present, no screening test is available to predict which monochorionic twin pregnancy will develop complications.

OBJECTIVE

We sought to assess ability of first-trimester pregnancy-related factors (ultrasound measurements, maternal characteristics, biomarkers) to predict complications in monochorionic twin pregnancies.

DATA SOURCES

Data sources were MEDLINE, Embase, ISI Web of Science, CINAHL, the Cochrane Central Registration of Controlled Trials and Research Registers, and Google Scholar, from inception to May 12, 2017. Gray literature and bibliographies of articles were checked.

STUDY ELIGIBILITY CRITERIA

Studies that reported ultrasound measurements, maternal characteristics, or potential biomarkers, measured in the first trimester in monochorionic-diamniotic twin pregnancies, where the potential prognostic ability between the variable and twin-twin transfusion syndrome, growth restriction, or intrauterine fetal death could be assessed, were included.

STUDY APPRAISAL AND SYNTHESIS METHODS

Quality assessment was evaluated using the Strengthening the Reporting of Observational Studies in Epidemiology checklist by 2 reviewers independently. For meta-analysis, odds ratios using a random effects model, or standardized mean difference were calculated. If a moderate association was found, the prognostic ability was evaluated by calculating the sensitivity and specificity. Risk of heterogeneity was reported as I² and publication bias was visually assessed by funnel plots and quantitatively by Egger test.

RESULTS

In all, 48 studies were eligible for inclusion. Twenty meta-analyses could be performed. A moderate association was demonstrated in 3 meta-analyses, between: nuchal translucency >95th centile in one/both fetuses and twin-twin transfusion syndrome (odds ratio, 2.29 [95% confidence interval, 1.05-4.96], I² = 6.6%, 4 studies, 615 pregnancies); crown-rump length discordance ≥10% and twin-twin transfusion syndrome (odds ratio, 2.43 [95% confidence interval, 1.13-5.21], I² = 14.1%, 3 studies, 708 pregnancies); and maternal ethnicity and twin-twin transfusion syndrome (odds ratio, 2.12 [95% confidence interval, 1.17-3.83], I² = 0.0%, 5 studies, 467 pregnancies), but none demonstrated a prognostic ability for any outcome under investigation.

CONCLUSION

It is not currently possible to predict adverse outcomes in monochorionic twin pregnancies. We have revealed a lack of research investigating first-trimester biomarkers in monochorionic twin pregnancies. Different assessment methods and definitions of each variable and outcome were an issue and this highlights the need for a large cohort study to evaluate these factors.

Role of IGF-binding proteins in regulating IGF responses to changes in metabolism

The IGF-binding protein family contains six members that share significant structural homology. Their principal function is to regulate the actions of IGF1 and IGF2. These proteins are present in plasma and extracellular fluids and regulate access of both IGF1 and II to the type I IGF receptor. Additionally, they have functions that are independent of their ability to bind IGFs. Each protein is regulated independently of IGF1 and IGF2, and this provides an important mechanism by which other hormones and physiologic variables can regulate IGF actions indirectly. Several members of the family are sensitive to changes in intermediary metabolism. Specifically the presence of obesity/insulin resistance can significantly alter the expression of these proteins. Similarly changes in nutrition or catabolism can alter their synthesis and degradation. Multiple hormones such as glucocorticoids, androgens, estrogen and insulin regulate IGFBP synthesis and bioavailability. In addition to their ability to regulate IGF access to receptors these proteins can bind to distinct cell surface proteins or proteins in extracellular matrix and several cellular functions are influenced by these interactions. IGFBPs can be transported intracellularly and interact with nuclear proteins to alter cellular physiology. In pathophysiologic states, there is significant dysregulation between the changes in IGFBP synthesis and bioavailability and changes in IGF1 and IGF2. These discordant changes can lead to marked alterations in IGF action. Although binding protein physiology and pathophysiology are complex, experimental results have provided an important avenue for understanding how IGF actions are regulated in a variety of physiologic and pathophysiologic conditions.

Monochorionic twin pregnancy: screening, pathogenesis of complications and management in the era of microinvasive fetal surgery

OBJECTIVE

The management of monochorionic (MC) twin pregnancies varies in different medical centers. This paper compares screening methods to predict the complications of the MC twin pregnancy and different treatment methods.

METHODS

We performed a literature search without language restriction in Cochrane library and PubMed (1970-2009). Case series and cohort screening studies, pathogenesis and management of complications of MC pregnancy were included.

RESULTS

Elevated risk for intrauterine fetal death (IUFD) and twin-to-twin transfusion syndrome (TTTS) can be detected sonographically. Monitoring of MC pregnancies at increased risk and regular training sessions for the operating team combined with reduced fetoscopic amniotic membrane damage increase fetal survival rate from laser coagulation to nearly 100% for at least one fetus and to 90% for both.

CONCLUSION

Monitoring of MC pregnancies at increased risk and laser treatment of TTTS in medical centers with sufficient experience might improve neonatal outcome.

Intrauterine growth restriction in monochorionic twins

Intrauterine growth restriction (IUGR) occurs in approximately 3-10% of singleton pregnancies, in 9.1% of all twins, and in 9.9% of monochorionic twins. Spontaneous demise of the IUGR twin may occur and may result in concomitant demise or severe neurological handicap of the other twin. Currently, monochorionic twins with selective IUGR (SIUGR) are managed expectantly. Alternatively, all adverse consequences resulting from the potential demise of the SIUGR twin could be averted by unlinking the circulations between the two fetuses. The latter can be achieved by laser photocoagulation of communicating vessels or by umbilical-cord occlusion. The purpose of this chapter is to review this important entity in obstetrics.

Leptin and bone turnover in monochorionic twins complicated by twin-twin transfusion syndrome

INTRODUCTION

To test the hypothesis that the bone metabolism of a growth-restricted foetus is regulated by genetic, placental and/or foetal factors through leptin, we investigated the foetal bone turnover in monochorionic pregnancies complicated with or without twin-twin transfusion syndrome (TTTS).

METHODS

Maternal and cord bloods were collected from gestational-age-matched monochorionic twins with (n=15) and without (n=15) TTTS. The samples were assayed for leptin, cross-linked carboxyl terminal telo-peptide (ICTP, a marker of bone resorption) and pro-peptide (PICP, a marker of bone formation) of type I collagen by radioimmunoassay (RIA).

RESULTS

In the growth-restricted donor twin, the plasma concentration of leptin (P < 0.001), PICP (P < 0.001) was lower, while that of ICTP (P < 0.001) was higher than the recipient twin of the TTTS group. In contrast, leptin, PICP and ICTP were comparable in non-TTTS twins. In the recipient twin of TTTS and non-TTTS twins, leptin was positively associated with PICP (r=0.73; n=45, P < 0.001) and negatively with ICTP (r=-0.68; n=45; P < 0.001). No such association was found between leptin and bone marker in the growth-restricted donor twin of the TTTS group.

CONCLUSION

Our data suggest that, in AGA twins, leptin maintains bone metabolism by inhibiting resorption and enhancing bone formation. In contrast, growth-restricted donor twins have high bone turnover and this does not seem to be due to leptin deficiency.

Type 1 collagen marker of bone turnover, insulin-like growth factor, and leptin in dichorionic twins with discordant birth weight

OBJECTIVE

We investigated the relationship between IGF-I-IGF binding protein (IGFBP)-1 and leptin levels with type 1 collagen markers of bone turnover in dichorionic twins with or without discordant birth weight of 20% or greater.

METHODS

Maternal and cord bloods were collected from gestational age-matched dichorionic twins with (n = 16) or without (n = 16) discordant birth weight. The samples were assayed for cross-linked carboxyl terminal telopeptide (ICTP, a marker of bone resorption) and propeptide (PICP, a marker of bone formation) of type I collagen, leptin, IGF-I, and IGFBP-1 by RIA.

RESULTS

The intrauterine growth-restricted (IUGR) twins of the discordant group had higher fetal ICTP (P < 0.001) and IGFBP-1 (P < 0.001) levels, whereas PICP (P < 0.001), IGF-I (P < 0.001), and leptin (P < 0.001) were lower than the cotwins with normal weight (AGA). In contrast, concentrations of IGF-I, IGFBP-1, ICTP, PICP, and leptin were comparable between concordant twin pairs. Leptin levels were positively correlated with PICP (r = 0.61; P < 0.001) and negatively with ICTP (r = -0.57; P < 0.001) in concordant and AGA twins but not in IUGR twins. In IUGR twins, IGF-I had positive association with PICP (r = 0.76; P < 0.001) and negative association with ICTP (r= -0.76; P < 0.001), whereas IGFBP-1 was negatively correlated with PICP levels (r = -0.65; P < 0.01). No such association was found in concordant and AGA twins.

CONCLUSION

These data suggest that IUGR twins had high bone turnover, which is independent of maternal factors and perhaps may be due to altered IGF axis.