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Liao CY, Chung CH, Wei KY, Tseng MF, Lin FH, Tsao CH, Chien WC, Chu P, Wu CC. Do patients with nephrotic syndrome have an increased risk of osteoporosis? A nationwide population-based retrospective cohort study in Taiwan. BMJ Open 2024; 14:e080858. [PMID: 38719315 PMCID: PMC11086532 DOI: 10.1136/bmjopen-2023-080858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 04/03/2024] [Indexed: 05/12/2024] Open
Abstract
OBJECTIVES To evaluate whether nephrotic syndrome (NS) and further corticosteroid (CS) use increase the risk of osteoporosis in Asian population during the period January 2000-December 2010. DESIGN Nationwide population-based retrospective cohort study. SETTING All healthcare facilities in Taiwan. PARTICIPANTS A total of 28 772 individuals were enrolled. INTERVENTIONS 26 614 individuals with newly diagnosed NS between 2000 and 2010 were identified and included in out study. 26 614 individuals with no NS diagnosis prior to the index date were age matched as controls. Diagnosis of osteoporosis prior to the diagnosis of NS or the same index date was identified, age, sex and NS-associated comorbidities were adjusted. PRIMARY OUTCOME MEASURE To identify risk differences in developing osteoporosis among patients with a medical history of NS. RESULTS After adjusting for covariates, osteoporosis risk was found to be 3.279 times greater in the NS cohort than in the non-NS cohort, when measured over 11 years after NS diagnosis. Stratification revealed that age older than 18 years, congestive heart failure, hyperlipidaemia, chronic kidney disease, liver cirrhosis and NS-related disease including diabetes mellitus, hepatitis B infection, hepatitis C infection, lymphoma and hypothyroidism, increased the risk of osteoporosis in the NS cohort, compared with the non-NS cohort. Additionally, osteoporosis risk was significantly higher in NS patients with CS use (adjusted HR (aHR)=3.397). The risk of osteoporosis in NS patients was positively associated with risk of hip and vertebral fracture (aHR=2.130 and 2.268, respectively). A significant association exists between NS and subsequent risk for osteoporosis. CONCLUSION NS patients, particularly those treated with CS, should be evaluated for subsequent risk of osteoporosis.
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Affiliation(s)
- Chen-Yi Liao
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chi-Hsiang Chung
- School of Public Health, National Defense Medical Center, Taipei, Taiwan
| | - Kuang-Yu Wei
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Min-Feng Tseng
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, Zuoying Branch Of Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan
| | - Fu-Huang Lin
- School of Public Health, National Defense Medical Center, Taipei, Taiwan
| | - Chang-Huei Tsao
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
- Department of Microbiology & Immunology, National Defense Medical Center, Taipei City, Taiwan
| | - Wu-Chien Chien
- School of Public Health, National Defense Medical Center, Taipei, Taiwan
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Pauling Chu
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chia-Chao Wu
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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Goodwin Davies AJ, Xiao R, Razzaghi H, Bailey LC, Utidjian L, Gluck C, Eckrich D, Dixon BP, Deakyne Davies SJ, Flynn JT, Ranade D, Smoyer WE, Kitzmiller M, Dharnidharka VR, Magnusen B, Mitsnefes M, Somers M, Claes DJ, Burrows EK, Luna IY, Furth SL, Forrest CB, Denburg MR. Skeletal Outcomes in Children and Young Adults with Glomerular Disease. J Am Soc Nephrol 2022; 33:2233-2246. [PMID: 36171052 PMCID: PMC9731624 DOI: 10.1681/asn.2021101372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 08/10/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Children with glomerular disease have unique risk factors for compromised bone health. Studies addressing skeletal complications in this population are lacking. METHODS This retrospective cohort study utilized data from PEDSnet, a national network of pediatric health systems with standardized electronic health record data for more than 6.5 million patients from 2009 to 2021. Incidence rates (per 10,000 person-years) of fracture, slipped capital femoral epiphysis (SCFE), and avascular necrosis/osteonecrosis (AVN) in 4598 children and young adults with glomerular disease were compared with those among 553,624 general pediatric patients using Poisson regression analysis. The glomerular disease cohort was identified using a published computable phenotype. Inclusion criteria for the general pediatric cohort were two or more primary care visits 1 year or more apart between 1 and 21 years of age, one visit or more every 18 months if followed >3 years, and no chronic progressive conditions defined by the Pediatric Medical Complexity Algorithm. Fracture, SCFE, and AVN were identified using SNOMED-CT diagnosis codes; fracture required an associated x-ray or splinting/casting procedure within 48 hours. RESULTS We found a higher risk of fracture for the glomerular disease cohort compared with the general pediatric cohort in girls only (incidence rate ratio [IRR], 1.6; 95% CI, 1.3 to 1.9). Hip/femur and vertebral fracture risk were increased in the glomerular disease cohort: adjusted IRR was 2.2 (95% CI, 1.3 to 3.7) and 5 (95% CI, 3.2 to 7.6), respectively. For SCFE, the adjusted IRR was 3.4 (95% CI, 1.9 to 5.9). For AVN, the adjusted IRR was 56.2 (95% CI, 40.7 to 77.5). CONCLUSIONS Children and young adults with glomerular disease have significantly higher burden of skeletal complications than the general pediatric population.
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Affiliation(s)
- Amy J Goodwin Davies
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Rui Xiao
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hanieh Razzaghi
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - L Charles Bailey
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Levon Utidjian
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Caroline Gluck
- Division of Nephrology, Nemours/Alfred I. DuPont Hospital for Children, Wilmington, Delaware
| | - Daniel Eckrich
- Division of Nephrology, Nemours/Alfred I. DuPont Hospital for Children, Wilmington, Delaware
| | - Bradley P Dixon
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
- Children's Hospital Colorado, Aurora, Colorado
| | | | - Joseph T Flynn
- Department of Pediatrics, University of Washington, Seattle, Washington
- Seattle Children's Hospital, Seattle, Washington
| | | | - William E Smoyer
- Department of Pediatrics, The Ohio State University, Columbus, Ohio
- Nationwide Children's Hospital, Columbus, Ohio
| | | | - Vikas R Dharnidharka
- Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri
- St. Louis Children's Hospital, St. Louis, Missouri
| | | | - Mark Mitsnefes
- Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Michael Somers
- Boston Children's Hospital, Harvard University, Boston, Massachusetts
| | - Donna J Claes
- Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Evanette K Burrows
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ingrid Y Luna
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Susan L Furth
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Christopher B Forrest
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Michelle R Denburg
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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3
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Ziolkowski S, Liu S, Montez-Rath ME, Denburg M, Winkelmayer WC, Chertow GM, O'Shaughnessy MM. Association between cause of kidney failure and fracture incidence in a national US dialysis population cohort study. Clin Kidney J 2022; 15:2245-2257. [PMID: 36381373 PMCID: PMC9664571 DOI: 10.1093/ckj/sfac193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Indexed: 11/25/2022] Open
Abstract
Background Whether fracture rates, overall and by fracture site, vary by cause of kidney failure in patients receiving dialysis is unknown. Methods Using the US Renal Data System, we compared fracture rates across seven causes of kidney failure in patients who started dialysis between 1997 and 2014. We computed unadjusted and multivariable adjusted proportional sub-distribution hazard models, with fracture events (overall, and by site) as the outcome and immunoglobulin A nephropathy as the reference group. Kidney transplantation and death were competing events. Results Among 491 496 individuals, with a median follow-up of 2.0 (25%, 75% range 0.9–3.9) years, 62 954 (12.8%) experienced at least one fracture. Patients with diabetic nephropathy, vasculitis or autosomal polycystic kidney disease (ADPKD) had the highest (50, 46 and 40 per 1000 person-years, respectively), and patient with lupus nephritis had the lowest (20 per 1000 person-years) fracture rates. After multivariable adjustment, diabetic nephropathy [hazard ratio (HR) 1.43, 95% confidence interval 1.33–1.53], ADPKD (HR 1.37, 1.26–1.48), vasculitis (HR 1.22, 1.09–1.34), membranous nephropathy (HR 1.16, 1.02–1.30) and focal segmental glomerulosclerosis (FSGS) (HR 1.13, 1.02–1.24) were associated with a significantly higher, and lupus nephritis with a significantly lower (HR 0.85, 0.71–0.98) fracture hazard. The hazards for upper extremity and lower leg fractures were significantly higher in diabetic nephropathy, ADPKD, FSGS and membranous nephropathy, while the hazard for vertebral fracture was significantly higher in vasculitis. Our findings were limited by the lack of data on medication use and whether fractures were traumatic or non-traumatic, among other factors. Conclusions Fracture risk, overall and by fracture site, varies by cause of end-stage kidney disease. Future work to determine underlying pathogenic mechanisms contributing to differential risks might inform more tailored treatment strategies. Our study was limited by lack of data regarding numerous potential confounders or mediators including medications and measures or bone biomarkers.
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Affiliation(s)
- Susan Ziolkowski
- Department of Medicine, Stanford University School of Medicine , Stanford, CA , USA
| | - Sai Liu
- Department of Medicine, Stanford University School of Medicine , Stanford, CA , USA
| | - Maria E Montez-Rath
- Department of Medicine, Stanford University School of Medicine , Stanford, CA , USA
| | - Michelle Denburg
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Division of Nephrology, Children's Hospital of Philadelphia , Philadelphia, PA , USA
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine , Houston, TX , USA
| | - Glenn M Chertow
- Department of Medicine, Stanford University School of Medicine , Stanford, CA , USA
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Henning P, Conaway HH, Lerner UH. Stimulation of osteoclast formation and bone resorption by glucocorticoids: Synergistic interactions with the calcium regulating hormones parathyroid hormone and 1,25(OH) 2-vitamin D3. VITAMINS AND HORMONES 2022; 120:231-270. [PMID: 35953112 DOI: 10.1016/bs.vh.2022.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Osteoporosis is a significant health problem, with skeletal fractures increasing morbidity and mortality. Excess glucocorticoids (GC) represents the leading cause of secondary osteoporosis. The first phase of glucocorticoid-induced osteoporosis is increased bone resorption. In this Chapter, in vitro studies of the direct glucocorticoid receptor (GR) mediated cellular effects of GC on osteoclasts to affect bone resorption and indirect effects on osteoblast lineage cells to increase the RANKL/OPG ratio and stimulate osteoclastogenesis and bone resorption are reviewed in detail, together with detailed descriptions of in vivo effects of GC in different portions of the skeleton in research animals and humans. Brief sections are devoted to contrasting functions of GC in osteonecrosis, vitamin D formation, in vitro and in vivo bone resorptive actions dependent on vitamin D receptor and vitamin D toxicity, as well as the molecular basis of GR action. Included are also more detailed assessments of the interactions of GC with the major calcium regulating hormones, 1,25(OH)2-vitamin D3 and parathyroid hormone, describing the in vitro increases in RANKL/OPG ratios, osteoclastogenesis and synergistic bone resorption that occurs when GC is combined with either 1,25(OH)2-vitamin D3 or parathyroid hormone. Additionally, a molecular basic for the synergistic interaction of GC with 1,25(OH)2-vitamin D3 is provided along with a suggested molecular basic for the interaction between GC and parathyroid hormone.
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Affiliation(s)
- Petra Henning
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Osteoporosis Centre and Centre for Bone and Arthritis Research at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - H Herschel Conaway
- Department of Physiology and Cell Biology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Ulf H Lerner
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Osteoporosis Centre and Centre for Bone and Arthritis Research at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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Kindler JM, Guo M, Baker J, McCormack S, Armenian SH, Zemel BS, Leonard MB, Mostoufi-Moab S. Persistent Musculoskeletal Deficits in Pediatric, Adolescent and Young Adult Survivors of Allogeneic Hematopoietic Stem-Cell Transplantation. J Bone Miner Res 2022; 37:794-803. [PMID: 35080067 DOI: 10.1002/jbmr.4513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 01/17/2022] [Accepted: 01/19/2022] [Indexed: 11/08/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (alloHSCT) is a common therapy for pediatric hematologic malignancies. With improved supportive care, addressing treatment-related late effects is at the forefront of survivor long-term health and quality of life. We previously demonstrated that alloHSCT survivors had increased adiposity, decreased lean mass, and lower bone density and strength, 7 years (median) from alloHSCT compared to their healthy peers. Yet it is unknown whether these deficits persist. Our longitudinal study characterized changes in muscle and bone over a period of 3.4 (range, 2.0 to 4.9) years in 47 childhood alloHSCT survivors, age 5-26 years at baseline (34% female). Tibia cortical bone geometry and volumetric density and lower leg muscle cross-sectional area (MCSA) were assessed via peripheral quantitative computed tomography (pQCT). Anthropometric and pQCT measurements were converted to age, sex, and ancestry-specific standard deviation scores, adjusted for leg length. Muscle-specific force was assessed as strength relative to MCSA adjusted for leg length (strength Z-score). Measurements were compared to a healthy reference cohort (n = 921), age 5-30 years (52% female). At baseline and follow-up, alloHSCT survivors demonstrated lower height Z-scores, weight Z-scores, and leg length Z-scores compared to the healthy reference cohort. Deficits in MCSA, trabecular volumetric bone density, and cortical bone size and estimated strength (section modulus) were evident in survivors (all p < 0.05). Between the two study time points, anthropometric, muscle, and bone Z-scores did not change significantly in alloHSCT survivors. Approximately 15% and 17% of alloHSCT survivors had MCSA and section modulus Z-score < -2.0, at baseline and follow-up, respectively. Furthermore, those with a history of total body irradiation compared to those without demonstrated lower MCSA at follow-up. The persistent muscle and bone deficits in pediatric alloHSCT survivors support the need for strategies to improve bone and muscle health in this at-risk population. © 2022 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Joseph M Kindler
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michelle Guo
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Joshua Baker
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.,Division of Rheumatology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Shana McCormack
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Division of Endocrinology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Saro H Armenian
- Department of Pediatrics, City of Hope, Duarte, CA, USA.,Department of Population Sciences, City of Hope, Duarte, CA, USA
| | - Babette S Zemel
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Mary B Leonard
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Sogol Mostoufi-Moab
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Division of Endocrinology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Christian MT, Maxted AP. Optimizing the corticosteroid dose in steroid-sensitive nephrotic syndrome. Pediatr Nephrol 2022; 37:37-47. [PMID: 33611671 PMCID: PMC7896825 DOI: 10.1007/s00467-021-04985-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 01/13/2021] [Accepted: 02/03/2021] [Indexed: 01/31/2023]
Abstract
The use of corticosteroids in the treatment of steroid-sensitive nephrotic (SSNS) syndrome in children has evolved surprisingly slowly since the ISKDC consensus over 50 years ago. From a move towards longer courses of corticosteroid to treat the first episode in the 1990s and 2000s, more recent large, well-designed randomized controlled trials (RCTs) have unequivocally shown no benefit from an extended course, although doubt remains whether this applies across all age groups. With regard to prevention of relapses, daily ultra-low-dose prednisolone has recently been shown to be more effective than low-dose alternate-day prednisolone. Daily low-dose prednisolone for a week at the time of acute viral infection seems to be effective in the prevention of relapses but the results of a larger RCT are awaited. Recently, corticosteroid dosing to treat relapses has been questioned, with data suggesting lower doses may be as effective. The need for large RCTs to address the question of whether corticosteroid doses can be reduced was the conclusion of the authors of the recent corticosteroid therapy for nephrotic syndrome in children Cochrane update. This review summarizes development in thinking on corticosteroid use in SSNS and makes suggestions for areas that merit further scrutiny.
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Affiliation(s)
- Martin T Christian
- Department of Paediatric Nephrology, Nottingham Children's Hospital, Nottingham, NG7 2UH, UK.
| | - Andrew P Maxted
- Department of Paediatric Nephrology, Nottingham Children's Hospital, Nottingham, NG7 2UH, UK
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Wakeman M. A Literature Review of the Potential Impact of Medication on Vitamin D Status. Risk Manag Healthc Policy 2021; 14:3357-3381. [PMID: 34421316 PMCID: PMC8373308 DOI: 10.2147/rmhp.s316897] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 07/12/2021] [Indexed: 12/23/2022] Open
Abstract
In recent years, there has been a significant increase in media coverage of the putative actions of vitamin D as well as the possible health benefits that supplementation might deliver. However, the potential effect that medications may have on the vitamin D status is rarely taken into consideration. This literature review was undertaken to assess the degree to which vitamin D status may be affected by medication. Electronic databases were searched to identify literature relating to this subject, and study characteristics and conclusions were scrutinized for evidence of potential associations. The following groups of drugs were identified in one or more studies to affect vitamin D status in some way: anti-epileptics, laxatives, metformin, loop diuretics, angiotensin-converting enzyme inhibitors, thiazide diuretics, statins, calcium channel blockers, antagonists of vitamin K, platelet aggregation inhibitors, digoxin, potassium-sparing diuretics, benzodiazepines, antidepressants, proton pump inhibitors, histamine H2-receptor antagonists, bile acid sequestrants, corticosteroids, antimicrobials, sulphonamides and urea derivatives, lipase inhibitors, hydroxychloroquine, highly active antiretroviral agents, and certain chemotherapeutic agents. Given that the quality of the data is heterogeneous, newer, more robustly designed studies are required to better define likely interactions between vitamin D and medications. This is especially so for cytochrome P450 3A4 enzyme (CYP3A4)-metabolized medications. Nevertheless, this review suggests that providers of health care ought to be alert to the potential of vitamin D depletions induced by medications, especially in elderly people exposed to multiple-drug therapy, and to provide supplementation if required.
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Affiliation(s)
- Michael Wakeman
- Faculty of Health and Wellbeing, University of Sunderland, Sunderland, SR1 3SD, UK
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8
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Tung JYL, Lam TP, Chan SHS. Bone microarchitectural alterations in boys with Duchenne muscular dystrophy on long-term glucocorticoid treatment. J Bone Miner Metab 2021; 39:606-611. [PMID: 33400004 DOI: 10.1007/s00774-020-01196-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 12/10/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Osteoporosis is a major health issue in boys with Duchenne muscular dystrophy (DMD). Data on the specific bone deficits and microarchitectural alterations in children with DMD were limited. This study aimed to assess the bone microarchitectural alterations in boys with DMD on long-term glucocorticoid using high-resolution peripheral quantitative computed tomography (HR-pQCT). MATERIALS AND METHODS This was a cross-sectional, case-control study. Boys with DMD older than 5 years with no prior history of symptomatic fracture and had been on long-term glucocorticoid treatment were recruited from a single tertiary centre. For each participant, three gender- and age-matched controls were selected randomly from an existing HR-pQCT database of healthy individuals. RESULTS Nine boys with DMD at a median age of 9.3 years were included. Three were found to have asymptomatic vertebral compression fracture. The HR-pQCT findings of these nine boys were compared with 27 healthy controls. Trabecular microstructure indices at the distal radius were significantly lower but the cortical vBMD was significantly higher in the DMD boys when compared with healthy controls. CONCLUSION Lower microarchitectural measurement of trabecular bones, but higher cortical vBMD, was observed in DMD boys on long-term oral glucocorticoid. The results from this study provide preliminary, yet important insights into the bone microarchitecture of this group of patients.
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Affiliation(s)
- Joanna Yuet-Ling Tung
- Department of Paediatrics, Hong Kong Children's Hospital, 1 Shing Cheong Road, Kowloon Bay, Kowloon, Hong Kong.
- Department of Paediatrics & Adolescent Medicine, Queen Mary Hospital, LKS Faculty of Medicine, The University of Hong Kong, Shatin, Hong Kong.
| | - Tsz-Ping Lam
- SH Ho Scoliosis Research Lab, Joint Scoliosis Research Center of the Chinese University of Hong Kong and Nanjing University, Nanjing, China
- Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Sophelia Hoi-Shan Chan
- Department of Paediatrics & Adolescent Medicine, Queen Mary Hospital, LKS Faculty of Medicine, The University of Hong Kong, Shatin, Hong Kong
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Lalayiannis AD, Fewtrell M, Biassoni L, Silva S, Goodman N, Shroff R, Crabtree NJ. Studying bone mineral density in young people: The complexity of choosing a pQCT reference database. Bone 2021; 143:115713. [PMID: 33122089 DOI: 10.1016/j.bone.2020.115713] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 10/07/2020] [Accepted: 10/24/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Many chronic illnesses affect bone health, and commonly lead to mineralization abnormalities in young people. As cortical and trabecular bone may be differentially affected in certain diseases, an imaging technique that allows for detailed study of the bone structure is required. Peripheral quantitative computed tomography (pQCT) overcomes the limitations of dual energy X-ray absorptiometry (DXA) and is perhaps more widely available for use in research than bone biopsy. However, in contrast to DXA, where there are large reference datasets, this is not the case for pQCT. METHODS Fifty-five children and young adults aged 7 to 30 years had the non-dominant tibia scanned at the 3% & 4% sites for trabecular bone mineral density and the 38% site for cortical bone mineral density and bone mineral content. Image acquisition and analysis was undertaken according to the protocols of two of the largest reference datasets for tibial pQCT. The Z-scores generated were compared to examine the differences between protocols and the differences from the expected median of zero in a healthy population. RESULTS The trabecular bone mineral density Z-scores generated by the two protocols were similar. The same was true for cortical mineral content Z-scores at the 38% site. Cortical bone mineral density was significantly different between protocols and likely affected by differences in the ethnicity of our cohort compared to the reference datasets. Only one reference dataset extended from childhood to young adulthood. Only trabecular bone mineral density, periosteal and endosteal circumference Z-scores from one methodology were not significantly biased when tested for deviation of the median from zero. CONCLUSIONS pQCT is a useful tool for studying trabecular and cortical compartments separately but, there are variations in pQCT scanning protocols, analysis methodology, and a paucity of reference data. Reference datasets may not be generalizable to local study populations, even when analysed using identical analysis protocols.
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Affiliation(s)
- A D Lalayiannis
- UCL Great Ormond Street Hospital Institute of Child Health, London, UK.
| | - M Fewtrell
- UCL Great Ormond Street Hospital Institute of Child Health, London, UK
| | - L Biassoni
- UCL Great Ormond Street Hospital Institute of Child Health, London, UK
| | - S Silva
- UCL Great Ormond Street Hospital Institute of Child Health, London, UK
| | - N Goodman
- UCL Great Ormond Street Hospital Institute of Child Health, London, UK
| | - R Shroff
- UCL Great Ormond Street Hospital Institute of Child Health, London, UK
| | - N J Crabtree
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
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10
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Epsley S, Tadros S, Farid A, Kargilis D, Mehta S, Rajapakse CS. The Effect of Inflammation on Bone. Front Physiol 2021; 11:511799. [PMID: 33584321 PMCID: PMC7874051 DOI: 10.3389/fphys.2020.511799] [Citation(s) in RCA: 90] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 11/30/2020] [Indexed: 12/21/2022] Open
Abstract
Bone remodeling is the continual process to renew the adult skeleton through the sequential action of osteoblasts and osteoclasts. Nuclear factor RANK, an osteoclast receptor, and its ligand RANKL, expressed on the surface of osteoblasts, result in coordinated control of bone remodeling. Inflammation, a feature of illness and injury, plays a distinct role in skewing this process toward resorption. It does so via the interaction of inflammatory mediators and their related peptides with osteoblasts and osteoclasts, as well as other immune cells, to alter the expression of RANK and RANKL. Such chemical mediators include TNFα, glucocorticoids, histamine, bradykinin, PGE2, systemic RANKL from immune cells, and interleukins 1 and 6. Conditions, such as periodontal disease and alveolar bone erosion, aseptic prosthetic loosening, rheumatoid arthritis, and some sports related injuries are characterized by the result of this process. A thorough understanding of bone response to injury and disease, and ability to detect such biomarkers, as well as imaging to identify early structural and mechanical property changes in bone architecture, is important in improving management and outcomes of bone related pathology. While gut health and vitamin and mineral availability appear vitally important, nutraceuticals also have an impact on bone health. To date most pharmaceutical intervention targets inflammatory cytokines, although strategies to favorably alter inflammation induced bone pathology are currently limited. Further research is required in this field to advance early detection and treatments.
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Affiliation(s)
- Scott Epsley
- Philadelphia 76ers, Philadelphia, PA, United States
| | - Samuel Tadros
- Department of Radiology and Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Alexander Farid
- Department of Radiology and Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Daniel Kargilis
- Department of Radiology and Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | | | - Chamith S. Rajapakse
- Department of Radiology and Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, United States
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Ehren R, Benz MR, Brinkkötter PT, Dötsch J, Eberl WR, Gellermann J, Hoyer PF, Jordans I, Kamrath C, Kemper MJ, Latta K, Müller D, Oh J, Tönshoff B, Weber S, Weber LT. Pediatric idiopathic steroid-sensitive nephrotic syndrome: diagnosis and therapy -short version of the updated German best practice guideline (S2e) - AWMF register no. 166-001, 6/2020. Pediatr Nephrol 2021; 36:2971-2985. [PMID: 34091756 PMCID: PMC8445869 DOI: 10.1007/s00467-021-05135-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/26/2021] [Accepted: 05/12/2021] [Indexed: 01/21/2023]
Abstract
Idiopathic nephrotic syndrome is the most frequent glomerular disease in children in most parts of the world. Children with steroid-sensitive nephrotic syndrome (SSNS) generally have a good prognosis regarding the maintenance of normal kidney function even in the case of frequent relapses. The course of SSNS is often complicated by a high rate of relapses and the associated side effects of repeated glucocorticoid (steroid) therapy. The following recommendations for the treatment of SSNS are based on the comprehensive consideration of published evidence by a working group of the German Society for Pediatric Nephrology (GPN) based on the systematic Cochrane reviews on SSNS and the guidelines of the KDIGO working group (Kidney Disease - Improving Global Outcomes).
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Affiliation(s)
- Rasmus Ehren
- Faculty of Medicine and University Hospital Cologne, Pediatric Nephrology, Children's and Adolescents' Hospital, University of Cologne, Cologne, Germany.
| | - Marcus R Benz
- Faculty of Medicine and University Hospital Cologne, Pediatric Nephrology, Children's and Adolescents' Hospital, University of Cologne, Cologne, Germany
| | - Paul T Brinkkötter
- Department II of Internal Medicine and Center for Molecular Medicine Cologne (CMMC), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Cologne Cluster of Excellence on Cellular Stress Responses in Ageing-Associated Diseases (CECAD), Cologne, Germany
| | - Jörg Dötsch
- Faculty of Medicine and University Hospital Cologne, Pediatric Nephrology, Children's and Adolescents' Hospital, University of Cologne, Cologne, Germany
| | - Wolfgang R Eberl
- Department of Pediatrics, Städtisches Klinikum Braunschweig, Braunschweig, Germany
| | - Jutta Gellermann
- Pediatric Nephrology, Charité Children's Hospital, Berlin, Germany
| | - Peter F Hoyer
- Center for Children and Adolescents, Pediatric Clinic II, University of Duisburg-Essen, Essen, Germany
| | - Isabelle Jordans
- Bundesverband Niere eV (German National Kidney-Patients Association), Mainz, Germany
| | - Clemens Kamrath
- Division of Pediatric Endocrinology & Diabetology, Center of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany
| | - Markus J Kemper
- Department of Pediatrics, Asklepios Medical School, Hamburg, Germany
| | - Kay Latta
- Clementine Kinderhospital Frankfurt, Frankfurt, Germany
| | - Dominik Müller
- Pediatric Nephrology, Charité Children's Hospital, Berlin, Germany
| | - Jun Oh
- Division of Pediatric Nephrology, Hepatology and Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany
| | - Stefanie Weber
- Department of Pediatrics II, University Children's Hospital, Philipps-University Marburg, Marburg, Germany
| | - Lutz T Weber
- Faculty of Medicine and University Hospital Cologne, Pediatric Nephrology, Children's and Adolescents' Hospital, University of Cologne, Cologne, Germany
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12
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Quantifying cortical bone free water using short echo time (STE-MRI) at 1.5 T. Magn Reson Imaging 2020; 71:17-24. [PMID: 32387394 DOI: 10.1016/j.mri.2020.04.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 04/12/2020] [Accepted: 04/19/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE The purpose of our study was to use Dual-TR STE-MR protocol as a clinical tool for cortical bone free water quantification at 1.5 T and validate it by comparing the obtained results (MR-derived results) with dehydration results. METHODS Human studies were compliant with HIPPA and were approved by the institutional review board. Short Echo Time (STE) MR imaging with different Repetition Times (TRs) was used for quantification of cortical bone free water T1 (T1free) and concentration (ρfree). The proposed strategy was compared with the dehydration technique in seven bovine cortical bone samples. The agreement between the two methods was quantified by using Bland and Altman analysis. Then we applied the technique on a cross-sectional population of thirty healthy volunteers (18F/12M) and examined the association of the biomarkers with age. RESULTS The mean values of ρfree for bovine cortical bone specimens were quantified as 4.37% and 5.34% by using STE-MR and dehydration techniques, respectively. The Bland and Altman analysis showed good agreement between the two methods along with the suggestion of 0.99% bias between them. Strong correlations were also reported between ρfree (r2 = 0.62) and T1free and age (r2 = 0.8). The reproducibility of the method, evaluated in eight subjects, yielded an intra-class correlation of 0.95. CONCLUSION STE-MR imaging with dual-TR strategy is a clinical solution for quantifying cortical bone ρfree and T1free.
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Abstract
PURPOSE OF REVIEW To summarize the literature regarding alterations in bone health in patients with glomerular kidney disease and highlight areas in need of additional investigation. RECENT FINDINGS There is mounting evidence that children and adults with glomerular conditions, with or without compromised kidney function, comprise a distinct subgroup of patients with unique risk factors for altered bone health. Patients with glomerular kidney disease are exposed to both disease-related and treatment-related factors that affect bone structure and function. In addition to chronic kidney disease-related risk factors for impaired bone health, high rates of exposure to osteotoxic medications, varying degrees of systemic inflammation, and altered vitamin D metabolism may contribute to compromised bone health in individuals with glomerular disease. Further study is needed to better understand these risk factors and the complex interaction between the immune system and bone cells in glomerular disease.
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Affiliation(s)
- Dorey A Glenn
- UNC Kidney Center, Universirty of North Carolina at Chapel Hill, 7024 Burnett Womack Building, Chapell Hill, NC, 27599-7155, USA
| | - Michelle R Denburg
- The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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Adamczyk P, Szczepanska M, Pluskiewicz W. Skeletal status assessment by quantitative ultrasound and bone densitometry in children with different renal conditions. Osteoporos Int 2018; 29:2667-2675. [PMID: 30128765 PMCID: PMC6267138 DOI: 10.1007/s00198-018-4659-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 08/06/2018] [Indexed: 11/28/2022]
Abstract
UNLABELLED Two methods of skeletal status assessment-quantitative ultrasound (QUS) and densitometry (DXA)-were applied and compared in a group of children with different renal disorders. Skeletal assessments in children with different renal conditions should rather not be based on a single diagnostic tool. Lumbar spine DXA is very effective to reveal disturbances secondary to glucocorticoids, whereas total body DXA and QUS are both better in identification of disturbances related to decreased GFR. INTRODUCTION The aim of the study was to evaluate the skeletal status in children in different stages of chronic kidney disease (CKD) or treated with glucocorticoids, using either densitometry (DXA) or quantitative ultrasound (QUS) methods. METHODS Seventy-six subjects (27 girls/49 boys) at the mean age of 11.8 ± 4.0 years were enrolled to the reported study. They were divided into three subgroups: with normal glomerular filtration rate (GFR) but treated with glucocorticoids (GCs, n = 38), with decreased GFR (CKD 2-5, n = 26) and with normal GFR and without any bone-toxic treatment (CKD 1, n = 12). DXA scans were carried out at lumbar spine (LS) and at total body (TB), and quantitative ultrasound (QUS) imaging was done at hand phalanges. QUS results were compared to those obtained from 310 healthy matched controls. RESULTS The average Z-score for LS-BMD and TB-BMD was below zero in all the study subgroups. Neither were there any significant differences in the mean Z-score for LS among the subgroups. The mean Z-score for TB was significantly the lowest in the CKD 2-5 subgroup. The percentage of subjects with TB Z-score ≤ - 2.0 was the highest in the CKD 2-5 subgroup (69.2%), whereas the percentage of subjects with LS Z-score ≤ - 2.0 was the highest in the GC subgroup (23.7%). QUS results in CKD 2-5 were significantly lower than those in the controls, whereas the results, obtained in GC and CKD 1 subgroups, were similar to those in healthy subjects. CONCLUSIONS Skeletal status assessment in children and adolescents with different renal conditions should not be based on single diagnostic approach. DXA scanning, performed at lumbar spine, is potentially more appropriate to reveal disturbances secondary to long-term GC therapy, whereas TB-DXA is highly effective in the identification of skeletal disturbances related to decreased kidney function. QUS at hand phalanges seems to be a useful diagnostic means in CKD with diminished GFR but insufficient to detect GC-related disturbances.
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Affiliation(s)
- P Adamczyk
- Department of Paediatrics, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia in Katowice, Katowice, Poland.
| | - M Szczepanska
- Department of Paediatrics, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia in Katowice, Katowice, Poland
| | - W Pluskiewicz
- Chair of Internal Medicine, Diabetology and Nephrology, Metabolic Bone Diseases Unit, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia in Katowice, Katowice, Poland
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15
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Singh DN, Krishnamurthy S, Kamalanathan SK, Harichandrakumar KT, Sivamurukan P. Three-monthly bolus vitamin D supplements (1000 vs 400 IU/day) for prevention of bone loss in children with difficult-to-treat nephrotic syndrome: a randomised clinical trial. Paediatr Int Child Health 2018; 38:251-260. [PMID: 30092157 DOI: 10.1080/20469047.2018.1505589] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Nephrotic syndrome (NS) in children is one of the most common chronic diseases with a remitting and relapsing course. Glucocorticoids (prednisolone) are considered to be the treatment of choice but are associated with osteoporosis. There are no uniform consensus guidelines regarding the optimum dose of calcium and vitamin D for osteoprotection. Some authorities suggest a daily dose of 1000 IU vitamin D for children for osteoprotection, while others suggest a daily dose of 400 IU. OBJECTIVES To compare the efficacy of three-monthly bolus vitamin D supplementation (1000 vs 400 IU/day) to prevent bone loss in children with difficult-to-treat NS (DTNS). METHODS In this parallel-group, open-label, randomised clinical trial, 60 children aged 1-18 years with DTNS [37 with frequently relapsing NS (FRNS), 13 steroid-dependent NS (SDNS) and 10 steroid-resistant NS (SRNS)] were enrolled and block randomised in a 1:1 allocation ratio to receive 1000 IU/day vitamin D (Group A, n = 30) or 400 IU/day (Group B, n = 30), administered as three-monthly bolus supplemental doses. In Group A, vitamin D (cholecalciferol, Calcirol®sachet) was administered as a stat dose of 90,000 IU every three months (calculated for a period of three months at 1000 IU/day). In Group B, vitamin D (cholecalciferol) was administered as a stat dose of 36,000 IU every three months (calculated for a period of three months at 400 IU/day). The proportionate change in bone mineral content (BMC) was studied by dual energy X-ray absorptiometry (DEXA) scan in both groups after vitamin D supplementation by analysing the values of BMC obtained 12 months apart (baseline vs. after 12 months). RESULTS Sixty children were randomised to receive vitamin D at a dose of either 1000 IU/day (Group A) or 400 IU/day (Group B). The two groups were comparable in their baseline clinical and laboratory parameters (including BMC and bone mineral density (BMD)). The distribution of the three types of NS (FRNS, SDNS and SRNS) was also comparable in both groups. In Group A, there were 19, 6 and 5 children with FRNS, SDNS and SRNS, respectively, and in Group B there were 18, 7 and 5 children with FRNS, SDNS and SRNS, respectively. The proportionate change in BMC was not significantly different between the two groups (median proportionate change in BMC in Group A 13.36% vs 11.59% in Group B, p = 0.22). Overall, BMC increased in both groups (96.7% in each). Only one (3.3%) patient in each group exhibited bone loss. None of the patients had a urinary calcium:creatinine ratio >0.2 at the end of the study. CONCLUSION Three-monthly bolus vitamin D dosing regimens administered either as 1000 or 400 IU/day prevent bone loss in children with DTNS who require long-term steroids. Overall, three-monthly bolus supplemental prophylactic vitamin D, either 1000 or 400 IU/day, would seem to be an effective strategy for preventing bone loss in children with DTNS, as evidenced by the extremely low rates of bone loss (3.3% in each group), and is useful for delivering optimal care to children with DTNS. However, since this study was designed as an equivalence trial and not a superiority trial, further studies are required to demonstrate the superiority of the former regimen over the latter. ABBREVIATIONS BMC, bone mineral content; BMD, bone mineral density; DEXA, dual energy X-ray absorptiometry; DTNS, difficult-to-treat nephrotic syndrome; FRNS, frequently relapsing nephrotic syndrome; IFRNS, infrequently relapsing nephrotic syndrome; iPTH, intact parathyroid hormone; NS, nephrotic syndrome; SDNS, steroid-dependent nephrotic syndrome; SRNS steroid-resistant nephrotic syndrome.
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Affiliation(s)
- Dhurva Nandan Singh
- a Departments of Pediatrics , Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) , Pondicherry , India
| | - Sriram Krishnamurthy
- a Departments of Pediatrics , Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) , Pondicherry , India
| | - Sadish Kumar Kamalanathan
- b Endocrinology , Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) , Pondicherry , India
| | - K T Harichandrakumar
- c Biostatistics , Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) , Pondicherry , India
| | - Palanisamy Sivamurukan
- a Departments of Pediatrics , Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) , Pondicherry , India
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Gabel L, Macdonald HM, Nettlefold LA, McKay HA. Sex-, Ethnic-, and Age-Specific Centile Curves for pQCT- and HR-pQCT-Derived Measures of Bone Structure and Strength in Adolescents and Young Adults. J Bone Miner Res 2018; 33:987-1000. [PMID: 29394462 DOI: 10.1002/jbmr.3399] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 01/18/2018] [Accepted: 01/31/2018] [Indexed: 12/15/2022]
Abstract
There are presently no adolescent centile curves for bone parameters at the tibial midshaft using peripheral quantitative computed tomography (pQCT) or at the distal radius and tibia using high-resolution pQCT (HR-pQCT). Thus, we aimed to develop sex-, ethnic-, site-, and age-specific centile curves for pQCT and HR-pQCT-derived bone outcomes for youth and young adults aged 10 to 21 years. We acquired pQCT scans (XCT3000 or XCT2000) at the tibial midshaft (50% site) and HR-pQCT scans (XtremeCT) at the distal radius (7% site) and tibia (8% site) in a convenience sample of participants in the mixed-longitudinal University of British Columbia Healthy Bones III Study. We scanned 778 10- to 21-year-olds annually for a maximum of 11 years using pQCT (413 girls, 56% Asian; 365 boys, 54% Asian; n = 3160 observations) and 349 10- to 21-year-olds annually for a maximum of 4 years using HR-pQCT (189 girls, 51% Asian; 165 boys, 50% Asian; n = 1090 observations). For pQCT, we report cortical bone mineral density (BMD), total bone cross-sectional area, and polar strength-strain index. For HR-pQCT, we report standard measures (total BMD, trabecular number, thickness, and bone volume fraction) and automated segmentation measures (total bone cross-sectional area, cortical BMD, porosity, and thickness). We applied finite element analysis to estimate failure load. We applied the lamda, mu, sigma (LMS) method using LMS ChartMaker Light (version 2.5, The Institute of Child Health, London, UK) to construct LMS tables and centile plots. We report sex- and age-specific centiles (3rd, 10th, 25th, 50th, 75th, and 97th) for whites and Asians for pQCT bone parameters at the tibial midshaft and HR-pQCT bone parameters at the distal radius and tibia. These centile curves might be used by clinicians and scientists to interpret values or better understand trajectories of bone parameters in clinical populations, those from different geographic regions or of different ethnic origins. © 2018 American Society for Bone and Mineral Research.
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Affiliation(s)
- Leigh Gabel
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Canada.,McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Canada
| | - Heather M Macdonald
- Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute, Vancouver, Canada.,Department of Family Practice, University of British Columbia, Vancouver, Canada
| | - Lindsay A Nettlefold
- Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute, Vancouver, Canada
| | - Heather A McKay
- Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute, Vancouver, Canada.,Department of Family Practice, University of British Columbia, Vancouver, Canada.,Department of Orthopaedics, University of British Columbia, Vancouver, Canada
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Muske S, Krishnamurthy S, Kamalanathan SK, Rajappa M, Harichandrakumar KT, Sivamurukan P. Effect of two prophylactic bolus vitamin D dosing regimens (1000 IU/day vs. 400 IU/day) on bone mineral content in new-onset and infrequently-relapsing nephrotic syndrome: a randomised clinical trial. Paediatr Int Child Health 2018; 38:23-33. [PMID: 28466679 DOI: 10.1080/20469047.2017.1319528] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To examine the efficacy of two vitamin D dosages (1000 vs. 400 IU/day) for osteoprotection in children with new-onset and infrequently-relapsing nephrotic syndrome (IFRNS) receiving corticosteroids. METHODS This parallel-group, open label, randomised clinical trial enrolled 92 children with new-onset nephrotic syndrome (NS) (n = 28) or IFRNS (n = 64) to receive 1000 IU/day (Group A, n = 46) or 400 IU/day (Group B, n = 46) vitamin D (administered as a single bolus initial supplemental dose) by block randomisation in a 1:1 allocation ratio. In Group A, vitamin D (cholecalciferol in a Calcirol® sachet) was administered in a single stat dose of 84,000 IU on Day 1 of steroid therapy (for new-onset NS), calculated for a period of 12 weeks@1000 IU/day) and 42,000 IU on Day 1 of steroid therapy (for IFRNS, calculated for a period of 6 weeks@1000 IU/day). In Group B, vitamin D (cholecalciferol in a Calcirol® sachet) was administered as a single stat dose of 33,600 IU on Day 1 of steroid therapy (for new-onset NS, calculated for a period of 12 weeks@400 IU/day) and 16,800 IU on Day 1 of steroid therapy (for IFRNS, calculated for a period of 6 weeks@400 IU/day). The proportionate change in bone mineral content (BMC) was analysed in both groups after vitamin D supplementation. RESULTS Of the 92 children enrolled, 84 (n = 42 new onset, n = 42 IFRNS) completed the study and were included in the final analysis. Baseline characteristics including initial BMC, bone mineral density, cumulative prednisolone dosage and serum 25-hydroxycholecalciferol levels were comparable in the two groups. There was a greater median proportionate change in BMC in the children who received 1000 IU/day vitamin D (3.25%, IQR -1.2 to 12.4) than in those who received 400 IU/day vitamin D (1.2%, IQR -2.5 to 3.8, p = 0.048). The difference in proportionate change in BMC was only statistically significant in the combined new-onset and IFRNS, but not for IFRNS alone. There was a greater median proportionate change in serum 25-hydroxycholecalciferol, in the children who received 1000 IU/day vitamin D (20.6%, IQR 14.9-36.75) than in those who received 400 IU/day vitamin D (7.7%, IQR 3.5-18.5, p < 0.01). There was a greater median proportionate change in serum calcium in the children who received 1000 IU/day vitamin D (20%, IQR 13.1-29.0) than in those who received 400 IU/day vitamin D (11.3%, IQR 2.8-25.0, p = 0.03). Despite vitamin D therapy, BMC decreased from the baseline in 15 (32.6%) children receiving 1000 IU/day vitamin D and in 17 (36.9%) children receiving 400 IU/day vitamin D. There were no adverse effects attributable to vitamin D. CONCLUSION The 1000 IU/day dose is marginally more effective than 400 IU/day and it is likely than an even larger dose is required. Further research is required to assess the efficacy and safety of vitamin D doses higher than 1000 IU/day.
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Affiliation(s)
- Sravani Muske
- a Department of Pediatrics , Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) , Pondicherry , India
| | - Sriram Krishnamurthy
- a Department of Pediatrics , Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) , Pondicherry , India
| | - Sadish Kumar Kamalanathan
- b Department of Endocrinology , Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) , Pondicherry , India
| | - Medha Rajappa
- c Department of Biochemistry , Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) , Pondicherry , India
| | - K T Harichandrakumar
- d Department of Biostatistics , Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) , Pondicherry , India
| | - Palanisamy Sivamurukan
- a Department of Pediatrics , Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) , Pondicherry , India
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Abstract
PURPOSE OF REVIEW This review summarizes recent findings on musculoskeletal health in three chronic renal conditions of childhood: chronic kidney disease stages 2-5D, nephrotic syndrome, and urolithiasis. Findings with important clinical implications warranting further investigation are highlighted. RECENT FINDINGS Recent cohort studies have demonstrated a high burden of fracture and progressive deficits of cortical bone in children with chronic kidney disease. Lower cortical density is associated with incident fracture and may be an important therapeutic target. Parathyroid hormone and calcium are independent correlates of cortical density, and modifiable factors for fracture include parathyroid hormone and phosphate binder use. Children with nephrotic syndrome, even with normal renal function, have evidence of abnormal bone metabolism and structure, and vitamin D deficiency may be an important modifiable risk factor in this population. Urolithiasis has been associated with reduced bone mineral density and is increasingly common in children and adolescents. Population-based data found a significantly increased risk of fracture in adolescent males and young women. SUMMARY Recent findings substantiate concern regarding the particular vulnerability of the growing skeleton to chronic renal disease. Studies are needed to determine how to optimize assessment and management of bone health in children with these conditions, particularly in terms of calcium and vitamin D requirements, with the goal of improving childhood bone accrual for lifelong fracture prevention.
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Choi YJ, Chung YS, Suh CH, Jung JY, Kim HA. Trabecular bone score as a supplementary tool for the discrimination of osteoporotic fractures in postmenopausal women with rheumatoid arthritis. Medicine (Baltimore) 2017; 96:e8661. [PMID: 29137106 PMCID: PMC5690799 DOI: 10.1097/md.0000000000008661] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Rheumatoid arthritis (RA) is a risk factor for bone fragility, and its effect on fracture risk is independent of bone mineral density (BMD). The trabecular bone score (TBS) is a new indirect parameter of bone quality. In this study, BMD and the TBS were compared between female postmenopausal RA patients with and those without vertebral fractures (VFs).This study had a cross-sectional design. Two hundred seventy-nine postmenopausal women with RA aged 50 years or older were included in this study. TBS measurements were performed on the same vertebrae as those for the BMD measurements.Among the 279 subjects, 34 had VFs (12.5%). There was a significant difference in the TBS (P = .005) but not L-spine BMD (P = .142) between the subjects with and those without VFs. The odds ratio (OR) for the TBS per standard deviation decrease was significant, even after adjusting for confounding factors such as age, height, rheumatoid factor positivity, the disease activity score for 28 joints (DAS28), the cumulative dose of glucocorticoids (GCs), the time since menopause and osteoporosis drug use (OR = 2.86; 95% CI, 1.34-6.09), and L-spine BMD (OR = 2.57; 95% CI, 1.19-5.54). The TBS was negatively correlated with the cumulative dose of GCs, but not with the DAS28 or erythrocyte sedimentation rate. However, the correlation was an L-shaped nonlinear relationship.The TBS could be a supplementary tool for discriminating osteoporotic fractures in postmenopausal women with RA, and it may have a nonlinear relationship with the cumulative dose of GCs, but not with RA disease activity.
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Affiliation(s)
| | | | - Chang-Hee Suh
- Department of Rheumatology, Ajou University School of Medicine, Suwon, South Korea
| | - Ju-Yang Jung
- Department of Rheumatology, Ajou University School of Medicine, Suwon, South Korea
| | - Hyoun-Ah Kim
- Department of Rheumatology, Ajou University School of Medicine, Suwon, South Korea
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Yadav VK, Sharma S, Debata PK, Patel S, Kabi BC, Aggrawal KC. Change in Bone Mineral Density and Role of Vitamin D and Calcium Supplementation During Treatment of First Episode Nephrotic Syndrome. J Clin Diagn Res 2017; 11:SC18-SC21. [PMID: 29207799 DOI: 10.7860/jcdr/2017/27030.10657] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 07/28/2017] [Indexed: 11/24/2022]
Abstract
Introduction Nephrotic Syndrome (NS) is one of the common illnesses in childhood. Oral glucocorticoids are mainstay of treatment, which are known to cause various short term and long term adverse effects including osteoporosis. Children with first episode and infrequent relapsing NS are not prescribed Calcium (Ca) and Vitamin D (VitD) supplements routinely. Aim To observe change in Bone Mineral Density (BMD) in children during first episode of NS and role of VitD and Ca supplementation during the treatment of first episode of NS. Materials and Methods A double blind randomized control trial was conducted in Department of Paediatrics at a tertiary care center in New Delhi, India, from October 2011 to March 2013. Three groups were made, each having sample size of 20. Group A (intervention group) consisted of first episode NS patients who received steroids along with VitD and Ca supplements. Group B (placebo group) had children with first episode of NS treated with steroids and placebo. Biochemical tests and BMD assessment were done at start and after three months of steroid treatment. Groupwise differences in BMD, VitD, Ca, Phosphate (PO4) and Alkaline Phosphatase (ALP) were assessed at baseline and after three months through Analysis Of Variance (ANOVA). Linear regression models for repeated measures were used to test the association between different variables and BMD and also between various study groups. Results Among study population, Group B had significant decrease in VitD levels (28.85±5.52 ng/dl to 14.22±1.36 ng/dl) than to Group A (23.59±6.08 ng/dl to 13.27±1.35 ng/dl) after three months of steroid treatment. Similarly BMD decreased significantly in Group B (-0.033g/cm2) as compared to Group A (0.001g/cm2) showing significant decrease in VitD and BMD in children with first episode of NS after three months of steroid treatment whereas use of VitD and Ca supplements improves the deficit. Conclusion Ca and VitD supplement should be used during treatment of first episode of NS, but further studies are required to ascertain the adequate dose for the same.
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Affiliation(s)
- Virendra Kumar Yadav
- Senior Resident, Department of Paediatrics, VMMC and Safdarjung Hospital, New Delhi, India
| | - Shobha Sharma
- Associate Professor, Department of Paediatrics, VMMC and Safdarjung Hospital, New Delhi, India
| | - Pradeep Kumar Debata
- Assistant Professor, Department of Paediatrics, VMMC and Safdarjung Hospital, New Delhi, India
| | - Seema Patel
- Senior Resident, Department of Biochemistry, VMMC and Safdarjung Hospital, New Delhi, India
| | - Bhaskar C Kabi
- Professor, Department of Biochemistry, VMMC and Safdarjung Hospital, New Delhi, India
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Schulz MC, Kowald J, Estenfelder S, Jung R, Kuhlisch E, Eckelt U, Mai R, Hofbauer LC, Stroszczynski C, Stadlinger B. Site-Specific Variations in Bone Mineral Density under Systemic Conditions Inducing Osteoporosis in Minipigs. Front Physiol 2017; 8:426. [PMID: 28676766 PMCID: PMC5476774 DOI: 10.3389/fphys.2017.00426] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Accepted: 06/01/2017] [Indexed: 01/03/2023] Open
Abstract
Osteoporosis is a systemic bone disease with an increasing prevalence in the elderly population. There is conflicting opinion about whether osteoporosis affects the alveolar bone of the jaws and whether it poses a risk to the osseointegration of dental implants. The aim of the present study was to evaluate the effects of systemic glucocorticoid administration on the jaw bone density of minipigs. Thirty-seven adult female minipigs were randomly divided into two groups. Quantitative computed tomography (QCT) was used to assess bone mineral density BMD of the lumbar spine as well as the mandible and maxilla, and blood was drawn. One group of minipigs initially received 1.0 mg prednisolone per kg body weight daily for 2 months. The dose was tapered to 0.5 mg per kg body weight per day thereafter. The animals in the other group served as controls and received placebo. QCT and blood analysis were repeated after 6 and 9 months. BMD was compared between the two groups by measuring Hounsfield units, and serum levels of several bone metabolic markers were also assessed. A decrease in BMD was observed in the jaws from baseline to 9 months. This was more pronounced in the prednisolone group. Statistically significant differences were reached for the mandible (p < 0.001) and the maxilla (p < 0.001). The administration of glucocorticoids reduced the BMD in the jaws of minipigs. The described model shows promise in the evaluation of osseointegration of dental implants in bone that is compromised by osteoporosis.
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Affiliation(s)
- Matthias C Schulz
- Department of Oral and Maxillofacial Surgery, Medical Faculty "Carl Gustav Carus," Technische Universität DresdenDresden, Germany
| | - Jan Kowald
- Department of Radiology, Medical Faculty "Carl Gustav Carus," Technische Universität DresdenDresden, Germany.,Division of Nephrology, Department of Internal Medicine III, Medical Faculty "Carl Gustav Carus," Technische Universität DresdenDresden, Germany
| | - Sven Estenfelder
- Department of Radiology, Medical Faculty "Carl Gustav Carus," Technische Universität DresdenDresden, Germany.,Department of Internal Medicine III, University of UlmUlm, Germany
| | - Roland Jung
- Experimental Center, Medical Faculty "Carl Gustav Carus," Technische Universität DresdenDresden, Germany
| | - Eberhard Kuhlisch
- Institute for Medical Informatics and Biometry, Medical Faculty "Carl Gustav Carus," Technische Universität DresdenDresden, Germany
| | - Uwe Eckelt
- Department of Oral and Maxillofacial Surgery, Medical Faculty "Carl Gustav Carus," Technische Universität DresdenDresden, Germany
| | - Ronald Mai
- Department of Oral and Maxillofacial Surgery, Medical Faculty "Carl Gustav Carus," Technische Universität DresdenDresden, Germany
| | - Lorenz C Hofbauer
- Division of Endocrinology, Diabetes and Bone Diseases, Department of Medicine III, Medical Faculty "Carl Gustav Carus," Technische Universität DresdenDresden, Germany
| | | | - Bernd Stadlinger
- Clinic of Cranio-Maxillofacial and Oral Surgery, University of Zurich, University Hospital ZurichZurich, Switzerland
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Abbasi-Rad S, Saligheh Rad H. Quantification of Human Cortical Bone Bound and Free Water in Vivo with Ultrashort Echo Time MR Imaging: A Model-based Approach. Radiology 2017; 283:862-872. [DOI: 10.1148/radiol.2016160780] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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23
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DiVasta AD, Feldman HA, Rubin CT, Gallagher JS, Stokes N, Kiel DP, Snyder BD, Gordon CM. The ability of low-magnitude mechanical signals to normalize bone turnover in adolescents hospitalized for anorexia nervosa. Osteoporos Int 2017; 28:1255-1263. [PMID: 27909781 PMCID: PMC9769086 DOI: 10.1007/s00198-016-3851-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 11/21/2016] [Indexed: 12/24/2022]
Abstract
UNLABELLED We sought to determine whether low-magnitude mechanical stimulation (LMMS) normalizes bone turnover among adolescents hospitalized for anorexia nervosa (AN). Brief, daily LMMS prevents the decline in bone turnover typically seen during bed rest in AN. LMMS may have application for patients with AN in the inpatient setting to protect bone health. INTRODUCTION Malnourished adolescents with AN requiring medical hospitalization are at high risk for rapid reduction in skeletal quality. Even short-term bed rest can suppress normal patterns of bone turnover. We sought to determine whether LMMS normalizes bone turnover among adolescents hospitalized for complications of AN. METHODS In this randomized, double-blind trial, we prospectively enrolled adolescent females (n = 41) with AN, age 16.3 ± 1.9 years (mean ± SD) and BMI 15.6 ± 1.7 kg/m2. Participants were randomized to stand on a platform delivering LMMS (0.3 g at 32-37 Hz) or placebo platform for 10 min/day for 5 days. Serum markers of bone formation [bone-specific alkaline phosphatase (BSAP)], turnover [osteocalcin (OC)], and bone resorption [serum C-telopeptides (CTx)] were measured. From a random coefficients model, we constructed estimates and confidence intervals for all outcomes. RESULTS BSAP decreased by 2.8% per day in the placebo arm (p = 0.03) but remained stable in the LMMS group (p = 0.51, pdiff = 0.04). CTx did not change with placebo (p = 0.56) but increased in the LMMS arm (+6.2% per day, p = 0.04; pdiff = 0.01). Serum OC did not change in either group (p > 0.70). CONCLUSIONS Bed rest during hospitalization for patients with AN is associated with a suppression of bone turnover, which may contribute to diminished bone quality. Brief, daily LMMS prevents a decline in bone turnover during bed rest in AN. Protocols prescribing strict bed rest may not be appropriate for protecting bone health for these patients. LMMS may have application for these patients in the inpatient setting.
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Affiliation(s)
- A D DiVasta
- Division of Adolescent Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA.
- Division of Gynecology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.
| | - H A Feldman
- Clinical Research Program, Boston Children's Hospital, Boston, MA, USA
| | - C T Rubin
- Department of Biomedical Engineering, State University of New York Stony Brook, Stony Brook, NY, USA
| | - J S Gallagher
- Division of Adolescent Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - N Stokes
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - D P Kiel
- Institute for Aging Research, Hebrew SeniorLife, Roslindale, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - B D Snyder
- Department of Orthopedic Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - C M Gordon
- Division of Adolescent and Transition Medicine, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH, USA
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DiVasta AD, Feldman HA, O'Donnell JM, Long J, Leonard MB, Gordon CM. Skeletal outcomes by peripheral quantitative computed tomography and dual-energy X-ray absorptiometry in adolescent girls with anorexia nervosa. Osteoporos Int 2016; 27:3549-3558. [PMID: 27392467 PMCID: PMC5881112 DOI: 10.1007/s00198-016-3685-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 06/20/2016] [Indexed: 10/21/2022]
Abstract
We conducted the first comparison of dual-energy X-ray absorptiometry (DXA) and peripheral quantitative computed tomography (pQCT) outcomes in adolescent girls with anorexia nervosa. We observed deficits in bone density by both tools. pQCT assessments were associated with many of the same clinical parameters as have been previously established for DXA. INTRODUCTION Adolescents with anorexia nervosa (AN) commonly exhibit bone loss, but effects on bone geometry are less clear. We compared measures obtained by DXA and pQCT in girls with AN. METHODS Seventy females (age 15.5 ± 1.9 years ) with AN and 132 normal-weighted controls underwent tibial measures by pQCT including trabecular volumetric bone mineral density (vBMD) at the 3 % site, cortical vBMD and dimensions at the 38 % site, and muscle cross-sectional area (CSA) at the 66 % site. Participants with AN also underwent standard DXA measures. Independent t tests compared the pQCT results, while Pearson coefficient assessed correlations among DXA and pQCT measures. RESULTS Trabecular vBMD Z-scores were lower in AN compared to controls (AN -0.31 ± 1.42 vs +0.11 ± 1.01, p = 0.01) and cortical vBMD Z-scores were higher (AN +0.18 ± 0.92 vs -0.50 ± 0.88, p < 0.001). Trabecular vBMD and cortical CSA Z-scores positively correlated with DXA BMD Z-scores (r range 0.57-0.82, p < 0.001). Markers of nutritional status positively correlated with Z-scores for trabecular vBMD, cortical CSA, section modulus, and muscle CSA (p < 0.04 for all). CONCLUSIONS This study is the first to compare DXA and pQCT measurements in adolescent girls with AN. We observed deficits in BMD by both DXA and pQCT. pQCT assessments correlated well with DXA bone and body composition measures and were associated with many of the same clinical parameters and disease severity markers as have been previously established for DXA. The differences in cortical vBMD merit further study.
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Affiliation(s)
- A D DiVasta
- Division of Adolescent Medicine, Boston Children's Hospital and Harvard Medical School, 333 Longwood Avenue, Boston, MA, 02115, USA.
- Division of Gynecology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.
| | - H A Feldman
- Clinical Research Program, Boston Children's Hospital, Boston, MA, USA
- Division of Endocrinology, Boston Children's Hospital, Boston, MA, USA
| | - J M O'Donnell
- Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - J Long
- Division of Pediatric Nephrology, Stanford University School of Medicine, Stanford, CA, USA
| | - M B Leonard
- Division of Pediatric Nephrology, Stanford University School of Medicine, Stanford, CA, USA
| | - C M Gordon
- Division of Adolescent and Transition Medicine, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Stagi S, Cavalli L, Cavalli T, de Martino M, Brandi ML. Peripheral quantitative computed tomography (pQCT) for the assessment of bone strength in most of bone affecting conditions in developmental age: a review. Ital J Pediatr 2016; 42:88. [PMID: 27670687 PMCID: PMC5037897 DOI: 10.1186/s13052-016-0297-9] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 09/15/2016] [Indexed: 12/13/2022] Open
Abstract
Peripheral quantitative computed tomography provides an automatical scan analysis of trabecular and cortical bone compartments, calculating not only their bone mineral density (BMD), but also bone geometrical parameters, such as marrow and cortical Cross-Sectional Area (CSA), Cortical Thickness (CoTh), both periosteal and endosteal circumference, as well as biomechanical parameters like Cross-Sectional Moment of Inertia (CSMI), a measure of bending, polar moment of inertia, indicating bone strength in torsion, and Strength Strain Index (SSI). Also CSA of muscle and fat can be extracted. Muscles, which are thought to stimulate bones to adapt their geometry and mineral content, are determinant to preserve or increase bone strength; thus, pQCT provides an evaluation of the functional 'muscle-bone unit', defined as BMC/muscle CSA ratio. This functional approach to bone densitometry can establish if bone strength is normally adapted to the muscle force, and if muscle force is adequate for body size, providing more detailed insights to targeted strategies for the prevention and treatment of bone fragility. The present paper offers an extensive review of technical features of pQCT and its possible clinical application in the diagnostic of bone status as well as in the monitoring of the skeleton's health follow-up.
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Affiliation(s)
- Stefano Stagi
- Health Sciences Department, University of Florence, Anna Meyer Children’s University Hospital, viale Pieraccini 24, 50139 Florence, Italy
| | - Loredana Cavalli
- Department of Surgery and Translational Medicine, Endocrinology Unit, University of Florence, Florence, Italy
| | - Tiziana Cavalli
- Department of Surgery and Translational Medicine, Emergency and Digestive Surgery with Oncological and Functional Address Unit, University of Florence, Florence, Italy
| | - Maurizio de Martino
- Health Sciences Department, University of Florence, Anna Meyer Children’s University Hospital, viale Pieraccini 24, 50139 Florence, Italy
| | - Maria Luisa Brandi
- Department of Surgery and Translational Medicine, Endocrinology Unit, University of Florence, Florence, Italy
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Kelly A, Schall J, Stallings VA, Zemel BS. Trabecular and cortical bone deficits are present in children and adolescents with cystic fibrosis. Bone 2016; 90:7-14. [PMID: 27143111 DOI: 10.1016/j.bone.2016.04.030] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Revised: 04/28/2016] [Accepted: 04/29/2016] [Indexed: 12/26/2022]
Abstract
Osteopenia and increased fracture rates are well-recognized in adults with CF, but neither the specific contributions of cortical and trabecular bone deficits to bone fragility nor their presence in youth with CF are well-characterized. This study sought to characterize cortical and trabecular volumetric bone mineral density (vBMD), geometry, and biomechanical competence in children with CF and determine their relationship to growth, body composition, and disease severity. Peripheral quantitative computerized tomography (pQCT) measures of total, cortical, and trabecular vBMD, cortical, muscle, and fat cross-sectional areas (CSA), periosteal and endosteal circumferences, and the polar unweighted section modulus (Zp) of the tibia were converted to age- and tibial length-adjusted Z-scores in 97 CF and 199 healthy children (aged 8-21y). Effects of body composition and pulmonary function (forced expiratory volume in 1s, FEV1) upon pQCT outcomes were determined using linear regression. Children with CF (FEV1%-predicted: 84.4+19.7) had lower weight-, height-, BMI-, and whole body lean mass (LBM)-Z and tibial length. Females with CF had lower (p<0.01) total and trabecular vBMD; cortical, muscle, and fat CSA; Zp and periosteal circumference than females in the healthy reference group. These bone differences persisted after adjustment for BMI-Z and to a great extent following adjustment for muscle CSA. Males with CF had lower (p<0.01) cortical, muscle, and fat CSA and their trabecular vBMD deficit approached significance (p=0.069). Deficits were attenuated by adjustment for BMI-Z and to a greater extent adjustment for muscle CSA-Z. The relationship between FEV1%-predicted and pQCT outcomes persisted only in males following adjustment for age and BMI-Z. The CF cohort had lower tibial muscle CSA than expected for their LBM. In this relatively healthy, young CF cohort, deficits in trabecular and multiple cortical bone parameters were present. In females, deficits were greater at older ages and were not fully explained by alterations in body composition. In males worsening pulmonary function was associated with greater deficits that was not explained by increasing age or compromised nutritional status. The occurrence of these differences in CF youth highlights the importance of instituting measures to optimize peak bone mass early in the course of CF.
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Affiliation(s)
- Andrea Kelly
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, 3535 Market St., Philadelphia, PA 19104, USA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Joan Schall
- Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, 3535 Market St., Philadelphia, PA 19104, USA.
| | - Virginia A Stallings
- Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, 3535 Market St., Philadelphia, PA 19104, USA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Babette S Zemel
- Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, 3535 Market St., Philadelphia, PA 19104, USA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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Wendel D, Weber D, Leonard MB, Magge SN, Kelly A, Stallings VA, Pipan M, Stettler N, Zemel BS. Body composition estimation using skinfolds in children with and without health conditions affecting growth and body composition. Ann Hum Biol 2016; 44:108-120. [PMID: 27121656 DOI: 10.3109/03014460.2016.1168867] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Body composition prediction equations using skinfolds are useful alternatives to advanced techniques, but their utility across diverse paediatric populations is unknown. AIM To evaluate published and new prediction equations across diverse samples of children with health conditions affecting growth and body composition. SUBJECTS AND METHODS Anthropometric and dual-energy X-ray absorptiometry (DXA) body composition measures were obtained in children with Down syndrome (n = 59), Crohn disease (n = 128), steroid-sensitive nephrotic syndrome (n = 67) and a healthy reference group (n = 835). Published body composition equations were evaluated. New equations were developed for ages 3-21 years using the healthy reference sample and validated in other groups and national survey data. RESULTS Fat mass (FM), fat-free mass (FFM) and percentage body fat (%BF) from published equations were highly correlated with DXA-derived measures (r = 0.71-0.98), but with poor agreement (mean difference = 2.4 kg, -1.9 kg and 6.3% for FM, FFM and %BF). New equations produced similar correlations (r = 0.85-1.0) with improved agreement for the reference group (0.2 kg, 0.4 kg and 0.0% for FM, FFM and %BF, respectively) and in sub-groups. CONCLUSIONS New body composition prediction equations show excellent agreement with DXA and improve body composition estimation in healthy children and those with selected conditions affecting growth.
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Affiliation(s)
| | - David Weber
- b Golisano Children's Hospital, School of Medicine and Dentistry, University of Rochester , Rochester , NY , USA
| | - Mary B Leonard
- c Stanford University School of Medicine , Palo Alto , CA , USA
| | - Sheela N Magge
- d Children's National Health System , Washington , DC , USA
| | - Andrea Kelly
- e The Children's Hospital of Philadelphia , Philadelphia , PA , USA
| | | | - Mary Pipan
- e The Children's Hospital of Philadelphia , Philadelphia , PA , USA
| | | | - Babette S Zemel
- e The Children's Hospital of Philadelphia , Philadelphia , PA , USA
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Selewski DT, Chen A, Shatat IF, Pais P, Greenbaum LA, Geier P, Nelson RD, Kiessling SG, Brophy PD, Quiroga A, Seifert ME, Straatmann CE, Mahan JD, Ferris ME, Troost JP, Gipson DS. Vitamin D in incident nephrotic syndrome: a Midwest Pediatric Nephrology Consortium study. Pediatr Nephrol 2016; 31:465-72. [PMID: 26498119 PMCID: PMC4758900 DOI: 10.1007/s00467-015-3236-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 09/12/2015] [Accepted: 09/28/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Cross-sectional studies of children with prevalent nephrotic syndrome (NS) have shown 25-vitamin D (25(OH)D) deficiency rates of 20-100 %. Information on 25(OH)D status in incident patients or following remission is limited. This study aimed to assess 25(OH)D status of incident idiopathic NS children at presentation and longitudinally with short-term observation. METHODS Multicenter longitudinal study of children (2-18 years old) from 14 centers across the Midwest Pediatric Nephrology Consortium with incident idiopathic NS. 25(OH)D levels were assessed at diagnosis and 3 months later. RESULTS Sixty-one children, median age 5 (3, 11) years, completed baseline visit and 51 completed second visit labs. All 61 (100 %) had 25(OH)D < 20 ng/ml at diagnosis. Twenty-seven (53 %) had 25(OH)D < 20 ng/ml at follow-up. Fourteen (28 %) children were steroid resistant. Univariate analysis showed that children prescribed vitamin D supplements were less likely to have 25(OH)D deficiency at follow-up (OR 0.2, 95 % CI 0.04, 0.6). Steroid response, age, and season did not predict 25(OH)D deficiency. Multivariable linear regression modeling showed higher 25(OH)D levels at follow-up by 13.2 ng/ml (SE 4.6, p < 0.01) in children supplemented with vitamin D. CONCLUSIONS In this incident idiopathic NS cohort, all children at diagnosis had 25(OH)D deficiency and the majority continued to have a deficiency at 2-4 months. Supplemental vitamin D decreased the odds of 25(OH)D deficiency at follow-up, supporting a role for supplementation in incident NS.
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Affiliation(s)
- David T. Selewski
- Division of Nephrology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Ashton Chen
- Department of Pediatrics, Section of Pediatric Nephrology, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Ibrahim F. Shatat
- Division of Pediatric Nephrology and Hypertension, Sidra Medical and Research Center, Doha, Qatar,Medical University of South Carolina, Charleston, SC, USA
| | - Priya Pais
- Department of Pediatric Nephrology, St. John’s Medical College Hospital, St John’s National Academy of Health Sciences, Bangalore, India
| | | | - Pavel Geier
- Division of Nephrology, Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Raoul D. Nelson
- Division of Nephrology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | | | - Patrick D. Brophy
- Stead Family Department of Pediatrics, Division of Nephrology, University of Iowa, Iowa City, IA, USA
| | | | - Michael E. Seifert
- Division of Pediatric Nephrology, Department of Pediatrics, Washington University at St. Louis, St. Louis, MO, USA,Department of Pediatrics, Southern Illinois University, Springfield, IL, USA
| | - Caroline E. Straatmann
- Department of Pediatrics, Louisiana State University and Children’s Hospital, New Orleans, LA, USA
| | - John D. Mahan
- Nationwide Children’s Hospital, The Ohio State University, College of Medicine, Columbus, OH, USA
| | - Maria E. Ferris
- Pediatric Nephrology, UNC Kidney Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jonathan P. Troost
- Division of Nephrology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Debbie S. Gipson
- Division of Nephrology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor, MI, USA
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Akbari A, Abbasi-Rad S, Rad HS. T1 correlates age: A short-TE MR relaxometry study in vivo on human cortical bone free water at 1.5T. Bone 2016; 83:17-22. [PMID: 26475122 DOI: 10.1016/j.bone.2015.10.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Revised: 10/03/2015] [Accepted: 10/12/2015] [Indexed: 11/30/2022]
Abstract
Large pores of human cortical bone (>30μm) are filled with fluids, essentially consisting of water, suggesting that cortical bone free water can be considered as a reliable surrogate measure of cortical bone porosity and hence quality. Signal from such pores can be reliably captured using Short Echo Time (STE) pulse sequence with echo-time in the range of 1-1.5msec (which should be judiciously selected correspond to T2(⁎) value of free water molecules). Furthermore, it is well-known that cortical bone T1-relaxivity is a function of its geometry, suggesting that cortical bone free water increases with age. In this work, we quantified cortical bone free water longitudinal relaxation time (T1) by a Dual-TR technique using STE pulse sequence. In the sequel, we investigated relationship between STE-derived cortical bone free water T1-values and age in a group of healthy volunteers (thirty subjects covering the age range of 20-70years) at 1.5T. Preliminary results showed that cortical bone free water T1 highly correlates with age (r(2)=0.73, p<0.0001), representing cortical bone free water T1 as a reliable indicator of cortical bone porosity and age-related deterioration. It can be concluded that STE-MRI can be utilized as proper alternative in quantifying cortical bone porosity parameters in-vivo, with the advantages of widespread clinical availability and being cost-effective.
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Affiliation(s)
- Atena Akbari
- Quantitative MR Imaging and Spectroscopy Group, Research Center for Cellular and Molecular Imaging, Tehran University of Medical Sciences, Tehran, Iran; Medical Physics and Biomedical Engineering Department, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahrokh Abbasi-Rad
- Quantitative MR Imaging and Spectroscopy Group, Research Center for Cellular and Molecular Imaging, Tehran University of Medical Sciences, Tehran, Iran; Medical Physics and Biomedical Engineering Department, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamidreza Saligheh Rad
- Quantitative MR Imaging and Spectroscopy Group, Research Center for Cellular and Molecular Imaging, Tehran University of Medical Sciences, Tehran, Iran; Medical Physics and Biomedical Engineering Department, Tehran University of Medical Sciences, Tehran, Iran.
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Leib ES, Winzenrieth R. Bone status in glucocorticoid-treated men and women. Osteoporos Int 2016; 27:39-48. [PMID: 26252975 DOI: 10.1007/s00198-015-3211-1] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 06/12/2015] [Indexed: 01/01/2023]
Abstract
UNLABELLED We recorded the results of areal bone mineral density (aBMD) and microarchitecture of the bone measured by trabecular bone score (TBS) in 416 glucocorticoid-treated men and women aged 40 years and older with or without fracture to 1104 controls. TBS better discriminated those with fracture compared to aBMD. These differences were the greatest in men. INTRODUCTION The aim of this study is to evaluate glucocorticoid (GC)-induced effects on areal bone mineral density (aBMD) and bone microarchitectural texture measured by trabecular bone score (TBS). METHODS TBS and aBMD were evaluated at L1-L4 postero-anterior (PA) spine by dual X-ray absorptiometry (DXA) in 1520 men and women aged 40 years and over. Four hundred sixteen subjects who received GCs (≥5 mg/day, for ≥3 months) were matched with 1104 sex-, age-, and BMI-matched control subjects. Clinical data, osteoporotic fractures (OPF), and dietary habits were documented in the medical report. RESULTS GC-treated patients were characterized by a significant decrease of TBS (1.267 vs. 1.298, p < 0.001) compared with control-matched subjects while no change in BMD was observed at any sites. These decreases were even more pronounced when fracture status was taken into account (1.222 vs. 1.298, p < 0.001). The odds ratio (OR) for TBS was 1.44 (1.095-1.89) for OPF, whereas no association was found for BMD at any sites (all p > 0.3). A similar effect on microarchitecture measured by TBS was seen by the presence of fracture as by the use of glucocorticoids. An influence on TBS by sex was also noted with a decrease in TBS of greater magnitude in men. CONCLUSIONS GC-treated individuals have a significant deterioration of bone microarchitectural texture as assessed by TBS which is more marked in those with OPF and in men. TBS seems to be more sensitive than aBMD for GC-related fracture detection and should be a good surrogate indicator of bone health in such secondary osteoporosis.
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Affiliation(s)
- E S Leib
- Department of Medicine, University of Vermont College of Medicine, Burlington, VT, USA
| | - R Winzenrieth
- R & D Department, Med-Imaps, 5 rue Henri Becquerel, Merignac, 33700, Bordeaux, France.
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Lewiecki EM, Baron R, Bilezikian JP, Gagel RE, Leonard MB, Leslie WD, McClung MR, Miller PD. Proceedings of the 2015 Santa Fe Bone Symposium: Clinical Applications of Scientific Advances in Osteoporosis and Metabolic Bone Disease. J Clin Densitom 2016; 19:102-16. [PMID: 26750746 PMCID: PMC6706250 DOI: 10.1016/j.jocd.2015.11.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 11/19/2015] [Indexed: 12/30/2022]
Abstract
The 2015 Santa Fe Bone Symposium was a venue for healthcare professionals and clinical researchers to present and discuss the clinical relevance of recent advances in the science of skeletal disorders, with a focus on osteoporosis and metabolic bone disease. Symposium topics included new developments in the translation of basic bone science to improved patient care, osteoporosis treatment duration, pediatric bone disease, update of fracture risk assessment, cancer treatment-related bone loss, fracture liaison services, a review of the most significant studies of the past year, and the use of telementoring with Bone Health Extension for Community Healthcare Outcomes, a force multiplier to improve the care of osteoporosis in underserved communities.
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Affiliation(s)
- E Michael Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, Albuquerque, NM, USA.
| | - Roland Baron
- Harvard Medical School and Massachusetts General Hospital, Harvard School of Dental Medicine, Boston, MA, USA
| | - John P Bilezikian
- Columbia University College of Physicians and Surgeons, New York City, NY, USA
| | - Robert E Gagel
- University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | | | - William D Leslie
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Paul D Miller
- Colorado Center for Bone Research, Lakewood, CO, USA
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Saraff V, Högler W. ENDOCRINOLOGY AND ADOLESCENCE: Osteoporosis in children: diagnosis and management. Eur J Endocrinol 2015; 173:R185-97. [PMID: 26041077 DOI: 10.1530/eje-14-0865] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 06/03/2015] [Indexed: 01/21/2023]
Abstract
Osteoporosis in children can be primary or secondary due to chronic disease. Awareness among paediatricians is vital to identify patients at risk of developing osteoporosis. Previous fractures and backaches are clinical predictors, and low cortical thickness and low bone density are radiological predictors of fractures. Osteogenesis Imperfecta (OI) is a rare disease and should be managed in tertiary paediatric units with the necessary multidisciplinary expertise. Modern OI management focuses on functional outcomes rather than just improving bone mineral density. While therapy for OI has improved tremendously over the last few decades, this chronic genetic condition has some unpreventable, poorly treatable and disabling complications. In children at risk of secondary osteoporosis, a high degree of suspicion needs to be exercised. In affected children, further weakening of bone should be avoided by minimising exposure to osteotoxic medication and optimising nutrition including calcium and vitamin D. Early intervention is paramount. However, it is important to identify patient groups in whom spontaneous vertebral reshaping and resolution of symptoms occur to avoid unnecessary treatment. Bisphosphonate therapy remains the pharmacological treatment of choice in both primary and secondary osteoporosis in children, despite limited evidence for its use in the latter. The duration and intensity of treatment remain a concern for long-term safety. Various new potent antiresorptive agents are being studied, but more urgently required are studies using anabolic medications that stimulate bone formation. More research is required to bridge the gaps in the evidence for management of paediatric osteoporosis.
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Affiliation(s)
- Vrinda Saraff
- Department of Endocrinology and DiabetesBirmingham Children's Hospital, Steelhouse Lane, Birmingham B4 6NH, UK
| | - Wolfgang Högler
- Department of Endocrinology and DiabetesBirmingham Children's Hospital, Steelhouse Lane, Birmingham B4 6NH, UK
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La croissance staturale des enfants ayant un syndrome néphrotique cortico-sensible en Côte d’Ivoire. Nephrol Ther 2015; 11:160-3. [DOI: 10.1016/j.nephro.2014.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 11/29/2014] [Accepted: 12/01/2014] [Indexed: 11/20/2022]
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Gaudio A, Muratore F, Fiore V, Rapisarda R, Signorelli SS, Fiore CE. Decreased bone cortical density at the forearm in subjects with subclinical peripheral arterial disease. Osteoporos Int 2015; 26:1747-53. [PMID: 25672808 DOI: 10.1007/s00198-015-3057-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 01/28/2015] [Indexed: 12/14/2022]
Abstract
UNLABELLED The association between peripheral arterial disease (PAD) and low bone mass is controversial. In our study, peripheral quantitative computed tomography shows a reduction of cortical but not trabecular, bone mineral density (BMD) at the forearm, in patients with subclinical PAD. INTRODUCTION Some controversy exists regarding the association between peripheral arterial disease (PAD) and low bone mass. Previous studies have evaluated bone mineral density (BMD) in patients with subclinical PAD, with mixed results. Inconsistency of data may depend on the fact that most studies measured areal bone mineral density (aBMD) by Dual-energy-x ray absorptiometry (DXA). Because DXA cannot distinguish between cortical and trabecular compartments, we reasoned that a study aimed to establish whether these compartments were differentially affected by PAD status could give more information on the nature of this association. METHODS In this cross-sectional study, we used peripheral quantitative computed tomography (pQCT) to examine volumetric cortical and trabecular mineral density at the radius (vBMD) in a cohort of subjects with subclinical PAD as defined by ABI ≤0.90 and compared them with healthy subjects with no evidence of PAD. RESULTS Patients with subclinical PAD had significantly reduced cortical density (1101.0 ± 45.4 vs 1156.2 ± 51.3 mg/cm(3), p < 0.001) and cortical area (75.0 ± 20.9 vs 99.9 ± 18.2 mm(2), p < 0.001) than healthy subjects. Trabecular density (178.1 ± 47.9 vs 165.8 ± 29.6 mg/cm(3)) was not significantly different in the two groups. CONCLUSION Subclinical PAD induces a selective bone loss at the radius compartment, not identified by standard DXA, which seems to occur primarily at the cortical level.
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Affiliation(s)
- A Gaudio
- Department of Clinical and Experimental Medicine, Section of Metabolic Bone Disease, University of Catania, Clinica Medica OVE, Via Plebiscito 628, 95124, Catania, Italy
| | - F Muratore
- Department of Clinical and Experimental Medicine, Section of Metabolic Bone Disease, University of Catania, Clinica Medica OVE, Via Plebiscito 628, 95124, Catania, Italy
| | - V Fiore
- Department of Clinical and Experimental Medicine, Section of Vascular Medicine, Medical Angiology Unit, University of Catania, Garibaldi Hospital, Piazza S. Maria di Gesù 5, 95123, Catania, Italy
| | - R Rapisarda
- Department of Clinical and Experimental Medicine, Section of Metabolic Bone Disease, University of Catania, Clinica Medica OVE, Via Plebiscito 628, 95124, Catania, Italy
| | - S S Signorelli
- Department of Clinical and Experimental Medicine, Section of Vascular Medicine, Medical Angiology Unit, University of Catania, Garibaldi Hospital, Piazza S. Maria di Gesù 5, 95123, Catania, Italy
| | - C E Fiore
- Department of Clinical and Experimental Medicine, Section of Metabolic Bone Disease, University of Catania, Clinica Medica OVE, Via Plebiscito 628, 95124, Catania, Italy.
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Lee DY, Wetzsteon RJ, Zemel BS, Shults J, Organ JM, Foster BJ, Herskovitz RM, Foerster DL, Leonard MB. Muscle torque relative to cross-sectional area and the functional muscle-bone unit in children and adolescents with chronic disease. J Bone Miner Res 2015; 30:575-83. [PMID: 25264231 PMCID: PMC4532328 DOI: 10.1002/jbmr.2375] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Revised: 09/22/2014] [Accepted: 09/23/2014] [Indexed: 12/14/2022]
Abstract
Measures of muscle mass or size are often used as surrogates of forces acting on bone. However, chronic diseases may be associated with abnormal muscle force relative to muscle size. The muscle-bone unit was examined in 64 children and adolescents with new-onset Crohn's disease (CD), 54 with chronic kidney disease (CKD), 51 treated with glucocorticoids for nephrotic syndrome (NS), and 264 healthy controls. Muscle torque was assessed by isometric ankle dynamometry. Calf muscle cross-sectional area (CSA) and tibia cortical section modulus (Zp) were assessed by quantitative CT. Log-linear regression was used to determine the relations among muscle CSA, muscle torque, and Zp, adjusted for tibia length, age, Tanner stage, sex, and race. Muscle CSA and muscle torque-relative-to-muscle CSA were significantly lower than controls in advanced CKD (CSA -8.7%, p = 0.01; torque -22.9%, p < 0.001) and moderate-to-severe CD (CSA -14.1%, p < 0.001; torque -7.6%, p = 0.05), but not in NS. Zp was 11.5% lower in advanced CKD (p = 0.005) compared to controls, and this deficit was attenuated to 6.7% (p = 0.05) with adjustment for muscle CSA. With additional adjustment for muscle torque and body weight, Zp was 5.9% lower and the difference with controls was no longer significant (p = 0.09). In participants with moderate-to-severe CD, Zp was 6.8% greater than predicted (p = 0.01) given muscle CSA and torque deficits (R(2) = 0.92), likely due to acute muscle loss in newly-diagnosed patients. Zp did not differ in NS, compared with controls. In conclusion, muscle torque relative to muscle CSA was significantly lower in CKD and CD, compared with controls, and was independently associated with Zp. Future studies are needed to determine if abnormal muscle strength contributes to progressive bone deficits in chronic disease, independent of muscle area. © 2014 American Society for Bone and Mineral Research.
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Affiliation(s)
- Dale Y. Lee
- Department of Pediatrics, Children’s Hospital of Philadelphia, 34 Street and Civic Center Blvd., CHOP North Room 868, Philadelphia, PA 19104, USA
| | - Rachel J. Wetzsteon
- Department of Pediatrics, Children’s Hospital of Philadelphia, 34 Street and Civic Center Blvd., CHOP North Room 868, Philadelphia, PA 19104, USA
| | - Babette S. Zemel
- Department of Pediatrics, Children’s Hospital of Philadelphia, 34 Street and Civic Center Blvd., CHOP North Room 868, Philadelphia, PA 19104, USA
| | - Justine Shults
- Department of Pediatrics, Children’s Hospital of Philadelphia, 34 Street and Civic Center Blvd., CHOP North Room 868, Philadelphia, PA 19104, USA
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104, USA
| | - Jason M. Organ
- Department of Anatomy and Cell Biology, Indiana University, 635 Barnhill Drive, MS 5035, Indianapolis, Indiana 46202
| | - Bethany J. Foster
- Department of Pediatrics, Montreal Children’s Hospital, 2300 Tupper St., H3H 1P3, Montreal, Quebec, Canada
| | - Rita M. Herskovitz
- Department of Pediatrics, Children’s Hospital of Philadelphia, 34 Street and Civic Center Blvd., CHOP North Room 868, Philadelphia, PA 19104, USA
| | - Debbie L. Foerster
- Department of Pediatrics, Children’s Hospital of Philadelphia, 34 Street and Civic Center Blvd., CHOP North Room 868, Philadelphia, PA 19104, USA
| | - Mary B. Leonard
- Department of Pediatrics, Children’s Hospital of Philadelphia, 34 Street and Civic Center Blvd., CHOP North Room 868, Philadelphia, PA 19104, USA
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104, USA
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Aceto G, D'Addato O, Messina G, Carbone V, Cavallo L, Brunetti G, Faienza MF. Bone health in children and adolescents with steroid-sensitive nephrotic syndrome assessed by DXA and QUS. Pediatr Nephrol 2014; 29:2147-55. [PMID: 24902941 DOI: 10.1007/s00467-014-2834-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Revised: 04/14/2014] [Accepted: 04/17/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND The management of steroid-sensitive nephrotic syndrome (SSNS) requires treatment with high-dose glucocorticoids (GCs), but GC usage causes the most frequent form of drug-induced osteoporosis. The aim of our study was to evaluate the impact of GCs on bone mineralization in patients with SSNS using two diagnostic tools, dual-energy X-ray densitometry (DXA) and quantitative ultrasound (QUS), and to compare the diagnostic efficacy of these two imaging tools. METHODS A total of 30 children with SSNS (age 5.20 ± 2.20 years) were evaluated at the start (T0) and after 1 (T1), 2.44 ± 0.75 (T2, 18 patients) and 5.96 ± 2.33 years (T4, 12 patients) of GC treatment. Patients who stopped at T2 were also evaluated at the 1-year timepoint after ceasing GC treatment (T3). RESULTS Of the patients assessed at T2, 11 had bone mineralization at the lower limit of normal versus those at T0 and T1, with bone mineralization rescue at the 1-year timepoint after GC discontinuation. At T4, 6/12 patients had densitometric parameters at the lower limit of normal values, and 3/12 patients showed reduced bone mineralization. The parameters derived from measurements of DXA and QUS were significantly related to each timepoint. CONCLUSIONS Patients with SSNS receiving GC therapy undergo bone status alteration related to the dosage and duration of the therapy. In terms of diagnostic efficacy, DXA and QUS were comparable, indicating that QUS is a reliable tool to evaluate bone health in children with SSNS.
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Affiliation(s)
- Gabriella Aceto
- Division of Pediatric Nephrology, Children's Hospital Giovanni XXIII, Bari, Italy
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Lin S, Huang J, Zheng L, Liu Y, Liu G, Li N, Wang K, Zou L, Wu T, Qin L, Cui L, Li G. Glucocorticoid-induced osteoporosis in growing rats. Calcif Tissue Int 2014; 95:362-73. [PMID: 25086673 DOI: 10.1007/s00223-014-9899-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 07/17/2014] [Indexed: 01/16/2023]
Abstract
This study evaluated whether growing rats were appropriate animal models of glucocorticoid-induced osteoporosis. The 3-month-old male rats were treated with either vehicle or prednisone acetate at 1.5, 3.0, and 6.0 mg/kg/day by oral gavage, respectively. All rats were injected with tetracycline and calcein before sacrificed for the purpose of double in vivo labeling. Biochemistry, histomorphometry, mechanical test, densitometry, micro-CT, histology, and component analysis were performed. We found that prednisone treatments dose dependently decreased body weight, serum biomarkers, biomechanical markers, bone formation, and bone resorption parameters in both tibial and femoral trabecular bone without trabecular bone loss. We also found that significant bone loss happened in femoral cortical bone in the glucocorticoid-treated rats. The results suggested that prednisone not only inhibited bone formation, but also inhibited bone resorption which resulted in poor bone strength but with no cancellous bone loss in growing rats. These data also suggested that the effects of glucocorticoid on bone metabolism were different between cortical bone and trabecular bone, and different between tibia and femur. Growing rats may be a glucocorticoid-induced osteoporosis animal model when evaluated the effects of drugs upon juvenile patients exposed to GC for a long time.
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Affiliation(s)
- Sien Lin
- Department of Pharmacology, Guangdong Key Laboratory for Research and Development of Natural Drugs, Guangdong Medical College, Zhanjiang, Guangdong, 524023, China
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Faienza MF, Luce V, Lonero A, Ventura A, Colaianni G, Colucci S, Cavallo L, Grano M, Brunetti G. Treatment of osteoporosis in children with glucocorticoid-treated diseases. Expert Rev Endocrinol Metab 2014; 9:525-534. [PMID: 30736214 DOI: 10.1586/17446651.2014.936384] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Glucocorticoid induced osteoporosis (GIO) is the most frequent form of drug induced osteoporosis. Glucocorticoids affect osteoblastogenesis, osteoclastogenesis and promote the apoptosis of osteoblasts and osteocytes. A decrease of bone mineral density has been described in several pediatric diseases that require glucocorticoids, both as long-term replacement therapy, such as Congenital Adrenal Hyperplasia, and as treatment of acute phase or relapses, such as asthma, juvenile rheumatoid arthritis, inflammatory bowel diseases, systemic lupus erythematosus, organ transplantation and Steroid Sensitive Nephrotic Syndrome. The increasing number of children with GIO and at risk of fractures reflects the complex nature of this condition, and the need of development of anti-osteoporotic drugs. In this review, we focus on the mechanisms of GIO in some pediatric diseases and on treatment of osteoporosis. We also report data on new signaling pathways as potential targets for future anti-osteoporotic drugs.
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Affiliation(s)
- Maria Felicia Faienza
- a Section of Pediatrics, Department of Biomedical Sciences and Human Oncology, University "A. Moro", Bari, Italy
| | - Vincenza Luce
- a Section of Pediatrics, Department of Biomedical Sciences and Human Oncology, University "A. Moro", Bari, Italy
| | - Antonella Lonero
- a Section of Pediatrics, Department of Biomedical Sciences and Human Oncology, University "A. Moro", Bari, Italy
| | - Annamaria Ventura
- a Section of Pediatrics, Department of Biomedical Sciences and Human Oncology, University "A. Moro", Bari, Italy
| | - Graziana Colaianni
- b Section of Human Anatomy and Histology, Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | - Silvia Colucci
- b Section of Human Anatomy and Histology, Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | - Luciano Cavallo
- a Section of Pediatrics, Department of Biomedical Sciences and Human Oncology, University "A. Moro", Bari, Italy
| | - Maria Grano
- b Section of Human Anatomy and Histology, Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | - Giacomina Brunetti
- b Section of Human Anatomy and Histology, Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
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Tsampalieros A, Berkenstock MK, Zemel BS, Griffin L, Shults J, Burnham JM, Baldassano RN, Leonard MB. Changes in trabecular bone density in incident pediatric Crohn's disease: a comparison of imaging methods. Osteoporos Int 2014; 25:1875-83. [PMID: 24760243 PMCID: PMC4532327 DOI: 10.1007/s00198-014-2701-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 03/21/2014] [Indexed: 12/30/2022]
Abstract
UNLABELLED This study of changes in dual energy x-ray absorptiometry (DXA) spine BMD following diagnosis and treatment for childhood Crohn's disease demonstrated that changes in conventional posteroanterior BMD results were confounded by impaired growth, and suggested that lateral spine measurements and strategies to estimate volumetric BMD were more sensitive to disease and treatment effects. INTRODUCTION We previously reported significant increases in peripheral quantitative CT (pQCT) measures of trabecular volumetric bone mineral density (vBMD) following diagnosis and treatment of pediatric Crohn's disease (CD). The objective of this study was to compare pQCT trabecular vBMD and three DXA measures of spine BMD in this cohort: (1) conventional posteroanterior BMD (PA-BMD), (2) PA-BMD adjusted for height Z (PA-BMDHtZ), and (3) width-adjusted volumetric BMD (WA-BMD) estimated from PA and lateral scans. METHODS Spine DXA [lumbar (L1-4) for posteroanterior and L3 for lateral] and tibia pQCT scans were obtained in 65 CD subjects (ages 7-18 years) at diagnosis and 12 months later. BMD results were converted to sex, race, and age-specific Z-scores based on reference data in >650 children (ages 5-21 years). Multivariable linear regression models identified factors associated with BMD Z-scores. RESULTS At CD diagnosis, all BMD Z-scores were lower compared with the reference children (all p values <0.01). The pQCT vBMD Z-scores (-1.46 ± 1.30) were lower compared with DXA PA-BMD (-0.75 ± 0.98), PA-BMDHtZ (-0.53 ± 0.87), and WA-BMD (-0.61 ± 1.10) among CD participants. Only PA-BMD Z-scores were correlated with height Z-scores at baseline (R = 0.47, p < 0.0001). pQCT and WA-BMD Z-scores increased significantly over 12 months to -1.04 ± 1.26 and -0.20 ± 1.14, respectively. Changes in all four BMD Z-scores were positively associated with changes in height Z-scores (p < 0.05). Glucocorticoid doses were inversely associated with changes in WA-BMD (p < 0.01) only. CONCLUSIONS Conventional and height Z-score-adjusted PA DXA methods did not demonstrate the significant increases in trabecular vBMD noted on pQCT and WA-BMD scans. WA-BMD captured glucocorticoid effects, potentially due to isolation of the vertebral body on the lateral projection. Future studies are needed to identify the BMD measure that provides greatest fracture discrimination in CD.
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Affiliation(s)
- A. Tsampalieros
- Department of Pediatrics, The Children’s Hospital of Eastern Ontario, Faculty of Medicine, University of Ottawa, 401 Smyth Road, Ottawa, ON K1H 8 L1, Canada. Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Philadelphia, PA 19104, USA
| | - M. K. Berkenstock
- Department of Ophthalmology, Drexel University College of Medicine, 219 N. Broad St. 3rd Floor, Philadelphia, PA 19107, USA
| | - B. S. Zemel
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Philadelphia, PA 19104, USA
| | - L. Griffin
- Department of Radiology, NYU School of Medicine, 550 First Ave, New York, NY 10016, USA
| | - J. Shults
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - J. M. Burnham
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Philadelphia, PA 19104, USA
| | - R. N. Baldassano
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Philadelphia, PA 19104, USA
| | - M. B. Leonard
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Philadelphia, PA 19104, USA. Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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Adams JE, Engelke K, Zemel BS, Ward KA. Quantitative computer tomography in children and adolescents: the 2013 ISCD Pediatric Official Positions. J Clin Densitom 2014; 17:258-74. [PMID: 24792821 DOI: 10.1016/j.jocd.2014.01.006] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 01/14/2014] [Indexed: 12/24/2022]
Abstract
In 2007, International Society of Clinical Densitometry Pediatric Positions Task Forces reviewed the evidence for the clinical application of peripheral quantitative computed tomography (pQCT) in children and adolescents. At that time, numerous limitations regarding the clinical application of pQCT were identified, although its use as a research modality for investigation of bone strength was highlighted. The present report provides an updated review of evidence for the clinical application of pQCT, as well as additional reviews of whole body QCT scans of the central and peripheral skeletons, and high-resolution pQCT in children. Although these techniques remain in the domain of research, this report summarizes the recent literature and evidence of the clinical applicability and offers general recommendations regarding the use of these modalities in pediatric bone health assessment.
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Affiliation(s)
- Judith E Adams
- Department of Clinical Radiology, The Royal Infirmary, Central Manchester University Hospitals NHS Foundation Trust, Oxford Road, Manchester, England, UK.
| | - Klaus Engelke
- Institute of Medical Physics, University of Erlangen, Erlangen, Germany and Synarc A/S, Germany
| | - Babette S Zemel
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Kate A Ward
- MRC Human Nutrition Research, Elsie Widdowson Laboratory, Cambridge, UK
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Zilio M, Barbot M, Ceccato F, Camozzi V, Bilora F, Casonato A, Frigo AC, Albiger N, Daidone V, Mazzai L, Mantero F, Scaroni C. Diagnosis and complications of Cushing's disease: gender-related differences. Clin Endocrinol (Oxf) 2014; 80:403-10. [PMID: 23889360 DOI: 10.1111/cen.12299] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Revised: 05/10/2013] [Accepted: 07/22/2013] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Cushing's disease (CD) presents a remarkable preponderance in female gender, with a female-to-male ratio of 3-8:1. The aim of this study was to evaluate gender-related differences in the presentation of CD, as regards: biochemical indices of hypercortisolism; sensitivity of diagnostic tests; clinical features and complications of disease. METHODS We retrospectively studied 84 adult patients with CD, 67 women and 17 men, evaluated at diagnosis. We compared the features of the disease between the sexes and analysed the effect of gender on CD complications, adjusted for potential confounders (age, gonadal status, BMI, urinary free cortisol values). RESULTS We observed no differences between males and females as regards age at diagnosis, disease duration and BMI. Men, compared with women, presented higher urinary free cortisol values (P < 0·001) and ACTH values (P < 0·05). As regards diagnostic tests, men presented a lower ACTH response to DDAVP stimulation (P < 0·05). The pituitary tumour itself was less easily visualized by pituitary MRI in males compared with females (P < 0·05). Furthermore, some complications of disease were more frequent or more severe in men, in particular hypokalaemia (P < 0·05), hypercoagulable state and osteoporosis at lumbar spine (P < 0·01), with consequent higher risk of vertebral fractures. Male gender was found to be an independent risk factor for dyslipidaemia, severity of hypertension, lumbar osteoporosis and fractures. CONCLUSIONS Although CD is less frequent in male patients, in this gender, it presents with more florid clinical manifestations and may imply more diagnostic difficulties.
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Affiliation(s)
- Marialuisa Zilio
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Padova, Italy
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Blew RM, Lee VR, Farr JN, Schiferl DJ, Going SB. Standardizing evaluation of pQCT image quality in the presence of subject movement: qualitative versus quantitative assessment. Calcif Tissue Int 2014; 94:202-11. [PMID: 24077875 PMCID: PMC3949118 DOI: 10.1007/s00223-013-9803-x] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Accepted: 09/02/2013] [Indexed: 01/14/2023]
Abstract
Peripheral quantitative computed tomography (pQCT) is an essential tool for assessing bone parameters of the limbs, but subject movement and its impact on image quality remains a challenge to manage. The current approach to determine image viability is by visual inspection, but pQCT lacks a quantitative evaluation. Therefore, the aims of this study were to (1) examine the reliability of a qualitative visual inspection scale and (2) establish a quantitative motion assessment methodology. Scans were performed on 506 healthy girls (9-13 years) at diaphyseal regions of the femur and tibia. Scans were rated for movement independently by three technicians using a linear, nominal scale. Quantitatively, a ratio of movement to limb size (%Move) provided a measure of movement artifact. A repeat-scan subsample (n = 46) was examined to determine %Move's impact on bone parameters. Agreement between measurers was strong (intraclass correlation coefficient = 0.732 for tibia, 0.812 for femur), but greater variability was observed in scans rated 3 or 4, the delineation between repeat and no repeat. The quantitative approach found ≥95% of subjects had %Move <25 %. Comparison of initial and repeat scans by groups above and below 25% initial movement showed significant differences in the >25 % grouping. A pQCT visual inspection scale can be a reliable metric of image quality, but technicians may periodically mischaracterize subject motion. The presented quantitative methodology yields more consistent movement assessment and could unify procedure across laboratories. Data suggest a delineation of 25% movement for determining whether a diaphyseal scan is viable or requires repeat.
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Affiliation(s)
- Robert M. Blew
- Department of Physiological Sciences, The University of Arizona, 1713 E. University Blvd. #93, Tucson, AZ 85721, USA
| | - Vinson R. Lee
- Department of Physiological Sciences, The University of Arizona, 1713 E. University Blvd. #93, Tucson, AZ 85721, USA
| | - Joshua N. Farr
- Endocrine Research Unit, Guggenheim 7-95, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | | | - Scott B. Going
- Department of Nutritional Sciences, The University of Arizona, Shantz Building #309, 1177 E. 4th St., Tucson, AZ 85721, USA
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Phan V, Blydt-Hansen T, Feber J, Alos N, Arora S, Atkinson S, Bell L, Clarson C, Couch R, Cummings EA, Filler G, Grant RM, Grimmer J, Hebert D, Lentle B, Ma J, Matzinger M, Midgley J, Pinsk M, Rodd C, Shenouda N, Stein R, Stephure D, Taback S, Williams K, Rauch F, Siminoski K, Ward LM. Skeletal findings in the first 12 months following initiation of glucocorticoid therapy for pediatric nephrotic syndrome. Osteoporos Int 2014; 25:627-37. [PMID: 23948876 PMCID: PMC4100956 DOI: 10.1007/s00198-013-2466-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Accepted: 07/16/2013] [Indexed: 02/08/2023]
Abstract
UNLABELLED Incident vertebral fractures and lumbar spine bone mineral density (BMD) were assessed in the 12 months following glucocorticoid initiation in 65 children with nephrotic syndrome. The incidence of vertebral fractures was low at 12 months (6 %) and most patients demonstrated recovery in BMD Z-scores by this time point. INTRODUCTION Vertebral fracture (VF) incidence following glucocorticoid (GC) initiation has not been previously reported in pediatric nephrotic syndrome. METHODS VF was assessed on radiographs (Genant method); lumbar spine bone mineral density (LS BMD) was evaluated by dual-energy X-ray absorptiometry. RESULTS Sixty-five children were followed to 12 months post-GC initiation (median age, 5.4 years; range, 2.3-17.9). Three of 54 children with radiographs (6 %; 95 % confidence interval (CI), 2-15 %) had incident VF at 1 year. The mean LS BMD Z-score was below the healthy average at baseline (mean ± standard deviation (SD), -0.5 ± 1.1; p = 0.001) and at 3 months (-0.6 ± 1.1; p < 0.001), but not at 6 months (-0.3 ± 1.3; p = 0.066) or 12 months (-0.3 ± 1.2; p = 0.066). Mixed effect modeling showed a significant increase in LS BMD Z-scores between 3 and 12 months (0.22 SD; 95 % CI, 0.08 to 0.36; p = 0.003). A subgroup (N = 16; 25 %) had LS BMD Z-scores that were ≤-1.0 at 12 months. In these children, each additional 1,000 mg/m(2) of GC received in the first 3 months was associated with a decrease in LS BMD Z-score by 0.39 at 12 months (95 % CI, -0.71 to -0.07; p = 0.017). CONCLUSIONS The incidence of VF at 1 year was low and LS BMD Z-scores improved by 12 months in the majority. Twenty-five percent of children had LS BMD Z-scores ≤-1.0 at 12 months. In these children, LS BMD Z-scores were inversely associated with early GC exposure, despite similar GC exposure compared to the rest of the cohort.
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Affiliation(s)
- V Phan
- Université de Montréal, Montréal, QC, Canada
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Tsampalieros A, Griffin L, Terpstra AM, Kalkwarf HJ, Shults J, Foster BJ, Zemel BS, Foerster DL, Leonard MB. Changes in DXA and quantitative CT measures of musculoskeletal outcomes following pediatric renal transplantation. Am J Transplant 2014; 14:124-32. [PMID: 24298998 PMCID: PMC3951446 DOI: 10.1111/ajt.12524] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 08/30/2013] [Accepted: 09/27/2013] [Indexed: 01/25/2023]
Abstract
This prospective study evaluated changes in dual energy X-ray absorptiometry (DXA) whole body bone mineral content (WB-BMC) and spine areal bone mineral density (spine-BMD), and tibia quantitative computed tomography (QCT) trabecular and cortical volumetric BMD and cortical area in 56 children over 12 months following renal transplantation. At transplant, spine-BMD Z-scores were greater in younger recipients (<13 years), versus 898 reference participants (p < 0.001). In multivariate models, greater decreases in spine-BMD Z-scores were associated with greater glucocorticoid dose (p < 0.001) and declines in parathyroid hormone levels (p = 0.008). Changes in DXA spine-BMD and QCT trabecular BMD were correlated (r = 0.47, p < 0.01). At 12 months, spine-BMD Z-scores remained elevated in younger recipients, but did not differ in older recipients (≥ 13) and reference participants. Baseline WB-BMC Z-scores were significantly lower than reference participants (p = 0.02). Greater glucocorticoid doses were associated with declines in WB-BMC Z-scores (p < 0.001) while greater linear growth was associated with gains in WB-BMC Z-scores (p = 0.01). Changes in WB-BMC Z-scores were associated with changes in tibia cortical area Z-scores (r = 0.52, p < 0.001), but not changes in cortical BMD Z-scores. Despite resolution of muscle deficits, WB-BMC Z-scores at 12 months remained significantly reduced. These data suggest that spine and WB DXA provides insight into trabecular and cortical outcomes following pediatric renal transplantation.
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Affiliation(s)
- Anne Tsampalieros
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Lindsay Griffin
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Anniek M Terpstra
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Heidi J Kalkwarf
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center
| | - Justine Shults
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Bethany J Foster
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Babette S Zemel
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Debbie L Foerster
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Mary B. Leonard
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania
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Moon RJ, Gilbert RD, Page A, Murphy L, Taylor P, Cooper C, Dennison EM, Davies JH. Children with nephrotic syndrome have greater bone area but similar volumetric bone mineral density to healthy controls. Bone 2014; 58:108-13. [PMID: 24145304 PMCID: PMC4968633 DOI: 10.1016/j.bone.2013.10.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 09/17/2013] [Accepted: 10/14/2013] [Indexed: 12/23/2022]
Abstract
BACKGROUND Glucocorticoid use has been associated with an increased fracture risk and reduced bone mineral density (BMD), particularly in the trabecular compartment. However the contribution of the underlying inflammatory disease process to these outcomes is poorly understood. Childhood nephrotic syndrome (NS) typically follows a relapsing-remitting course often requiring recurrent courses of glucocorticoids, but with low systemic inflammation during remission. NS therefore represents a useful clinical model to investigate the effects of glucocorticoids on BMD and bone geometry in childhood. METHODS Children with NS were compared to age and sex matched healthy controls. Body composition and areal BMD (whole body, lumbar spine and hip) were assessed by DXA. Peripheral quantitative computed tomography (pQCT) scans were obtained at metaphyseal (4%) and diaphyseal (66%) sites of the tibia to determine volumetric BMD and bone cross-sectional geometry. Lifetime cumulative glucocorticoid exposure was calculated from medical records. RESULTS 29 children with NS (55% male, age 10.7±3.1years) were compared to 29 healthy controls (55% male, age 11.0±3.0years). The children with NS were of similar height SDS to controls (p=0.28), but were heavier (0.65±1.28SDS vs -0.04±0.89SDS, p=0.022) and had greater body fat percentage SDS (0.31±1.01 vs -0.52±1.10, p=0.008). Tibial trabecular and cortical vBMD were similar between the two groups but bone cross-sectional area (CSA) was significantly greater in children with NS at both the metaphysis (954±234mm(2) vs 817±197mm(2), p=0.002) and diaphysis (534.9±162.7mm(2) vs 463.2±155.5mm(2), p=0.014). Endosteal and periosteal circumferences were greater in children with NS than controls (both p<0.01), resulting in reduced cortical thickness (2.4±0.7mm vs 2.8±0.7mm, p=0.018), but similar cortical CSA (p=0.22). The differences in cortical geometry were not statistically significant when weight was included as a confounding factor. There were no associations between cumulative steroid exposure, duration of NS or number of relapses and any bone parameter. CONCLUSIONS Tibial bone CSA is increased in children with NS. We speculate that this is a compensatory response to increased body weight. Defects in trabecular BMD were not identified in this cohort of children with NS.
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Affiliation(s)
- RJ Moon
- Paediatric Endocrinology, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK
- MRC Lifecourse Epidemiology Unit, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - RD Gilbert
- Paediatric Nephrology, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - A Page
- Paediatric Endocrinology, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - L Murphy
- Paediatric Endocrinology, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - P Taylor
- Osteoporosis Centre, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - C Cooper
- MRC Lifecourse Epidemiology Unit, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - EM Dennison
- MRC Lifecourse Epidemiology Unit, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - JH Davies
- Paediatric Endocrinology, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK
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Banerjee S, Basu S, Sengupta J. Vitamin D in nephrotic syndrome remission: a case-control study. Pediatr Nephrol 2013; 28:1983-9. [PMID: 23708762 DOI: 10.1007/s00467-013-2511-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 04/16/2013] [Accepted: 05/08/2013] [Indexed: 01/06/2023]
Abstract
BACKGROUND Vitamin D deficiency may contribute to osteoporosis in nephrotic syndrome (NS). METHODS A cross-sectional case-control study was performed to investigate 25 hydroxycholecalciferol [25(OH)D] status in 40 patients with NS in remission and 40 healthy controls. Serum levels of 25(OH)D, calcium, phosphate, alkaline phosphatase (ALP), and intact parathyroid hormone (PTH) were assayed. NS patients were segregated by age at onset, current age, type and duration of NS, months since relapse and current drug therapy. RESULTS Levels of 25(OH)D showed a positive correlation with months elapsed since last NS relapse (r s = +0.4, p = 0.012) and were lower in NS patients within 3 months of relapse but similar to that of controls in patients in remission for >3 months [median 14.23 (interquartile range 12.19-17.63) vs. 19.75 (14.04-28.38) ng/ml, respectively; p = 0.039]. There was no correlation of 25(OH)D levels with other disease characteristics or drug therapy. ALP levels were also lowest after relapse (r s = +0.34, p = 0.036). Overall, 25(OH)D levels of <20 ng/ml occurred in 62.5 % of NS patients + controls, and correlated negatively with age (r s = -0.24, p = 0.037) but showed no significant correlation with calcium, phosphate, or PTH levels. CONCLUSIONS In our patients with NS, vitamin D stores remained low for 3 months after NS relapse but showed an increase with longer remission time to control levels. Vitamin D stores were not influenced by disease characteristics or therapy. Longitudinal studies are required to confirm these findings and evaluate the effect of vitamin D on bones, particularly in frequent relapsers.
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Affiliation(s)
- Sushmita Banerjee
- Department of Pediatric Nephrology, Institute of Child Health, 11 Dr Biresh Guha Street, Kolkata 700017, India.
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Vitamin D bioavailability and catabolism in pediatric chronic kidney disease. Pediatr Nephrol 2013; 28:1843-53. [PMID: 23728936 PMCID: PMC4053210 DOI: 10.1007/s00467-013-2493-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Revised: 04/14/2013] [Accepted: 04/16/2013] [Indexed: 01/06/2023]
Abstract
BACKGROUND Vitamin D-binding protein (DBP) and catabolism have not been examined in the clinical setting of childhood chronic kidney disease (CKD). METHODS The concentrations of serum vitamin D {25-hydroxyvitamin D [25(OH)D], 1,25-dihydroxyvitamin D [1,25(OH)(2)D], 24,25-dihydroxyvitamin D [24,25(OH)(2)D]}, DBP, intact parathyroid hormone (iPTH), and fibroblast growth factor-23 (FGF23) were measured in 148 participants with CKD stages 2-5D secondary to congenital anomalies of the kidney/urinary tract (CAKUT), glomerulonephritis (GN), or focal segmental glomerulosclerosis (FSGS). Free and bioavailable 25(OH)D concentrations were calculated using total 25(OH)D, albumin, and DBP concentrations. RESULTS The concentrations of all vitamin D metabolites were lower with more advanced CKD (p < 0.001) and glomerular diagnoses (p ≤ 0.002). Among non-dialysis participants, DBP was lower in FSGS versus other diagnoses (FSGS-dialysis interaction p = 0.02). Winter season, older age, FSGS and GN, and higher FGF23 concentrations were independently associated with lower concentrations of free and bioavailable 25(OH)D. Black race was associated with lower total 25(OH)D and DBP, but not free or bioavailable 25(OH)D. 24,25(OH)(2)D was the vitamin D metabolite most strongly associated with iPTH. Lower 25(OH)D and higher iPTH concentrations, black race, and greater CKD severity were independently associated with lower levels of 24,25(OH)(2)D, while higher FGF23 concentrations and GN were associated with higher levels of 24,25(OH)(2)D. CONCLUSIONS Children with CKD exhibit altered catabolism and concentrations of DBP and free and bioavailable 25(OH)D, and there is an important impact of their underlying disease.
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Abstract
In recent years, reports suggesting a resurgence of vitamin D deficiency in the Western world, combined with various proposed health benefits for vitamin D supplementation, have resulted in increased interest from health care professionals, the media, and the public. The aim of this position paper is to summarise the published data on vitamin D intake and prevalence of vitamin D deficiency in the healthy European paediatric population, to discuss the health benefits of vitamin D and to provide recommendations for the prevention of vitamin D deficiency in this population. Vitamin D plays a key role in calcium and phosphate metabolism and is essential for bone health. There is insufficient evidence from interventional studies to support vitamin D supplementation for other health benefits in infants, children, and adolescents. The pragmatic use of a serum concentration >50 nmol/L to indicate sufficiency and a serum concentration <25 nmol/L to indicate severe deficiency is recommended. Vitamin D deficiency occurs commonly among healthy European infants, children, and adolescents, especially in certain risk groups, including breast-fed infants, not adhering to the present recommendation for vitamin D supplementation, children and adolescents with dark skin living in northern countries, children and adolescents without adequate sun exposure, and obese children. Infants should receive an oral supplementation of 400 IU/day of vitamin D. The implementation should be promoted and supervised by paediatricians and other health care professionals. Healthy children and adolescents should be encouraged to follow a healthy lifestyle associated with a normal body mass index, including a varied diet with vitamin D-containing foods (fish, eggs, dairy products) and adequate outdoor activities with associated sun exposure. For children in risk groups identified above, an oral supplementation of vitamin D must be considered beyond 1 year of age. National authorities should adopt policies aimed at improving vitamin D status using measures such as dietary recommendations, food fortification, vitamin D supplementation, and judicious sun exposure, depending on local circumstances.
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Denburg MR, Tsampalieros AK, de Boer IH, Shults J, Kalkwarf HJ, Zemel BS, Foerster D, Stokes D, Leonard MB. Mineral metabolism and cortical volumetric bone mineral density in childhood chronic kidney disease. J Clin Endocrinol Metab 2013; 98:1930-8. [PMID: 23547048 PMCID: PMC3644604 DOI: 10.1210/jc.2012-4188] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
CONTEXT The relationships among cortical volumetric bone mineral density (CortBMD) and comprehensive measures of mineral metabolism have not been addressed in chronic kidney disease (CKD). OBJECTIVE The aim of the study was to identify the determinants of CortBMD in childhood CKD. A secondary objective was to assess whether CortBMD was associated with subsequent fracture. DESIGN AND PARTICIPANTS This prospective cohort study included 171 children, adolescents, and young adults (aged 5-21 years) with CKD stages 2-5D at enrollment and 89 1 year later. OUTCOMES Serum measures included vitamin D [25-hydroxyvitamin D (25[OH]D), 1,25-dihydroxyvitamin D (1,25(OH)₂D), 24,25-dihydroxyvitamin D], vitamin D-binding protein, intact PTH, fibroblast growth factor 23, calcium, and phosphorus. Tibia quantitative computed tomography measures of CortBMD were expressed as sex-, race-, and age-specific Z-scores based on 675 controls. Multivariable linear regression identified the independent correlates of CortBMD Z-scores and the change in CortBMD Z-scores. RESULTS Lower calcium (β = .31/1 mg/dL, P = .01) and 25(OH)D (β = .18/10 ng/mL, P = .04) and higher PTH (β = -.02/10%, P = .002) and 1,25(OH)₂D (β = -.07/10%, P < .001) were independently associated with lower CortBMD Z-scores at baseline. The correlations of total, free, and bioavailable 25(OH)D with CortBMD did not differ. Higher baseline 1,25(OH)₂D (P < .05) and greater increases in PTH (P < .001) were associated with greater declines in CortBMD Z-scores. Greater increases in calcium concentrations were associated with greater increases in CortBMD Z-scores in growing children (interaction P = .009). The hazard ratio for fracture was 1.75 (95% confidence interval 1.15-2.67; P = .009) per SD lower baseline CortBMD. CONCLUSIONS Greater PTH and 1,25(OH)₂D and lower calcium concentrations were independently associated with baseline and progressive cortical deficits in childhood CKD. Lower CortBMD Z-score was associated with increased fracture risk.
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Affiliation(s)
- Michelle R Denburg
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.
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Tsampalieros A, Gupta P, Denburg MR, Shults J, Zemel BS, Mostoufi-Moab S, Wetzsteon RJ, Herskovitz RM, Whitehead KM, Leonard MB. Glucocorticoid effects on changes in bone mineral density and cortical structure in childhood nephrotic syndrome. J Bone Miner Res 2013; 28:480-8. [PMID: 23044926 PMCID: PMC3578070 DOI: 10.1002/jbmr.1785] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Revised: 09/14/2012] [Accepted: 09/20/2012] [Indexed: 12/13/2022]
Abstract
The impact of glucocorticoids (GC) on skeletal development has not been established. The objective of this study was to examine changes in volumetric bone mineral density (vBMD) and cortical structure over 1 year in childhood nephrotic syndrome (NS) and to identify associations with concurrent GC exposure and growth. Fifty-six NS participants, aged 5 to 21 years, were enrolled a median of 4.3 (0.5 to 8.1) years after diagnosis. Tibia peripheral quantitative computed tomography (pQCT) scans were obtained at enrollment and 6 and 12 months later. Sex, race, and age-specific Z-scores were generated for trabecular vBMD (TrabBMD-Z), cortical vBMD (CortBMD-Z), and cortical area (CortArea-Z) based on >650 reference participants. CortArea-Z was further adjusted for tibia length-for-age Z-score. Quasi-least squares regression was used to identify determinants of changes in pQCT Z-scores. At enrollment, mean TrabBMD-Z (-0.54 ± 1.32) was significantly lower (p = 0.0001) and CortBMD-Z (0.73 ± 1.16, p < 0.0001) and CortArea-Z (0.27 ± 0.91, p = 0.03) significantly greater in NS versus reference participants, as previously described. Forty-eight (86%) participants were treated with GC over the study interval (median dose 0.29 mg/kg/day). On average, TrabBMD-Z and CortBMD-Z did not change significantly over the study interval; however, CortArea-Z decreased (p = 0.003). Greater GC dose (p < 0.001), lesser increases in tibia length (p < 0.001), and lesser increases in CortArea-Z (p = 0.003) were independently associated with greater increases in CortBMD-Z. Greater increases in tibia length were associated with greater declines in CortArea-Z (p < 0.01); this association was absent in reference participants (interaction p < 0.02). In conclusion, GC therapy was associated with increases in CortBMD-Z, potentially related to suppressed bone formation and greater secondary mineralization. Conversely, greater growth and expansion of CortArea-Z (ie, new bone formation) were associated with declines in CortBMD-Z. Greater linear growth was associated with impaired expansion of cortical area in NS. Studies are needed to determine the fracture implications of these findings.
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Affiliation(s)
- Anne Tsampalieros
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON
- Department of Pediatrics, Children’s Hospital of Philadelphia, Perlman School of Medicine at the University of Pennsylvania
| | - Pooja Gupta
- Department of Internal Medicine, Emory University Hospital
| | - Michelle R Denburg
- Department of Pediatrics, Children’s Hospital of Philadelphia, Perlman School of Medicine at the University of Pennsylvania
| | - Justine Shults
- Department of Pediatrics, Children’s Hospital of Philadelphia, Perlman School of Medicine at the University of Pennsylvania
- Department of Biostatistics and Epidemiology, Perlman School of Medicine at the University of Pennsylvania
| | - Babette S Zemel
- Department of Pediatrics, Children’s Hospital of Philadelphia, Perlman School of Medicine at the University of Pennsylvania
| | - Sogol Mostoufi-Moab
- Department of Pediatrics, Children’s Hospital of Philadelphia, Perlman School of Medicine at the University of Pennsylvania
| | - Rachel J Wetzsteon
- Department of Pediatrics, Children’s Hospital of Philadelphia, Perlman School of Medicine at the University of Pennsylvania
| | - Rita M Herskovitz
- Department of Pediatrics, Children’s Hospital of Philadelphia, Perlman School of Medicine at the University of Pennsylvania
| | - Krista M Whitehead
- Department of Pediatrics, Children’s Hospital of Philadelphia, Perlman School of Medicine at the University of Pennsylvania
| | - Mary B. Leonard
- Department of Pediatrics, Children’s Hospital of Philadelphia, Perlman School of Medicine at the University of Pennsylvania
- Department of Biostatistics and Epidemiology, Perlman School of Medicine at the University of Pennsylvania
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