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Ivaska KK, McGuigan FE, Malmgren L, Gerdhem P, Johansson H, Kanis JA, Akesson KE. Bone Turnover Marker Profiling and Fracture Risk in Older Women: Fracture Risk from Age 75 to 90. Calcif Tissue Int 2022; 111:288-299. [PMID: 35750934 PMCID: PMC9395308 DOI: 10.1007/s00223-022-00996-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 05/25/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE A major challenge in osteoporosis is to identify individuals at high fracture risk. We investigated six bone turnover markers (BTMs) to determine association with specific fracture types; the time-frame for risk prediction and whether these are influenced by age at assessment. METHODS Population-based OPRA cohort (n = 1044) was assessed at ages 75, 80, 85 and fractures documented for up to 15 years. Six BTMs were analyzed at each time-point (N-terminal propeptide of type I collagen, PINP; total osteocalcin, OC; bone-specific alkaline phosphatase, BALP; C-terminal telopeptide of type I collagen, CTX; tartrate-resistant acid phosphatase 5b, TRAcP5b; urinary osteocalcin). Hazard ratios (HR) for any, major osteoporotic, vertebral and hip fractures were calculated as short (1, 2, 3 years) and long-term risk (5, 10, 15 years). RESULTS At 75 year, high CTX levels were associated with an increased risk of all fractures, including major osteoporotic fractures, across most time-frames (HRs ranging: 1.28 to 2.28). PINP was not consistently associated. Urinary osteocalcin was consistently associated with elevated short-term risk (HRs ranging: 1.83-2.72). Other BTMs were directionally in accordance, though not all statistically significant. BTMs were not predictive for hip fractures. Association of all BTMs attenuated over time; at 80 year none were associated with an increased fracture risk. CONCLUSION CTX, urinary OC and TRAcP5b are predictive for fracture in a 1 to 3 year, perspective, whereas in the long-term or above age 80 years, BTMs appear less valuable. Resorption markers, particularly CTX, were more consistently associated with fracture risk than formation markers in the very elderly.
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Affiliation(s)
- Kaisa K Ivaska
- Institute of Biomedicine, University of Turku, Turku, Finland.
- Clinical and Molecular Osteoporosis Research Unit, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.
| | - Fiona E McGuigan
- Clinical and Molecular Osteoporosis Research Unit, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Linnea Malmgren
- Clinical and Molecular Osteoporosis Research Unit, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
- Department of Geriatrics, Skåne University Hospital, Malmö, Sweden
| | - Paul Gerdhem
- Clinical and Molecular Osteoporosis Research Unit, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
- Department of Clinical Science Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Surgical Sciences and Department of Orthopaedics, Uppsala University, Uppsala, Sweden
| | - Helena Johansson
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - John A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - Kristina E Akesson
- Clinical and Molecular Osteoporosis Research Unit, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.
- Department of Orthopedics Malmö, Skåne University Hospital, S-21428, Malmö, Sweden.
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Habibi Ghahfarrokhi S, Mohammadian-Hafshejani A, Sherwin CMT, Heidari-Soureshjani S. Relationship between serum vitamin D and hip fracture in the elderly: a systematic review and meta-analysis. J Bone Miner Metab 2022; 40:541-553. [PMID: 35639176 DOI: 10.1007/s00774-022-01333-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 04/03/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION This study investigated the relationship between serum 25-hydroxyvitamin D (25OHD) levels and the occurrence of hip fractures in the elderly using a systematic review and meta-analysis approach. MATERIALS AND METHODS PubMed, Web of Science, and Scopus were used to identify studies that outlined an association between serum 25OHD and the occurrence of a hip fracture in a geriatric patient. The analysis calculated odds ratios (OR) for a hip fracture using a random-effects model. RESULTS In this study, 28 studies were included, 61,744 elderlies and 9767 cases (15.81%) of hip fractures. In the lowest vs. highest categories of vitamin D in the elderly, pooled OR of hip fractures was 1.80 (95% CI 1.56-2.07, P ≤ 0.001), and modified OR was equal to 1.40 (95% CI 1.20-1.63 P ≤ 0.001). A subgroup analysis showed that the OR of a hip fracture was 2.16 (1.49-3.11, P ≤ 0.001) in case-control studies; 1.52 (1.29-1.79, P = 0.001) in cohort studies; and 1.41 (1.18-1.70, P ≤ 0.001) in case-cohort studies. CONCLUSION Low serum vitamin D levels in the elderly are associated with an increase in the odds of hip fracture.
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Affiliation(s)
- Shahrzad Habibi Ghahfarrokhi
- Department of Social Medicine, Modeling in Health Research Center, Shahrekord University of Medical Sciences, Social Determinants of Health Research Center, Shahrekord, Iran
- Deputy of Research and Technology Kashani Boulevard, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Abdollah Mohammadian-Hafshejani
- Deputy of Research and Technology Kashani Boulevard, Shahrekord University of Medical Sciences, Shahrekord, Iran
- Department of Epidemiology and Biostatistics, School of Public Health, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Catherine M T Sherwin
- Pediatric Clinical Pharmacology, Department of Pediatrics, Wright State University Boonshoft School of Medicine, Dayton Children's Hospital, Dayton, OH, USA
- Dayton Children's Hospital, 1 Childrens Plz, Dayton, OH, 45404-1873, USA
| | - Saeid Heidari-Soureshjani
- Deputy of Research and Technology Kashani Boulevard, Shahrekord University of Medical Sciences, Shahrekord, Iran.
- Modeling in Health Research Center, Shahrekord University of Medical Sciences, Shahrekord, Iran.
- Circuit of Research and Technology, Shahrekord University of Medical Sciences, Shahrekord, Iran.
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Desbiens LC, Sidibé A, Ung RV, Mac-Way F. FGF23-Klotho Axis and Fractures in Patients Without and With Early CKD: A Case-Cohort Analysis of CARTaGENE. J Clin Endocrinol Metab 2022; 107:e2502-e2512. [PMID: 35139204 PMCID: PMC9113817 DOI: 10.1210/clinem/dgac071] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Whether fibroblast growth factor-23 (FGF23) and α-Klotho are associated with fractures, especially in chronic kidney disease (CKD), remains controversial. OBJECTIVE We evaluated how FGF23, α-Klotho, and traditional mineral parameters predict fractures in individuals with and without early CKD. METHODS We conducted a stratified case-cohort analysis using CARTaGENE, a population-based survey from Quebec, Canada. Individuals aged 40 to 69 years were selected according to outcome and CKD status (non-CKD: eGFR > 60 mL/min/1.73 m2; CKD stage 3: eGFR 30-60 mL/min/1.73 m2]). Baseline levels of c-terminal FGF23 (cFGF23), α-Klotho, parathyroid hormone (PTH), phosphate, and calcium were analyzed for associations with osteoporotic fracture incidence from recruitment (2009-2010) through March 2016. Adjusted Cox models were used, and predictors were treated linearly or flexibly using splines. RESULTS A total of 312 patients (159 non-CKD; 153 CKD) were included; 98 had ≥ 1 fracture at any site during a median follow up of 70 months. Compared with non-CKD, CKD patients had increased levels of cFGF23 but similar levels of α-Klotho. cFGF23 was linearly associated with increased fracture incidence (adjusted HR = 1.81 [1.71, 1.93] per doubling for all participants). The association of α-Klotho with fracture followed a U-curve (overall P = 0.019) but was attenuated by adjustment for potential mediators (bone mineral density, phosphate, PTH). PTH and phosphate also had U-shaped associations with fracture. Associations were mostly similar between non-CKD and CKD. Adjustment for cFGF23 strongly attenuated the association between CKD status and fractures. CONCLUSION cFGF23 is associated linearly with fracture incidence while α-Klotho, PTH, and phosphate levels have a U-shaped association.
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Affiliation(s)
- Louis-Charles Desbiens
- CHU de Québec Research Center, L’Hôtel-Dieu-de-Québec Hospital, Endocrinology and Nephrology Axis, Quebec City, QC G1R 2J6, Canada
- Department and Faculty of Medicine, Université Laval, Quebec City, QC G1V 5C3, Canada
| | - Aboubacar Sidibé
- CHU de Québec Research Center, L’Hôtel-Dieu-de-Québec Hospital, Endocrinology and Nephrology Axis, Quebec City, QC G1R 2J6, Canada
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Quebec City, QC G1V 5C3, Canada
| | - Roth-Visal Ung
- CHU de Québec Research Center, L’Hôtel-Dieu-de-Québec Hospital, Endocrinology and Nephrology Axis, Quebec City, QC G1R 2J6, Canada
| | - Fabrice Mac-Way
- CHU de Québec Research Center, L’Hôtel-Dieu-de-Québec Hospital, Endocrinology and Nephrology Axis, Quebec City, QC G1R 2J6, Canada
- Department and Faculty of Medicine, Université Laval, Quebec City, QC G1V 5C3, Canada
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Abstract
Bone fragility fractures remain an important worldwide health and economic problem due to increased morbidity and mortality. The current methods for predicting fractures are largely based on the measurement of bone mineral density and the utilization of mathematical risk calculators based on clinical risk factors for bone fragility. Despite these approaches, many bone fractures remain undiagnosed. Therefore, current research is focused on the identification of new factors such as bone turnover markers (BTM) for risk calculation. BTM are a group of proteins and peptides released during bone remodeling that can be found in serum or urine. They derive from bone resorptive and formative processes mediated by osteoclasts and osteoblasts, respectively. Potential use of BTM in monitoring these phenomenon and therefore bone fracture risk is limited by physiologic and pathophysiologic factors that influence BTM. These limitations in predicting fractures explain why their inclusion in clinical guidelines remains limited despite the large number of studies examining BTM.
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Affiliation(s)
- Lisa Di Medio
- Department of Surgery and Translational Medicine, University Hospital of Florence, Florence, Italy.
| | - Maria Luisa Brandi
- Department of Surgery and Translational Medicine, University Hospital of Florence, Florence, Italy
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Hsu S, Hoofnagle AN, Gupta DK, Gutierrez OM, Peralta CA, Shea S, Allen NB, Burke G, Michos ED, Ix JH, Siscovick D, Psaty BM, Watson KE, Kestenbaum B, de Boer IH, Robinson-Cohen C. Race, Ancestry, and Vitamin D Metabolism: The Multi-Ethnic Study of Atherosclerosis. J Clin Endocrinol Metab 2020; 105:dgaa612. [PMID: 32869845 PMCID: PMC7526733 DOI: 10.1210/clinem/dgaa612] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 08/27/2020] [Indexed: 02/06/2023]
Abstract
CONTEXT A comprehensive characterization of racial/ethnic variations in vitamin D metabolism markers may improve our understanding of differences in bone and mineral homeostasis and the risk of vitamin D-related diseases. OBJECTIVE Describe racial/ethnic differences in vitamin D metabolism markers and their associations with genetic ancestry. DESIGN, SETTING, PARTICIPANTS In a cross-sectional study within the Multi-Ethnic Study of Atherosclerosis (MESA), we compared a comprehensive panel of vitamin D metabolism markers across self-reported racial/ethnic groups of Black (N = 1759), White (N = 2507), Chinese (N = 788), and Hispanic (N = 1411). We evaluated associations of proportion African and European ancestry with this panel of markers in Black and Hispanic participants using ancestry informative markers. Latent class analysis evaluated associations between patterns of vitamin D measurements with race/ethnicity. RESULTS Compared with Black participants, White participants had significantly higher serum concentrations of 25-hydroxyvitamin D and fibroblast growth factor-23; lower concentrations of parathyroid hormone and 1,25-dihydroxyvitamin D; circulating vitamin D metabolite ratios suggesting lower CYP27B1 and higher CYP24A1 activity; higher urinary concentrations of calcium and phosphorus with higher urinary fractional excretion of phosphorus; and differences in vitamin D binding globulin haplotypes. Higher percent European ancestry was associated with higher 25-hydroxyvitamin D and lower parathyroid hormone concentrations among Black and Hispanic participants. Latent classes defined by vitamin D measurements reflected these patterns and differed significantly by race/ethnicity and ancestry. CONCLUSIONS Markers of vitamin D metabolism vary significantly by race/ethnicity, may serve to maintain bone and mineral homeostasis across ranges of 25-hydroxyvitamin D production, and be attributable, at least partly, to genetic ancestry.
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Affiliation(s)
- Simon Hsu
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
| | - Andrew N Hoofnagle
- Department of Laboratory Medicine, University of Washington, Seattle, Washington
| | - Deepak K Gupta
- Vanderbilt Translational and Clinical Cardiovascular Research Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Orlando M Gutierrez
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Carmen A Peralta
- Cricket Health, Inc., San Francisco, California
- The Kidney Health Research Collaborative, San Francisco, California
- University of California, San Francisco, San Francisco, California
| | - Steven Shea
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Norrina B Allen
- Department of Internal Medicine, Northwestern University, Chicago, Illinois
| | - Gregory Burke
- Division of Public Health Sciences Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Erin D Michos
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
- Department of Epidemiology and the Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Joachim H Ix
- Nephrology Section, Veterans Affairs San Diego Healthcare System, San Diego, California
- Division of Nephrology-Hypertension, University of California, San Diego, San Diego, California
| | | | - Bruce M Psaty
- Cardiovascular Health Research Unit, Departments of Medicine, Epidemiology and Health Services, University of Washington, Seattle, Washington
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Karol E Watson
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Bryan Kestenbaum
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
| | - Ian H de Boer
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
| | - Cassianne Robinson-Cohen
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Vanderbilt Center for Kidney Disease, Vanderbilt University Medical Center, Nashville, Tennessee
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Arima K, Mizukami S, Nishimura T, Tomita Y, Nakashima H, Abe Y, Aoyagi K. Epidemiology of the association between serum 25-hydroxyvitamin D levels and musculoskeletal conditions among elderly individuals: a literature review. J Physiol Anthropol 2020; 39:38. [PMID: 33243295 PMCID: PMC7690203 DOI: 10.1186/s40101-020-00249-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 11/18/2020] [Indexed: 12/02/2022] Open
Abstract
Background Vitamin D deficiency is associated with osteoporosis, fracture, muscle weakness, falls, and osteoarthritis in adults. Elderly individuals are more likely to present with poor musculoskeletal conditions. Recently, several epidemiological studies have assessed the correlation between serum 25-hydroxyvitamin D (25(OH)D) levels and musculoskeletal conditions in elderly individuals. Main text Osteoporosis is a skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture. Numerous studies have shown a positive association between serum 25(OH)D levels and bone mineral density. Only a few studies have reported an association between serum 25(OH)D levels and quantitative ultrasound (QUS) parameters. Low serum 25(OH)D level may be a risk factor for hip fracture. However, data on the association between vitamin D deficiency and the incidence of non-hip fracture are contrasting. Falls are a major cause of mortality and morbidity in older adults. Several prospective population-based cohort studies have shown that low 25(OH)D levels are associated with an increased risk of falls. Reduced muscle strength and physical performance are risk factors for adverse events, including disability, institutionalization, and mortality. The role of vitamin D in musculoskeletal functionality (muscle weakness and physical performance) among elderly individuals is still controversial. Osteoarthritis (OA) is the most common form of arthritis and is a leading cause of disability among older adults. Data on the association between serum 25(OH)D levels and OA are contrasting. Conclusion Some studies have shown that vitamin D deficiency may be a risk factor for poor musculoskeletal conditions, such as osteoporosis, fracture, muscle weakness, falls, and osteoarthritis in adults. However, other studies did not find an association between serum 25(OH)D levels and musculoskeletal conditions.
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Affiliation(s)
- Kazuhiko Arima
- Department of Public Health, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Satoshi Mizukami
- Department of Public Health, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Takayuki Nishimura
- Department of Human Science, Faculty of Design, Kyushu University, Fukuoka, Japan
| | - Yoshihito Tomita
- School of Rehabilitation, Department of Physical Therapy, Tokyo Professional University of Health Sciences, Tokyo, Japan
| | - Hiroki Nakashima
- Department of Public Health, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yasuyo Abe
- Department of Public Health, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kiyoshi Aoyagi
- Department of Public Health, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan.
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Genetic variants of mineral metabolism in health and disease. Curr Opin Nephrol Hypertens 2020; 29:387-393. [PMID: 32427690 DOI: 10.1097/mnh.0000000000000612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Disturbances in mineral metabolism are common among individuals with chronic kidney disease and have consistently been associated with cardiovascular and bone disease. The current review aims to describe the current knowledge of the genetic aspects of mineral metabolism disturbances and to suggest directions for future studies to uncover the cause and pathogenesis of chronic kidney disease - mineral bone disorder. RECENT FINDINGS The most severe disorders of mineral metabolism are caused by highly penetrant, rare, single-gene disruptive mutations. More recently, genome-wide association studies (GWAS) have made an important contribution to our understanding of the genetic determinants of circulating levels of 25-hydroxyvitamin D, calcium, phosphorus, fibroblast growth factor-23, parathyroid hormone, fetuin-A and osteoprotegerin. Although the majority of these genes are known members of mineral homeostasis pathways, GWAS with larger sample sizes have enabled the discovery of many genes not known to be involved in the regulation of mineral metabolism. SUMMARY GWAS have enabled remarkable developments in our ability to discover the genetic basis of mineral metabolism disturbances. Although we are far from using these findings to inform clinical practice, we are gaining understanding of novel biological mechanisms and providing insight into ethnic variation in these traits.
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Chou SH, LeBoff MS, Manson JE. Is the Sun Setting on Vitamin D? Clin Chem 2020; 66:635-637. [PMID: 32268365 DOI: 10.1093/clinchem/hvaa074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 02/27/2020] [Indexed: 12/31/2022]
Affiliation(s)
- Sharon H Chou
- Division of Endocrinology, Diabetes, and Hypertension, Department of Medicine, Brigham and Women's Hospital Boston, Boston, MA.,Harvard Medical School, Boston, MA
| | - Meryl S LeBoff
- Division of Endocrinology, Diabetes, and Hypertension, Department of Medicine, Brigham and Women's Hospital Boston, Boston, MA.,Harvard Medical School, Boston, MA
| | - JoAnn E Manson
- Harvard Medical School, Boston, MA.,Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
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Wang N, Chen Y, Ji J, Chang J, Yu S, Yu B. The relationship between serum vitamin D and fracture risk in the elderly: a meta-analysis. J Orthop Surg Res 2020; 15:81. [PMID: 32103764 PMCID: PMC7045381 DOI: 10.1186/s13018-020-01603-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 02/17/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The incidence of osteoporotic fractures has increased rapidly, and because of the poor prognosis and high mortality associated with osteoporotic fractures, they remain a prospective research area globally. One way to reduce their incidence is to investigate their intervention risk factors in the elderly. Hence, this study explores the correlation between serum 25-hydroxyvitamin D [25(OH)D] levels and osteoporotic fractures in elderly patients through a meta-analysis. METHODS We conducted our literature search mainly in PubMed and Embase for identifying studies that investigated the relationship between serum 25(OH)D levels and the risk for osteoporotic fractures. We performed categorical analysis, heterogeneity checks, publication bias analysis, and subgroup analyses. RESULTS In total, 20 studies were included, of which 4 were case-cohort studies and 16 were cohort studies. A total of 41,738 patients from 20 studies were included in the meta-analysis, of which 5916 had fractures, including 3237 hip fractures. By combining the lowest and highest categories of relative risks (RRs) and 95% confidence intervals (CIs), it was suggested that lower serum 25-hydroxyvitamin D levels may be a risk factor for fractures. RR (95% CI) for total and hip fractures were 1.11 (0.99, 1.24) and 0.89 (0.80, 0.98) after adjustments. CONCLUSIONS Our study showed that compared to low serum 25(OH)D levels, high serum 25(OH)D levels reduce the risk of hip fractures in the patients aged 60 years or older. In contrast, serum 25(OH)D has no significant relationship with total fracture risk.
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Affiliation(s)
- Ning Wang
- Shandong University of Traditional Chinese Medicine, Jingshi Road16369, Jinan, 250014 China
| | - Yungang Chen
- Department of Orthopaedics, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jingshi Road16369, Jinan, 250014 China
| | - Jindou Ji
- Shandong University of Traditional Chinese Medicine, Jingshi Road16369, Jinan, 250014 China
| | - Jinlei Chang
- Shandong University of Traditional Chinese Medicine, Jingshi Road16369, Jinan, 250014 China
| | - Shengwen Yu
- Shandong University of Traditional Chinese Medicine, Jingshi Road16369, Jinan, 250014 China
| | - Bo Yu
- Department of Orthopaedics, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jingshi Road16369, Jinan, 250014 China
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Yao P, Bennett D, Mafham M, Lin X, Chen Z, Armitage J, Clarke R. Vitamin D and Calcium for the Prevention of Fracture: A Systematic Review and Meta-analysis. JAMA Netw Open 2019; 2:e1917789. [PMID: 31860103 PMCID: PMC6991219 DOI: 10.1001/jamanetworkopen.2019.17789] [Citation(s) in RCA: 178] [Impact Index Per Article: 35.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 10/27/2019] [Indexed: 12/14/2022] Open
Abstract
Importance Vitamin D and calcium supplements are recommended for the prevention of fracture, but previous randomized clinical trials (RCTs) have reported conflicting results, with uncertainty about optimal doses and regimens for supplementation and their overall effectiveness. Objective To assess the risks of fracture associated with differences in concentrations of 25-hydroxyvitamin D (25[OH]D) in observational studies and the risks of fracture associated with supplementation with vitamin D alone or in combination with calcium in RCTs. Data Sources PubMed, EMBASE, Cochrane Library, and other RCT databases were searched from database inception until December 31, 2018. Searches were performed between July 2018 and December 2018. Study Selection Observational studies involving at least 200 fracture cases and RCTs enrolling at least 500 participants and reporting at least 10 incident fractures were included. Randomized clinical trials compared vitamin D or vitamin D and calcium with control. Data Extraction and Synthesis Two researchers independently extracted data according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and assessed possible bias. Rate ratios (RRs) were estimated using fixed-effects meta-analysis. Data extraction and synthesis took place between July 2018 and June 2019. Main Outcomes and Measures Any fracture and hip fracture. Results In a meta-analysis of 11 observational studies (39 141 participants, 6278 fractures, 2367 hip fractures), each increase of 10.0 ng/mL (ie, 25 nmol/L) in 25 (OH)D concentration was associated with an adjusted RR for any fracture of 0.93 (95% CI, 0.89-0.96) and an adjusted RR for hip fracture of 0.80 (95% CI, 0.75-0.86). A meta-analysis of 11 RCTs (34 243 participants, 2843 fractures, 740 hip fractures) of vitamin D supplementation alone (daily or intermittent dose of 400-30 000 IU, yielding a median difference in 25[OH]D concentration of 8.4 ng/mL) did not find a reduced risk of any fracture (RR, 1.06; 95% CI, 0.98-1.14) or hip fracture (RR, 1.14; 95% CI, 0.98-1.32), but these trials were constrained by infrequent intermittent dosing, low daily doses of vitamin D, or an inadequate number of participants. In contrast, a meta-analysis of 6 RCTs (49 282 participants, 5449 fractures, 730 hip fractures) of combined supplementation with vitamin D (daily doses of 400-800 IU, yielding a median difference in 25[OH]D concentration of 9.2 ng/mL) and calcium (daily doses of 1000-1200 mg) found a 6% reduced risk of any fracture (RR, 0.94; 95% CI, 0.89-0.99) and a 16% reduced risk of hip fracture (RR, 0.84; 95% CI, 0.72-0.97). Conclusions and Relevance In this systematic review and meta-analysis, neither intermittent nor daily dosing with standard doses of vitamin D alone was associated with reduced risk of fracture, but daily supplementation with both vitamin D and calcium was a more promising strategy.
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Affiliation(s)
- Pang Yao
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Derrick Bennett
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Marion Mafham
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Xu Lin
- Chinese Academy of Sciences Key Laboratory of Nutrition, Metabolism, and Food Safety, Shanghai Institute of Nutrition and Health, Chinese Academy of Sciences and University of the Chinese Academy of Sciences, Shanghai, China
- Shanghai Institute for Biological Sciences, Chinese Academy of Sciences and University of the Chinese Academy of Sciences, Shanghai, China
| | - Zhengming Chen
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Jane Armitage
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Robert Clarke
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
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Lorentzon M, Branco J, Brandi ML, Bruyère O, Chapurlat R, Cooper C, Cortet B, Diez-Perez A, Ferrari S, Gasparik A, Herrmann M, Jorgensen NR, Kanis J, Kaufman JM, Laslop A, Locquet M, Matijevic R, McCloskey E, Minisola S, Pikner R, Reginster JY, Rizzoli R, Szulc P, Vlaskovska M, Cavalier E. Algorithm for the Use of Biochemical Markers of Bone Turnover in the Diagnosis, Assessment and Follow-Up of Treatment for Osteoporosis. Adv Ther 2019; 36:2811-2824. [PMID: 31440982 PMCID: PMC6822833 DOI: 10.1007/s12325-019-01063-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Indexed: 12/02/2022]
Abstract
Introduction Increased biochemical bone turnover markers (BTMs) measured in serum are associated with bone loss, increased fracture risk and poor treatment adherence, but their role in clinical practice is presently unclear. The aim of this consensus group report is to provide guidance to clinicians on how to use BTMs in patient evaluation in postmenopausal osteoporosis, in fracture risk prediction and in the monitoring of treatment efficacy and adherence to osteoporosis medication. Methods A working group with clinical scientists and osteoporosis specialists was invited by the Scientific Advisory Board of European Society on Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO). Results Serum bone formation marker PINP and resorption marker βCTX-I are the preferred markers for evaluating bone turnover in the clinical setting due to their specificity to bone, performance in clinical studies, wide use and relatively low analytical variability. BTMs cannot be used to diagnose osteoporosis because of low sensitivity and specificity, but can be of value in patient evaluation where high values may indicate the need to investigate some causes of secondary osteoporosis. Assessing serum levels of βCTX-I and PINP can improve fracture prediction slightly, with a gradient of risk of about 1.2 per SD increase in the bone marker in addition to clinical risk factors and bone mineral density. For an individual patient, BTMs are not useful in projecting bone loss or treatment efficacy, but it is recommended that serum PINP and βCTX-I be used to monitor adherence to oral bisphosphonate treatment. Suppression of the BTMs greater than the least significant change or to levels in the lower half of the reference interval in young and healthy premenopausal women is closely related to treatment adherence. Conclusion In conclusion, the currently available evidence indicates that the principal clinical utility of BTMs is for monitoring oral bisphosphonate therapy.
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Urinary N-Telopeptide Can Predict Pseudarthrosis After Anterior Cervical Decompression and Fusion: A Prospective Study. Spine (Phila Pa 1976) 2019; 44:770-776. [PMID: 30475338 DOI: 10.1097/brs.0000000000002935] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective cohort study. OBJECTIVE To examine preoperative urinary cross-linked n-telopeptide (uNTx) and assess for association with fusion rates in patients undergoing single and multi-level anterior cervical decompression and fusion (ACDF). SUMMARY OF BACKGROUND DATA Although high rates of fusion have been reported for ACDF, the risk of pseudarthrosis remains substantial. An established marker of bone turnover, uNTx may prove useful as a predictor of fusion. METHODS Patients undergoing primary ACDF with allograft/plating technique from 2015 to 2017 by a single surgeon were consecutively enrolled and preoperative uNTx was collected. Patients undergoing revision, with creatinine >1.2, and with improperly-collected uNTx were excluded. Demographics, laboratory values, and fusion status were assessed at 6 months, 1 year, and 2 years postoperatively. RESULTS Of the 97 patients enrolled, 69 met inclusion criteria. Of included cases, 41%, 33%, 18%, and 8% underwent 1-, 2-, 3-, and 4-level ACDF, respectively. Overall, fusion rates were 37.3%, 70.9%, and 95.3% at 6 months, 1 year, and 2 years, respectively. uNTx was higher in the fusion group (31.1 vs. 22.2, P = 0.001) at 6 months and 1 year (30.0 vs. 21.0, P = 0.006), with no difference at 2 years. No differences were identified in the proportion of smokers, immunomodulatory agents, corpectomies, or fusion levels between groups. Multivariate regression analysis demonstrated that uNTx is an independent predictor of fusion (odds ratio, OR, 1.124, P = 0.003). Both groups experienced improvements in NDI and VAS neck pain at 6 months with no significant differences noted between groups. Of 16 patients with pseudarthrosis at 1 year, 2 underwent posterior cervical fusion for symptoms. CONCLUSION Preoperative uNTx was greater in patients with successful ACDF fusion compared with patients with pseudarthrosis at 6 months and 1 year. A negative correlation was found between preoperative uNTx and motion on dynamic imaging. These results suggest that uNTx could serve to identify patients at risk for pseudarthrosis after ACDF. LEVEL OF EVIDENCE 3.
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Bover J, Ureña P, Aguilar A, Mazzaferro S, Benito S, López-Báez V, Ramos A, daSilva I, Cozzolino M. Alkaline Phosphatases in the Complex Chronic Kidney Disease-Mineral and Bone Disorders. Calcif Tissue Int 2018; 103:111-124. [PMID: 29445837 DOI: 10.1007/s00223-018-0399-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 01/29/2018] [Indexed: 12/16/2022]
Abstract
Alkaline phosphatases (APs) remove the phosphate (dephosphorylation) needed in multiple metabolic processes (from many molecules such as proteins, nucleotides, or pyrophosphate). Therefore, APs are important for bone mineralization but paradoxically they can also be deleterious for other processes, such as vascular calcification and the increasingly known cross-talk between bone and vessels. A proper balance between beneficial and harmful activities is further complicated in the context of chronic kidney disease (CKD). In this narrative review, we will briefly update the complexity of the enzyme, including its different isoforms such as the bone-specific alkaline phosphatase or the most recently discovered B1x. We will also analyze the correlations and potential discrepancies with parathyroid hormone and bone turnover and, most importantly, the valuable recent associations of AP's with cardiovascular disease and/or vascular calcification, and survival. Finally, a basic knowledge of the synthetic and degradation pathways of APs promises to open new therapeutic strategies for the treatment of the CKD-Mineral and Bone Disorder (CKD-MBD) in the near future, as well as for other processes such as sepsis, acute kidney injury, inflammation, endothelial dysfunction, metabolic syndrome or, in diabetes, cardiovascular complications. However, no studies have been done using APs as a primary therapeutic target for clinical outcomes, and therefore, AP's levels cannot yet be used alone as an isolated primary target in the treatment of CKD-MBD. Nonetheless, its diagnostic and prognostic potential should be underlined.
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Affiliation(s)
- Jordi Bover
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, RedinRen, C. Cartagena, Catalonia, 340-350, Barcelona, Spain.
| | - Pablo Ureña
- Department of Nephrology and Dialysis, Clinique du Landy and Department of Renal Physiology, Necker Hospital, University of Paris Descartes, Paris, France
| | - Armando Aguilar
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, RedinRen, C. Cartagena, Catalonia, 340-350, Barcelona, Spain
| | - Sandro Mazzaferro
- Department of Cardiovascular, Respiratory, Nephrologic and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Silvia Benito
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, RedinRen, C. Cartagena, Catalonia, 340-350, Barcelona, Spain
| | - Víctor López-Báez
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, RedinRen, C. Cartagena, Catalonia, 340-350, Barcelona, Spain
| | - Alejandra Ramos
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, RedinRen, C. Cartagena, Catalonia, 340-350, Barcelona, Spain
| | - Iara daSilva
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, RedinRen, C. Cartagena, Catalonia, 340-350, Barcelona, Spain
| | - Mario Cozzolino
- Laboratory of Experimental Nephrology, Renal Division,San Paolo Hospital, DiSS University of Milan, Milan, Italy
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Crandall CJ, Vasan S, LaCroix A, LeBoff MS, Cauley JA, Robbins JA, Jackson RD, Bauer DC. Bone Turnover Markers Are Not Associated With Hip Fracture Risk: A Case-Control Study in the Women's Health Initiative. J Bone Miner Res 2018; 33:1199-1208. [PMID: 29923225 PMCID: PMC7060935 DOI: 10.1002/jbmr.3471] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 04/29/2018] [Accepted: 05/11/2018] [Indexed: 12/14/2022]
Abstract
Current guidelines recommend that serum C-terminal telopeptide of type I collagen (CTX) and serum procollagen type 1 aminoterminal propeptide (PINP), measured by standardized assays, be used as reference markers in observational and interventional studies. However, there are limited data to determine whether serum CTX and PINP are associated with hip fracture risk among postmenopausal women. We determined the associations of serum CTX and serum PINP with hip fracture risk among postmenopausal women aged 50 to 79 years at baseline. We performed a prospective case-control study (400 cases, 400 controls) nested in the Women's Health Initiative Observational Study, which enrolled participants at 40 US clinical centers. Cases were women with incident hip fracture not taking osteoporosis medication; hip fractures were confirmed using medical records. Untreated controls were matched by age, race/ethnicity, and date of blood sampling. Serum CTX and serum PINP were analyzed on 12-hour fasting blood samples. The main outcome measure was incident hip fracture risk (mean follow-up 7.13 years). After adjustment for body mass index, smoking, frequency of falls, history of fracture, calcium and vitamin D intake, and other relevant covariates, neither serum CTX level nor serum PINP level was statistically significantly associated with hip fracture risk (CTX ptrend = 0.22, PINP ptrend = 0.53). Our results do not support the utility of serum CTX level or PINP level to predict hip fracture risk in women in this age group. These results will inform future guidelines regarding the potential utility of these markers in fracture prediction. © 2018 American Society for Bone and Mineral Research.
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Affiliation(s)
- Carolyn J Crandall
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA, USA
| | - Sowmya Vasan
- Women's Health Initiative, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Andrea LaCroix
- Family and Preventive Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Meryl S LeBoff
- Endocrine, Diabetes, and Hypertension Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jane A Cauley
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - John A Robbins
- Department of Medicine, UC Davis Medical Center, Sacramento, CA, USA
| | - Rebecca D Jackson
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, The Ohio State University, Columbus, OH, USA
| | - Douglas C Bauer
- Departments of Medicine and Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, CA, USA
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Lv QB, Gao X, Liu X, Shao ZX, Xu QH, Tang L, Chi YL, Wu AM. The serum 25-hydroxyvitamin D levels and hip fracture risk: a meta-analysis of prospective cohort studies. Oncotarget 2018; 8:39849-39858. [PMID: 28418890 PMCID: PMC5503658 DOI: 10.18632/oncotarget.16337] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 02/13/2017] [Indexed: 12/31/2022] Open
Abstract
Hip fracture has increasingly become a social and economic burden. The relationship between serum 25-hydroxyvitamin D levels and the risk of hip fracture reported by previous studies remains controversial. We searched Pubmed and Embase to identify studies reporting the relationship between serum 25-hydroxyvitamin D levels and risk of hip fracture. Fifteen prospective cohort studies with a total of 51239 participants and 3386 hip fracture cases were included. By pooling the Relative Risk of the lowest vs. the highest categories indicated that lower levels of serum 25-hydroxyvitamin D were more likely to be a risk factor for hip fracture with adjusted Relative Risk (95%Confidence Interval) of 1.58 (1.41, 1.77). Subgroup meta-analysis examining the stability of the primary results achieved the same results. A dose-response meta-analysis showed that the risk of hip fracture was a descending curve below the line of RR=1. The descending trend was obvious when serum 25-hydroxyvitamin D levels were less than 60 nmol/L and was flat when serum 25-hydroxyvitamin D levels were more than 60 nmol/L. We found that individuals with low levels of serum 25-hydroxyvitamin D have an increased risk of hip fracture, and this effect was evident when the serum 25-hydroxyvitamin D levels were less than 60 nmol/L.
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Affiliation(s)
- Qing-Bo Lv
- Department of Orthopedics, Bone Research Institute, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Second Medical School of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Xiang Gao
- Department of Orthopedics, Bone Research Institute, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Second Medical School of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Xiang Liu
- Department of Orthopedics, Bone Research Institute, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Second Medical School of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Zhen-Xuan Shao
- Department of Orthopedics, Bone Research Institute, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Second Medical School of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Qian-Hui Xu
- Department of Orthopedics, Bone Research Institute, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Second Medical School of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Li Tang
- Department of Orthopedics, Bone Research Institute, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Second Medical School of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Yong-Long Chi
- Department of Orthopedics, Bone Research Institute, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Second Medical School of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Ai-Min Wu
- Department of Orthopedics, Bone Research Institute, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Second Medical School of Wenzhou Medical University, Wenzhou, Zhejiang, China
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Ginsberg C, Katz R, de Boer IH, Kestenbaum BR, Chonchol M, Shlipak MG, Sarnak MJ, Hoofnagle AN, Rifkin DE, Garimella PS, Ix JH. The 24,25 to 25-hydroxyvitamin D ratio and fracture risk in older adults: The cardiovascular health study. Bone 2018; 107:124-130. [PMID: 29155243 PMCID: PMC5794222 DOI: 10.1016/j.bone.2017.11.011] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 11/14/2017] [Accepted: 11/15/2017] [Indexed: 11/29/2022]
Abstract
25-hydroxyvitamin D [25(OH)D] may not optimally indicate vitamin D receptor activity. Higher concentrations of its catabolic product 24,25-dihydroxyvitmin D [24,25(OH)2D] and a higher ratio of 24,25(OH)2D to 25(OH)D (the vitamin D metabolite ratio [VMR]) may provide additional information on receptor activity. We compared the strength of associations of these markers with serum PTH concentrations, hip bone mineral density (BMD), and risk of incident hip fracture in community-living older participants in the Cardiovascular Health Study. Among 890 participants, the mean age was 78years, 60% were women, and the mean 25(OH)D was 28±11ng/ml. In cross-sectional analysis, the strength of association of each vitamin D measure with PTH was similar; a 1% higher 25(OH)D, 24,25(OH)2D, and VMR were associated with 0.32%, 0.25%, and 0.26% lower PTH, respectively (p<0.05 for all). Among 358 participants with available BMD data, we found no associations of 25(OH)D or VMR with BMD, whereas higher 24,25(OH)2D was modestly associated with greater hip BMD (1% higher 24,25(OH)2D associated with 0.04% [95% CI 0.01-0.08%] higher BMD). Risk of incident hip fracture risk was evaluated using a case-cohort design. There were 289 hip fractures during a mean follow up time of 8.4years. Both higher 24,25(OH)2D and VMR were associated with lower risk of hip fracture (HR per SD higher, 0.73 [0.61, 0.87] and 0.74 [0.61, 0.88], respectively) whereas 25(OH)D was not associated with hip fracture (HR 0.93 [0.79, 1.10]). We conclude that evaluating vitamin D status by incorporating assessment of 24,25(OH)D and the VMR provides information on bone health above and beyond 25(OH)D alone.
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Affiliation(s)
- Charles Ginsberg
- Nephrology Section, Veterans Affairs San Diego Healthcare System, San Diego, CA and Division of Nephrology-Hypertension, University of California, San Diego, San Diego, CA, United States.
| | - Ronit Katz
- Kidney Research Institute, University of Washington, Seattle, WA, United States
| | - Ian H de Boer
- Division of Nephrology and Kidney Research Institute, University of Washington, Seattle, WA, United States
| | - Bryan R Kestenbaum
- Kidney Research Institute, University of Washington, Seattle, WA, United States
| | - Michel Chonchol
- Division of Renal Diseases and Hypertension, University of Anschutz Medical Center, Aurora, CO, United States
| | - Michael G Shlipak
- Kidney Health Research Collaborative, Veterans Affairs Medical Center, San Francisco, CA and University of California, San Francisco, CA
| | - Mark J Sarnak
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, MA, United States
| | - Andrew N Hoofnagle
- Departments of Laboratory Medicine and Medicine, Kidney Research Institute, University of Washington, Seattle, WA, United States
| | - Dena E Rifkin
- Nephrology Section, Veterans Affairs San Diego Healthcare System, San Diego, CA and Division of Nephrology-Hypertension, University of California, San Diego, San Diego, CA, United States
| | - Pranav S Garimella
- Division of Nephrology-Hypertension, University of California, San Diego, San Diego, CA, United States
| | - Joachim H Ix
- Nephrology Section, Veterans Affairs San Diego Healthcare System, San Diego, CA and Division of Nephrology-Hypertension, University of California, San Diego, San Diego, CA, United States
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17
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Eastell R, Szulc P. Use of bone turnover markers in postmenopausal osteoporosis. Lancet Diabetes Endocrinol 2017; 5:908-923. [PMID: 28689768 DOI: 10.1016/s2213-8587(17)30184-5] [Citation(s) in RCA: 296] [Impact Index Per Article: 42.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 05/07/2017] [Accepted: 05/08/2017] [Indexed: 12/30/2022]
Abstract
Bone turnover comprises two processes: the removal of old bone (resorption) and the laying down of new bone (formation). N-terminal propeptide of type I procollagen (PINP) and C-telopeptide of type I collagen (CTX-I) are markers of bone formation and resorption, respectively, that are recommended for clinical use. Bone turnover markers can be measured on several occasions in one individual with good precision. However, these markers are subject to several sources of variability, including feeding (resorption decreases) and recent fracture (all markers increase for several months). Bone turnover markers are not used for diagnosis of osteoporosis and do not improve prediction of bone loss or fracture within an individual. In untreated women, very high bone turnover marker concentrations suggest secondary causes of high bone turnover (eg, bone metastases or multiple myeloma). In people with osteoporosis, bone turnover markers might be useful to assess the response to anabolic and antiresorptive therapies, to assess compliance to therapy, or to indicate possible secondary osteoporosis. Much remains to be learnt about how bone turnover markers can be used to monitor the effect of stopping bisphosphonate therapy (eg, to identify a threshold above which restarting therapy should be considered). More studies are needed to investigate the use of bone turnover markers for assessment of the bone safety of new medications.
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Affiliation(s)
- Richard Eastell
- Academic Unit of Bone Metabolism, University of Sheffield, Sheffield, UK.
| | - Pawel Szulc
- INSERM UMR 1033, University of Lyon, Hôpital Edouard Herriot, Lyon, France
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Abstract
Renal osteodystrophy is a feature of chronic kidney disease (CKD), with increasing prevalence as CKD progresses. This bone disease is responsible for major morbidity, including fractures, and a deterioration in the quality of life and its sequelae. Circulating biomarkers of renal osteodystrophy typically indicate bone turnover, but not other features of bone, like bone volume, mineralization, quality or strength. Bone turnover can be considered to be primarily a reflection of bone cell activity, in particular that of osteoblasts and osteoclasts. Since current treatments for bone disease usually target cellular activity, biomarkers are considered to be able to contribute to the decision-making for treatment and its follow-up. In CKD, one has to consider the impact of a diminished clearance of biomarkers or their altered metabolism, both potentially limiting its clinical use. Here, several aspects of the most frequently used biomarkers of bone turnover are reviewed, with an emphasis on the specific situation represented by CKD. This review is based on the overview lecture at the symposium held in Amsterdam, September 23, 2016: “The Bone In CKD”, organized by the CKD-MBD working group of ERA-EDTA.
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Affiliation(s)
- Marc G Vervloet
- Department of Nephrology and Institute of Cardiovascular Research, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
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Feng Y, Cheng G, Wang H, Chen B. The associations between serum 25-hydroxyvitamin D level and the risk of total fracture and hip fracture. Osteoporos Int 2017; 28:1641-1652. [PMID: 28220196 DOI: 10.1007/s00198-017-3955-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 01/31/2017] [Indexed: 02/07/2023]
Abstract
UNLABELLED In this meta-analysis, we evaluated the association between serum 25-hydroxyvitamin D (25(OH) vitamin D) level and the risk of total fractures and hip fractures. Low serum 25(OH) vitamin D level is associated with an increased risk of total and hip fractures. INTRODUCTION Data on the association between serum 25(OH) vitamin D level and the risk of fractures are conflicting. This study aimed to provide a summary of prospective cohort or nested case-control studies on the association between serum 25(OH) vitamin D level and the risk of total fractures and hip fractures. METHODS We identified relevant studies by searching the PubMed, EMBASE, and OVID databases from their inception to June 1, 2016. We included published prospective cohort or nested case-control studies evaluating the associations of serum 25(OH) vitamin D level with the fracture risk. Two reviewers abstracted the data independently. Relative risks (RRs) with 95% confidence intervals (CIs) were derived throughout the whole analysis. RESULTS Sixteen prospective cohort studies and three nested case-control studies were included. We found that low serum 25(OH) vitamin D level was significantly associated with the risk of total fractures (RR 1.25, 95% CI 1.06-1.43; I 2 = 31.3%, p for heterogeneity = 0.15) and hip fractures (RR 1.48, 95% CI 1.29-1.68; I 2 = 0%, p for heterogeneity = 0.51). The hip fracture risk was increased by 40% for each SD decrease in serum 25(OH) vitamin D level (RR 1.40, 95% CI 1.20-1.61; I 2 = 0%, p for heterogeneity = 0.51). The per SD decrease in serum 25(OH) vitamin D level was not associated with the increased risk of total fractures (RR 1.14, 95% CI 0.93-1.35; I 2 = 63.2%, p for heterogeneity = 0.04). CONCLUSIONS Our study suggests that low serum 25(OH) vitamin D level is associated with increased risks of total and hip fractures. In the analyzed studies, the per SD decrease in serum 25(OH) vitamin D level was associated with the hip fracture risk but not with the total fracture risk.
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Affiliation(s)
- Y Feng
- Department of Orthopedics, Ren Ji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - G Cheng
- Department of Orthopedics, Ren Ji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - H Wang
- Department of Orthopedics, Ren Ji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - B Chen
- Department of Orthopedics, Ren Ji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China.
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Greenblatt MB, Tsai JN, Wein MN. Bone Turnover Markers in the Diagnosis and Monitoring of Metabolic Bone Disease. Clin Chem 2016; 63:464-474. [PMID: 27940448 DOI: 10.1373/clinchem.2016.259085] [Citation(s) in RCA: 189] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 10/10/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Disorders of bone metabolism, most notably osteoporosis, are highly prevalent and predispose to fractures, causing high patient morbidity and mortality. Diagnosis and monitoring of bone metabolic defects can present a major challenge as these disorders are largely asymptomatic and radiographic measures of bone mass respond slowly to changes in bone physiology. CONTENT Bone turnover markers (BTMs) are a series of protein or protein derivative biomarkers released during bone remodeling by osteoblasts or osteoclasts. BTMs can offer prognostic information on fracture risk that supplements radiographic measures of bone mass, but testing using BTMs has to take into account the large number of preanalytic factors and comorbid clinical conditions influencing BTM levels. BTMs respond rapidly to changes in bone physiology, therefore, they have utility in determining patient response to and compliance with therapies for osteoporosis. SUMMARY BTMs are a useful adjunct for the diagnosis and therapeutic monitoring of bone metabolic disorders, but their use has to be tempered by the known limitations in their clinical utility and preanalytic variables complicating interpretation.
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Affiliation(s)
- Matthew B Greenblatt
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY;
| | - Joy N Tsai
- Endocrine Unit, Massachusetts General Hospital, Boston, MA
| | - Marc N Wein
- Endocrine Unit, Massachusetts General Hospital, Boston, MA
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Rong K, Liu XY, Wu XH, Li XL, Xia QQ, Chen J, Yin XF. Increasing Level of Leisure Physical Activity Could Reduce the Risk of Hip Fracture in Older Women: A Dose-Response Meta-analysis of Prospective Cohort Studies. Medicine (Baltimore) 2016; 95:e2984. [PMID: 26986111 PMCID: PMC4839892 DOI: 10.1097/md.0000000000002984] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Revised: 01/30/2016] [Accepted: 02/10/2016] [Indexed: 12/27/2022] Open
Abstract
We carried out the study to investigate and quantitatively assess the potential association between current level of physical activity and the risk of osteoporosis hip fracture in older women. Relevant publications before October 2015 were identified using the PubMed and Ovid searching tools. A dose-response meta-analysis was carried out to combine and analysis results. Fourteen prospective studies were included in the meta-analysis. A general analysis of 9 studies showed a significant inverse relationship between increasing level of physical activity and risk of hip fracture in older women [relative risk (RR) = 0.93, 95% confidence interval (95% CI): 0.91-0.96]. The result of a sensitivity analysis was consistent with the general analysis (RR = 0.94, 95% CI: 0.93-0.96). The association between increasing level of physical activity and risk of wrist fracture was not statistically significant in a general analysis of three studies (RR = 1.004, 95% CI: 0.98-1.03). A potential direct association between increasing level of physical activity and risk of wrist fracture was observed after removing 1 study with the greatest weight (RR = 1.01, 95% CI: 1.00-1.03). No significant publication bias was observed in our analysis. Our results show that increasing level of physical activity within an appropriate range may reduce the risk of hip fracture but not the risk of wrist fracture in older women.
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Affiliation(s)
- Ke Rong
- From the Department of Orthopedics (KR, XHW, QX, JC, XFY), Minhang Hospital, Fudan University, Shanghai, China; Shanghai Institute of Medical Imaging (XYL), Shanghai, China; Department of Interventional Radiology (XYL), Zhongshan Hospital, Fudan University, Shanghai, China; Department of Epidemiology (XYL), School of Public Health, Fudan University, Shanghai, China; and Department of Rehabilitation Medicine (XL), Minhang Hospital, Fudan University, Shanghai, China
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Cauley JA, Greendale GA, Ruppert K, Lian Y, Randolph JF, Lo JC, Burnett-Bowie SA, Finkelstein JS. Serum 25 hydroxyvitamin D, bone mineral density and fracture risk across the menopause. J Clin Endocrinol Metab 2015; 100:2046-54. [PMID: 25719933 PMCID: PMC4422899 DOI: 10.1210/jc.2014-4367] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Low levels of serum 25 Hydroxyvitamin D [25(OH)D] have been linked to greater fracture risk in older women. OBJECTIVE This study aimed to determine whether higher 25(OH)D is associated with slower loss of bone mineral density (BMD) and lower fracture risk during the menopausal transition. DESIGN, SETTING, AND PARTICIPANTS This was a prospective cohort study at five clinical centers in the United States. Mean age was 48.5 ± 2.7 years. The fracture analysis included 124 women with an incident traumatic fracture, 88 with incident nontraumatic fracture, and 1532 women without incident fractures; average followup was 9.5 years. BMD analysis included 922 women with a documented final menstrual period. MAIN OUTCOME MEASURES Serum 25(OH)D was measured by liquid chromatography tandem mass spectrometry at the third annual clinic visit. BMD was measured and incident fractures ascertained at each annual visit. RESULTS The mean 25(OH)D was 21.8 ng/mL; seven-hundred two (43%) of the women had 25(OH)D values <20 ng/mL. There was no significant association between 25(OH)D and traumatic fractures. In multivariate adjusted hazards models, the hazard ratio (HR) for nontraumatic fractures (95% confidence interval [CI]) was 0.72 (0.54-0.96) for each 10-ng/mL increase in 25(OH)D. Comparing women whose 25(OH)D was ≥20 vs <20 ng/mL, the HR (95% CI) for fracture was 0.54 (0.32-0.89). Changes in lumbar spine and femoral neck bone mineral density across menopause were not significantly associated with serum 25(OH)D level. CONCLUSION Serum 25(OH)D levels are inversely associated with nontraumatic fracture in mid-life women. Vitamin D supplementation is warranted in midlife women with 25(OH)D levels <20 ng/mL.
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Affiliation(s)
- Jane A Cauley
- Graduate School of Public Health, Department of Epidemiology (J.A.C., K.R., Y.L.), University of Pittsburgh, Pittsburgh, Pennsylvania 15261; Division of Geriatrics (G.A.G.), David Geffen School of Medicine at UCLA, Los Angeles, California 90095; Division of Reproductive Endocrinology and Infertility (J.F.R.), University of Michigan Medical School, Ann Arbor, Michigan 48109; Division of Research (J.C.L.), Kaiser Permanente Northern California, Oakland, California 94612; and Department of Medicine (S.-A.B.-B., J.S.F.), Endocrine Unit, MA General Hospital, Boston, Massachusetts 02114
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LeBoff MS, Yue AY, Copeland T, Cook NR, Buring JE, Manson JE. VITAL-Bone Health: rationale and design of two ancillary studies evaluating the effects of vitamin D and/or omega-3 fatty acid supplements on incident fractures and bone health outcomes in the VITamin D and OmegA-3 TriaL (VITAL). Contemp Clin Trials 2015; 41:259-68. [PMID: 25623291 PMCID: PMC4380672 DOI: 10.1016/j.cct.2015.01.007] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 01/14/2015] [Accepted: 01/17/2015] [Indexed: 12/12/2022]
Abstract
RATIONALE Although vitamin D is widely used to promote skeletal health, definitive data on benefits and risks of supplemental vitamin D alone on bone are lacking. Results from large, randomized controlled trials in the general population are sparse. Data on the effects of supplemental omega-3 fatty acids (FAs) on bone are also limited. DESIGN The VITamin D and OmegA-3 TriaL (VITAL) is a double-blind, placebo-controlled trial assessing the role of vitamin D3 (2000 IU/d) and omega-3 FA (1g/d) supplements in reducing risks of cancer and cardiovascular disease among U.S. men aged ≥50 and women aged ≥55. To comprehensively test effects of supplemental vitamin D and/or omega-3 FAs on skeletal health, the VITAL: Effects on Fractures ancillary study is determining the effects of these supplements on incident fractures among 25,875 participants enrolled in the parent trial. Study investigators adjudicate fractures through a detailed review of medical records and radiological images (hip and femur). In a complementary ancillary, VITAL: Effects on Structure and Architecture is determining the effects of supplemental vitamin D and/or omega-3 FAs on bone with detailed phenotyping during in-person visits. Comprehensive assessments of bone density, turnover, structure/architecture, body composition, and physical performance are being performed at baseline and 2 years post-randomization. CONCLUSION Results from these studies will clarify the relationship between supplemental vitamin D and/or omega-3 FAs on bone health outcomes, and inform clinical care and public health guidelines on the use of supplemental vitamin D for the primary prevention of fractures in women and men.
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Affiliation(s)
- Meryl S LeBoff
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, United States; Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, United States.
| | - Amy Y Yue
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, United States.
| | - Trisha Copeland
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02215, United States.
| | - Nancy R Cook
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02215, United States; Department of Epidemiology, Harvard School of Public Health, Boston, MA 02115, United States.
| | - Julie E Buring
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02215, United States; Department of Epidemiology, Harvard School of Public Health, Boston, MA 02115, United States.
| | - JoAnn E Manson
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02215, United States; Department of Epidemiology, Harvard School of Public Health, Boston, MA 02115, United States.
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Bansal N, Zelnick L, Robinson-Cohen C, Hoofnagle AN, Ix JH, Lima JA, Shoben AB, Peralta CA, Siscovick DS, Kestenbaum B, de Boer IH. Serum parathyroid hormone and 25-hydroxyvitamin D concentrations and risk of incident heart failure: the Multi-Ethnic Study of Atherosclerosis. J Am Heart Assoc 2014; 3:e001278. [PMID: 25468653 PMCID: PMC4338718 DOI: 10.1161/jaha.114.001278] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background Heart failure (HF) is common and is associated with high mortality. We aimed to determine associations of serum parathyroid hormone (PTH) and 25‐hydroxyvitamin D (25[OH]D) with incident HF and left ventricular mass. Methods and Results Among 6459 participants in the community‐based Multi‐Ethnic Study of Atherosclerosis, all of whom were free of prevalent clinical cardiovascular disease, we measured serum concentrations of PTH and 25(OH)D at the baseline examination. In longitudinal analyses, we tested associations of PTH and 25(OH)D with incident HF events, adjudicated by a panel of physicians. In cross‐sectional analyses of a subset of 4763 participants, we tested associations of PTH and 25(OH)D with left ventricular mass, measured by cardiac magnetic resonance imaging at baseline. Multivariable Cox proportional hazard and linear regression models were adjusted for demographics, physical examination measures, comorbidity, kidney function, and other mineral metabolism markers. Mean age was 62 years and 53% of participants were female. There were 180 incident HF events over a median (interquartile range) follow‐up time of 8.46 (7.67 to 8.63) years. Compared with participants with PTH <65 pg/mL, PTH ≥65 pg/mL was associated with a 50% greater risk of incident HF (95% CI: 3% to 210%) and a 5.3 g higher left ventricular mass (95% CI: 2.6, 7.9 g). In contrast, there was no association of 25(OH)D with risk of incident HF or elevated left ventricular mass. Conclusions In a racially/ethnically diverse population without prevalent cardiovascular disease, higher serum PTH concentration was associated with increased left ventricular mass and increased risk of incident HF. Further studies should be pursued to determine whether PTH excess may be a modifiable risk factor for HF.
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Affiliation(s)
- Nisha Bansal
- Kidney Research Institute, University of Washington, Seattle, WA (N.B., L.Z., C.R.C., A.N.H., B.K., I.H.B.)
| | - Leila Zelnick
- Kidney Research Institute, University of Washington, Seattle, WA (N.B., L.Z., C.R.C., A.N.H., B.K., I.H.B.)
| | - Cassianne Robinson-Cohen
- Kidney Research Institute, University of Washington, Seattle, WA (N.B., L.Z., C.R.C., A.N.H., B.K., I.H.B.)
| | - Andy N Hoofnagle
- Kidney Research Institute, University of Washington, Seattle, WA (N.B., L.Z., C.R.C., A.N.H., B.K., I.H.B.)
| | - Joachim H Ix
- University of California, San Diego, CA (J.H.I.)
| | - Joao A Lima
- Johns Hopkins University, Baltimore, MD (J.A.L.)
| | | | | | | | - Bryan Kestenbaum
- Kidney Research Institute, University of Washington, Seattle, WA (N.B., L.Z., C.R.C., A.N.H., B.K., I.H.B.)
| | - Ian H de Boer
- Kidney Research Institute, University of Washington, Seattle, WA (N.B., L.Z., C.R.C., A.N.H., B.K., I.H.B.)
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Lau WL, Kalantar-Zadeh K, Kovesdy CP, Mehrotra R. Alkaline phosphatase: Better than PTH as a marker of cardiovascular and bone disease? Hemodial Int 2014; 18:720-4. [DOI: 10.1111/hdi.12190] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Barbour KE, Lui LY, Ensrud KE, Hillier TA, LeBlanc ES, Ing SW, Hochberg MC, Cauley JA. Inflammatory markers and risk of hip fracture in older white women: the study of osteoporotic fractures. J Bone Miner Res 2014; 29:2057-64. [PMID: 24723386 PMCID: PMC4336950 DOI: 10.1002/jbmr.2245] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 03/04/2014] [Accepted: 03/17/2014] [Indexed: 11/12/2022]
Abstract
Hip fractures are the most devastating consequence of osteoporosis and impact 1 in 6 white women leading to a two- to threefold increased mortality risk in the first year. Despite evidence of inflammatory markers in the pathogenesis of osteoporosis, few studies have examined their effect on hip fracture. To determine if high levels of inflammation increase hip fracture risk and to explore mediation pathways, a case-cohort design nested in a cohort of 4709 white women from the Study of Osteoporotic Fractures was used. A random sample of 1171 women was selected as the subcohort (mean age 80.1 ± 4.2 years) plus the first 300 women with incident hip fracture. Inflammatory markers interleukin-6 (IL-6) and soluble receptors (SR) for IL-6 (IL-6 SR) and tumor necrosis factor (TNF SR1 and TNF SR2) were measured, and participants were followed for a median (interquartile range) of 6.3 (3.7, 6.9) years. In multivariable models, the hazard ratio (HR) of hip fracture for women in the highest inflammatory marker level (quartile 4) was 1.64 (95% confidence interval [CI], 1.09-2.48, p trend = 0.03) for IL-6 and 2.05 (95% CI, 1.35-3.12, p trend <0.01) for TNF SR1 when compared with women in the lowest level (quartile 1). Among women with 2 and 3-4 inflammatory markers in the highest quartile, the HR of hip fracture was 1.51 (95% CI, 1.07-2.14) and 1.42 (95% CI, 0.87-2.31) compared with women with zero to one marker(s) in the highest quartile (p trend = 0.03). After individually adjusting for seven potential mediators, cystatin-C (a biomarker of renal function) and bone mineral density (BMD) attenuated HRs among women with the highest inflammatory burden by 64% and 50%, respectively, suggesting a potential mediating role. Older white women with high inflammatory burden are at increased risk of hip fracture in part due to poor renal function and low BMD.
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Steingrimsdottir L, Halldorsson TI, Siggeirsdottir K, Cotch MF, Einarsdottir BO, Eiriksdottir G, Sigurdsson S, Launer LJ, Harris TB, Gudnason V, Sigurdsson G. Hip fractures and bone mineral density in the elderly--importance of serum 25-hydroxyvitamin D. PLoS One 2014; 9:e91122. [PMID: 24621578 PMCID: PMC3951316 DOI: 10.1371/journal.pone.0091122] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2013] [Accepted: 02/07/2014] [Indexed: 11/21/2022] Open
Abstract
Background The significance of serum 25-hydroxyvitamin D [25(OH)D] concentrations for hip fracture risk of the elderly is still uncertain. Difficulties reaching both frail and healthy elderly people in randomized controlled trials or large cohort studies may in part explain discordant findings. We determined hazard ratios for hip fractures of elderly men and women related to serum 25(OH)D, including both the frail and the healthy segment of the elderly population. Methods The AGES-Reykjavik Study is a prospective study of 5764 men and women, age 66–96 years, based on a representative sample of the population of Reykjavik, Iceland. Participation was 71.8%. Hazard ratios of incident hip fractures and baseline bone mineral density were determined according to serum concentrations of 25(OH)D at baseline. Results Mean follow-up was 5.4 years. Compared with referent values (50–75 nmol/L), hazard ratios for hip fractures were 2.24 (95% CI 1.63, 3.09) for serum 25(OH)D <30 nmol/L, adjusting for age, sex, body mass index, height, smoking, alcohol intake and season, and 2.08 (95% CI 1.51, 2.87), adjusting additionally for physical activity. No difference in risk was associated with 30–50 nmol/L or ≥75 nmol/L in either model compared with referent. Analyzing the sexes separately, hazard ratios were 2.61 (95% CI 1.47, 4.64) in men and 1.93 (95% CI 1.31, 2.84) in women. Values <30 nmol/L were associated with significantly lower bone mineral density of femoral neck compared with referent, z-scores -0.14 (95% CI −0.27, −0.00) in men and −0.11 (95% CI −0.22, −0.01) in women. Conclusions Our results lend support to the overarching importance of maintaining serum 25(OH)D above 30 nmol/L for bone health of elderly people while potential benefits of having much higher levels could not be detected.
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Affiliation(s)
- Laufey Steingrimsdottir
- Unit for Nutrition Research, University of Iceland and Landspitali University Hospital, Reykjavik, Iceland
- * E-mail:
| | - Thorhallur I. Halldorsson
- Unit for Nutrition Research, University of Iceland and Landspitali University Hospital, Reykjavik, Iceland
| | | | - Mary Frances Cotch
- Division of Epidemiology and Clinical Applications, National Eye Institute, Bethesda, Maryland, United States of America
| | | | | | | | - Lenore J. Launer
- Intramural Research Program, Laboratory of Epidemiology, Demography and Biometry, National Institute of Aging, Bethesda, Maryland, United States of America
| | - Tamara B. Harris
- Intramural Research Program, Laboratory of Epidemiology, Demography and Biometry, National Institute of Aging, Bethesda, Maryland, United States of America
| | - Vilmundur Gudnason
- Icelandic Heart Association Research Institute, Kopavogur, Iceland
- University of Iceland, Reykjavik, Iceland
| | - Gunnar Sigurdsson
- Icelandic Heart Association Research Institute, Kopavogur, Iceland
- University of Iceland, Reykjavik, Iceland
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Sachs MC, Shoben A, Levin GP, Robinson-Cohen C, Hoofnagle AN, Swords-Jenny N, Ix JH, Budoff M, Lutsey PL, Siscovick DS, Kestenbaum B, de Boer IH. Estimating mean annual 25-hydroxyvitamin D concentrations from single measurements: the Multi-Ethnic Study of Atherosclerosis. Am J Clin Nutr 2013; 97:1243-51. [PMID: 23615830 PMCID: PMC3652923 DOI: 10.3945/ajcn.112.054502] [Citation(s) in RCA: 116] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The seasonal variation in circulating 25-hydroxyvitamin D [25(OH)D] concentrations is large relative to mean values. Single measurements may misclassify annual exposure, which may lead to bias in research and complicate clinical decision making. OBJECTIVE We aimed to develop and validate a model for adjusting a single measurement of a serum 25(OH)D concentration to the time of year it was measured. DESIGN We measured serum 25(OH)D concentrations by using mass spectrometry in 6476 participants from the Multi-Ethnic Study of Atherosclerosis at baseline and again in a subset of 368 participants at a median of 17 mo later. We estimated a cosinor model to describe the seasonal variability in 25(OH)D concentrations and evaluated this model by using follow-up 25(OH)D measurements. RESULTS The mean age of subjects was 62.1 y, 61.2% of participants were nonwhite, and 53.3% of participants were women. The cosinor model predicted follow-up 25(OH)D concentrations better than a single measurement [difference in root mean squared error (RMSE): 1.3 ng/mL; P< 0.001]. The cosinor model also better predicted the measured annual mean 25(OH)D concentration (difference in RMSE: 1.0 ng/mL; P< 0.001). Annual mean 25(OH)D concentrations estimated from the cosinor model reclassified 7.1% of participants with regard to 25(OH)D deficiency, which was defined as <20 ng/mL. An estimated annual mean 25(OH)D concentration <20 ng/mL was significantly associated with lower bone mineral density, whereas an untransformed 25(OH)D concentration <20 ng/mL was not. CONCLUSIONS Cross-sectional data can be used to estimate subject-specific mean annual 25(OH)D concentrations from single values by using a cosinor model. The tool we developed by using this approach may assist research and clinical care of adults in North America by reducing the misclassification of 25(OH)D deficiency.
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Affiliation(s)
- Michael C Sachs
- Kidney Research Institute and Division of Nephrology, University of Washington, Seattle, WA, USA.
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Abstract
Results from previous prospective studies linking serum 25-hydroxyvitamin D (25OHD) with fracture risk have been inconsistent. The present study examined the relationship between serum 25OHD and risk of incident major osteoporotic fracture (hip, spine, radius, and humerus) in older U.S. adults. The study used a pooled cohort of 4749 men and women ages 65 years and older from the third National Health and Nutrition Examination Survey (NHANES III, 1988-1994) and NHANES 2000-2004. Incident fractures were identified using linked mortality and Medicare records that were obtained for participants from both surveys. Serum 25OHD values were measured by radioimmunoassay in both surveys. Cox proportional hazards models were used to estimate the relative risk (RR) of fracture by serum 25OHD level. There were 525 incident major osteoporotic fractures (287 hip fractures) in the sample. Serum 25OHD was a significant linear predictor of major osteoporotic fracture and significant quadratic predictor of hip fracture in the total sample and among those with less than 10 years of follow-up, but it was not related to risk of either fracture type among those with ≥ 10 years of follow-up. Major osteoporotic fracture risk was increased by 26% to 27% for each SD decrease in serum 25OHD among those with less than 10 years of follow-up. Serum 25OHD was significantly related to risk of major osteoporotic fractures as a group and to hip fracture alone in this cohort of older U.S. adults from NHANES III and NHANES 2000-2004. However, the predictive utility of serum 25OHD diminished after 10 years. In addition, the relationship appeared to be linear when major osteoporotic fracture risk was considered but quadratic when hip fracture risk was assessed.
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Affiliation(s)
- Anne C Looker
- National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, MD 20782, USA.
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Fisher A, Srikusalanukul W, Davis M, Smith P. Cardiovascular diseases in older patients with osteoporotic hip fracture: prevalence, disturbances in mineral and bone metabolism, and bidirectional links. Clin Interv Aging 2013; 8:239-56. [PMID: 23460043 PMCID: PMC3585505 DOI: 10.2147/cia.s38856] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Considerable controversy exists regarding the contribution of mineral/bone metabolism abnormalities to the association between cardiovascular diseases (CVDs) and osteoporotic fractures. AIMS AND METHODS To determine the relationships between mineral/bone metabolism biomarkers and CVD in 746 older patients with hip fracture, clinical data were recorded and serum concentrations of parathyroid hormone (PTH), 25-hydroxyvitamin D, calcium, phosphate, magnesium, troponin I, parameters of bone turnover, and renal, liver, and thyroid functions were measured. RESULTS CVDs were diagnosed in 472 (63.3%) patients. Vitamin D deficiency was similarly prevalent in patients with (78.0%) and without (82.1%) CVD. The CVD group had significantly higher mean PTH concentrations (7.6 vs 6.0 pmol/L, P < 0.001), a higher prevalence of secondary hyperparathyroidism (SPTH) (PTH > 6.8 pmol/L, 43.0% vs 23.3%, P < 0.001), and excess bone resorption (urinary deoxypyridinoline corrected by creatinine [DPD/Cr] > 7.5 nmol/μmol, 87.9% vs 74.8%, P < 0.001). In multivariate regression analysis, SHPT (odds ratio [OR] 2.6, P = 0.007) and high DPD/Cr (OR 2.8, P = 0.016) were independent indictors of CVD. Compared to those with both PTH and DPD/Cr in the normal range, multivariate-adjusted ORs for the presence of CVD were 17.3 (P = 0.004) in subjects with SHPT and 9.7 (P < 0.001) in patients with high DPD/Cr. CVD was an independent predicator of SHPT (OR 2.8, P = 0.007) and excess DPD/Cr (OR 2.5, P = 0.031). CVD was predictive of postoperative myocardial injury, while SHPT was also an independent predictor of prolonged hospital stay and in-hospital death. CONCLUSION SHPT and excess bone resorption are independent pathophysiological mediators underlying the bidirectional associations between CVD and hip fracture, and therefore are important diagnostic and therapeutic targets.
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Affiliation(s)
- A Fisher
- Department of Geriatric Medicine, The Canberra Hospital, Canberra, ACT, Australia.
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Levin GP, Robinson-Cohen C, de Boer IH, Houston DK, Lohman K, Liu Y, Kritchevsky SB, Cauley JA, Tanaka T, Ferrucci L, Bandinelli S, Patel KV, Hagström E, Michaëlsson K, Melhus H, Wang T, Wolf M, Psaty BM, Siscovick D, Kestenbaum B. Genetic variants and associations of 25-hydroxyvitamin D concentrations with major clinical outcomes. JAMA 2012; 308:1898-905. [PMID: 23150009 PMCID: PMC3645444 DOI: 10.1001/jama.2012.17304] [Citation(s) in RCA: 139] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
CONTEXT Lower serum 25-hydroxyvitamin D concentrations are associated with greater risks of many chronic diseases across large, prospective community-based studies. Substrate 25-hydroxyvitamin D must be converted to 1,25-dihydroxyvitamin D for full biological activity, and complex metabolic pathways suggest that interindividual variability in vitamin D metabolism may alter the clinical consequences of measured serum 25-hydroxyvitamin D. OBJECTIVE To investigate whether common variation within genes encoding the vitamin D-binding protein, megalin, cubilin, CYP27B1, CYP24A1, and the vitamin D receptor (VDR) modify associations of low 25-hydroxyvitamin D with major clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS Examination of 141 single-nucleotide polymorphisms in a discovery cohort of 1514 white participants (who were recruited from 4 US regions) from the community-based Cardiovascular Health Study. Participants had serum 25-hydroxyvitamin D measurements in 1992-1993 and were followed up for a median of 11 years (through 2006). Replication meta-analyses were conducted across the independent, community-based US Health, Aging, and Body Composition (n = 922; follow-up: 1998-1999 through 2005), Italian Invecchiare in Chianti (n = 835; follow-up: 1998-2000 through 2006), and Swedish Uppsala Longitudinal Study of Adult Men (n = 970; follow-up: 1991-1995 through 2008) cohort studies. MAIN OUTCOME MEASURE Composite outcome of incident hip facture, myocardial infarction, cancer, and mortality over long-term follow-up. RESULTS Interactions between 5 single-nucleotide polymorphisms and low 25-hydroxyvitamin D concentration were identified in the discovery phase and 1 involving a variant in the VDR gene replicated in independent meta-analysis. Among Cardiovascular Health Study participants, low 25-hydroxyvitamin D concentration was associated with hazard ratios for risk of the composite outcome of 1.40 (95% CI, 1.12-1.74) for those who had 1 minor allele at rs7968585 and 1.82 (95% CI, 1.31-2.54) for those with 2 minor alleles at rs7968585. In contrast, there was no evidence of an association (estimated hazard ratio, 0.93 [95% CI, 0.70-1.24]) among participants who had 0 minor alleles at this single-nucleotide polymorphism. CONCLUSION Known associations of low 25-hydroxyvitamin D with major health outcomes may vary according to common genetic differences in the vitamin D receptor.
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Affiliation(s)
- Gregory P Levin
- Department of Biostatistics, University of Washington, Seattle, USA
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De Rui M, Veronese N, Manzato E, Sergi G. Role of comprehensive geriatric assessment in the management of osteoporotic hip fracture in the elderly: an overview. Disabil Rehabil 2012; 35:758-65. [DOI: 10.3109/09638288.2012.707747] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Barbour KE, Houston DK, Cummings SR, Boudreau R, Prasad T, Sheu Y, Bauer DC, Tooze JA, Kritchevsky SB, Tylavsky FA, Harris TB, Cauley JA. Calciotropic hormones and the risk of hip and nonspine fractures in older adults: the Health ABC Study. J Bone Miner Res 2012; 27:1177-85. [PMID: 22228250 PMCID: PMC3541828 DOI: 10.1002/jbmr.1545] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The effects of vitamin D and parathyroid hormone (PTH) levels on incident fracture remain uncertain. To test the hypothesis that increasing serum 25-hydroxyvitamin D [25(OH)D] and decreasing PTH levels are associated with decreased risk of hip and any nonspine fracture, we conducted a prospective cohort study among 2614 community-dwelling white and black participants, aged ≥70 years, from the Health, Aging and Body Composition (Health ABC) Study. Serum and plasma samples were drawn at year 2, which formed the baseline for this analysis. Serum 25(OH)D and intact PTH (1-84) were measured using radioimmunoassay with DiaSorin reagents and EDTA plasma with a two-site immunoradiometric assay kit, respectively. Incident fractures (hip and any nonspine) were assessed after year 2, every 6 months, by self-report and validated by radiology reports. The median (interquartile range) follow-up times for hip and any nonspine fractures were 6.4 (6.1-6.5) and 6.4 (5.5-6.5) years, respectively. Cox proportional hazards regression was used to estimate the hazard ratios (HR) with 95% confidence intervals (CI) for fracture. There were 84 hip and 247 nonspine fractures that occurred over the follow-up period. The multivariable adjusted HRs (95% CIs) of hip fracture for participants in the lowest (≤17.78 ng/mL), second (17.79 to 24.36 ng/mL), and third quartiles (24.37 to 31.94 ng/mL) of 25(OH)D were 1.92 (0.97 to 3.83), 0.75 (0.32 to 1.72) and 1.86 (1.00 to 3.45), respectively, compared with participants in the highest 25(OH)D quartile (>31.94 ng/mL) (p trend = 0.217). Additional adjustment for IL-6 (p = 0.107), PTH (p = 0.124), and hip areal bone mineral density (p = 0.137) attenuated HRs of hip fracture in the lowest quartile by 16.3%, 17.4%, and 26.1%, respectively. There was no evidence of an association between 25(OH)D and any nonspine fractures, or between PTH and hip or any nonspine fractures. We found limited evidence to support an association between calciotropic hormones and hip and nonspine fractures in older men and women.
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Affiliation(s)
- Kamil E. Barbour
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Denise K. Houston
- Sticht Center on Aging, Department of Internal Medicine, Section on Gerontology and Geriatric Medicine, Wake Forest School of Medicine, Winston Salem, NC
| | - Steven R. Cummings
- San Francisco Coordinating Center, California Pacific Medical Center Research Institute and the University of California, San Francisco, CA, USA
| | - Robert Boudreau
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Tanushree Prasad
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Yahtyng Sheu
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Douglas C. Bauer
- Departments of Medicine and Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Janet A. Tooze
- Sticht Center on Aging, Department of Internal Medicine, Section on Gerontology and Geriatric Medicine, Wake Forest School of Medicine, Winston Salem, NC
| | - Stephen B. Kritchevsky
- Sticht Center on Aging, Department of Internal Medicine, Section on Gerontology and Geriatric Medicine, Wake Forest School of Medicine, Winston Salem, NC
| | - Frances A. Tylavsky
- Department of Preventive Medicine, University of Tennessee, Health Science Center, Memphis, Tennessee, USA
| | - Tamara B. Harris
- Laboratory of Epidemiology, Demography, and Biometry, National Institute of Aging, Bethesda, Maryland
| | - Jane A. Cauley
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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de Boer IH, Levin G, Robinson-Cohen C, Biggs ML, Hoofnagle AN, Siscovick DS, Kestenbaum B. Serum 25-hydroxyvitamin D concentration and risk for major clinical disease events in a community-based population of older adults: a cohort study. Ann Intern Med 2012; 156:627-34. [PMID: 22547472 PMCID: PMC3632351 DOI: 10.7326/0003-4819-156-9-201205010-00004] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Circulating concentrations of 25-hydroxyvitamin D [25-(OH)D] are used to define vitamin D deficiency. Current clinical 25-(OH)D targets based on associations with intermediate markers of bone metabolism may not reflect optimal levels for other chronic diseases and do not account for known seasonal variation in 25-(OH)D concentration. OBJECTIVE To evaluate the relationship of 25-(OH)D concentration with the incidence of major clinical disease events that are pathophysiologically relevant to vitamin D. DESIGN Cohort study. SETTING The Cardiovascular Health Study conducted in 4 U.S. communities. Data from 1992 to 2006 were included in this analysis. PARTICIPANTS 1621 white older adults. MEASUREMENTS Serum 25-(OH)D concentration (using a high-performance liquid chromatography-tandem mass spectrometry assay that conforms to National Institute of Standards and Technology reference standards) and associations with time to a composite outcome of incident hip fracture, myocardial infarction, cancer, or death. RESULTS Over a median 11-year follow-up, the composite outcome occurred in 1018 participants (63%). Defining events included 137 hip fractures, 186 myocardial infarctions, 335 incidences of cancer, and 360 deaths. The association of low 25-(OH)D concentration with risk for the composite outcome varied by season (P = 0.057). A concentration lower than a season-specific Z score of -0.54 best discriminated risk for the composite outcome and was associated with a 24% higher risk in adjusted analyses (95% CI, 9% to 42%). Corresponding season-specific 25-(OH)D concentrations were 43, 50, 61, and 55 nmol/L (17, 20, 24, and 22 ng/mL) in winter, spring, summer, and autumn, respectively. LIMITATION The observational study was restricted to white participants. CONCLUSION Threshold concentrations of 25-(OH)D associated with increased risk for relevant clinical disease events center near 50 nmol/L (20 ng/mL). Season-specific targets for 25-(OH)D concentration may be more appropriate than static targets when evaluating health risk. PRIMARY FUNDING SOURCE National Institutes of Health.
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Shoben AB, Kestenbaum B, Levin G, Hoofnagle AN, Psaty BM, Siscovick DS, de Boer IH. Seasonal variation in 25-hydroxyvitamin D concentrations in the cardiovascular health study. Am J Epidemiol 2011; 174:1363-72. [PMID: 22112344 DOI: 10.1093/aje/kwr258] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Low circulating concentrations of 25-hydroxyvitamin D (25(OH)D) are associated with adverse health outcomes in diverse populations. However, 25(OH)D concentrations vary seasonally with varying exposure to sunlight, so single measurements may poorly reflect long-term 25(OH)D exposure. The authors investigated cyclical trends in average serum 25(OH)D concentrations among 2,298 individuals enrolled in the Cardiovascular Health Study of community-based older adults (1992-1993). A sinusoidal model closely approximated observed 25(OH)D concentrations and fit the data significantly better than did a mean model (P < 0.0001). The mean annual 25(OH)D concentration was 25.1 ng/mL (95% confidence interval: 24.7, 25.5), and the mean peak-trough difference was 9.6 ng/mL (95% confidence interval: 8.5, 10.7). Male sex, higher latitude of study site, and greater physical activity levels were associated with larger peak-trough difference in 25(OH)D concentration (each P < 0.05). Serum concentrations of intact parathyroid hormone and bone-specific alkaline phosphatase also varied in a sinusoidal fashion (P < 0.0001), inversely to 25(OH)D. In conclusion, serum 25(OH)D varies in a sinusoidal manner, with large seasonal differences relative to mean concentration and laboratory evidence of biologic sequelae. Single 25(OH)D measurements might not capture overall vitamin D status, and the extent of misclassification could vary by demographic and behavioral factors. Accounting for collection time may reduce bias in research studies and improve decision-making in clinical care.
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Affiliation(s)
- Abigail B Shoben
- The Ohio State University, 1841 Neil Avenue, Columbus, OH 43210-1240, USA.
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