1
|
Wu J, Huang H, Yu X. How does Hashimoto's thyroiditis affect bone metabolism? Rev Endocr Metab Disord 2023; 24:191-205. [PMID: 36509987 DOI: 10.1007/s11154-022-09778-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/07/2022] [Indexed: 12/15/2022]
Abstract
Bone marrow contains resident cellular components that are not only involved in bone maintenance but also regulate hematopoiesis and immune responses. The immune system and bone interact with each other, coined osteoimmunology. Hashimoto's thyroiditis (HT) is one of the most common chronic autoimmune diseases which is accompanied by lymphocytic infiltration. It shows elevating thyroid autoantibody levels at an early stage and progresses to thyroid dysfunction ultimately. Different effects exert on bone metabolism during different phases of HT. In this review, we summarized the mechanisms of the long-term effects of HT on bone and the relationship between thyroid autoimmunity and osteoimmunology. For patients with HT, the bone is affected not only by thyroid function and the value of TSH, but also by the setting of the autoimmune background. The autoimmune background implies a breakdown of the mechanisms that control self-reactive system, featuring abnormal immune activation and presence of autoantibodies. The etiology of thyroid autoimmunity and osteoimmunology is complex and involves a number of immune cells, cytokines and chemokines, which regulate the pathogenesis of HT and osteoporosis at the same time, and have potential to affect each other. In addition, vitamin D works as a potent immunomodulator to influence both thyroid immunity and osteoimmunology. We conclude that HT affects bone metabolism at least through endocrine and immune pathways.
Collapse
Affiliation(s)
- Jialu Wu
- Laboratory of Endocrinology and Metabolism/Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, 37 Guoxue Lane, 610041, Chengdu, P.R. China
| | - Hui Huang
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, 37 Guoxue Lane, 610041, Chengdu, P.R. China
| | - Xijie Yu
- Laboratory of Endocrinology and Metabolism/Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, 37 Guoxue Lane, 610041, Chengdu, P.R. China.
| |
Collapse
|
2
|
Chao P, Zhang X, Zhang L, Cui X, Wang S, Yang Y. Causal effects for genetic variants of osteoprotegerin on the risk of acute myocardial infarction and coronary heart disease: A two-sample Mendelian randomization study. Front Cardiovasc Med 2023; 10:1041231. [PMID: 36960470 PMCID: PMC10028206 DOI: 10.3389/fcvm.2023.1041231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 01/26/2023] [Indexed: 03/09/2023] Open
Abstract
Although since the 1980s, the mortality of coronary heart disease(CHD) has obviously decreased due to the rise of coronary intervention, the mortality and disability of CHD were still high in some countries. Etiological studies of acute myocardial infarction(AMI) and CHD were extremely important. In this study, we used two-sample Mendelian randomization(TSMR) method to collect GWAS statistics of osteoprotegerin (OPG), AMI and CHD to reveal the causal relationship between OPG and these two diseases. In total, we identified 7 genetic variants associated with AMI and 7 genetic variants associated with CHD that were not found to be in linkage disequilibrium(LD; r 2 < 0.001). Evidence of a positive effect of an OPG genetic susceptibility on AMI was discovered(IVW OR = 0.877; 95% CI = 0.787-0.977; p = 0.017; 7 SNPs) and CHD (IVW OR = 0.892; 95% CI = 0.803-0.991; p = 0.033; 7 SNPs). After removing the influence of rs1385492, we found that there was a correlation between OPG and AMI/CHD (AMI: weighted median OR = 0.818;95% CI = 0.724-0.950; p = 0.001; 6SNPs;CHD: weighted median OR = 0.842; 95% CI = 0.755-0.938; p = 1.893 × 10-3; 6SNPs). The findings of our study indicated that OPG had a tight genetic causation association with MI or CHD. This genetic causal relationship presented us with fresh ideas for the etiology of AMI and CHD, which is an area of research that will continue in the future.
Collapse
Affiliation(s)
- Peng Chao
- Department of Cardiology, People's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang, China
| | - Xueqin Zhang
- Department of Nephropathy, People's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang, China
| | - Lei Zhang
- Department of Endocrine, People's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang, China
| | - Xinyue Cui
- Department of Nephropathy, People's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang, China
| | - Shanshan Wang
- Department of Nephropathy, People's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang, China
| | - Yining Yang
- Department of Cardiology, People's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang, China
- *Correspondence: Yining Yang,
| |
Collapse
|
3
|
Giannakopoulos A, Katsantoni E, Kritikou D, Chrysis D. Osteoprotegerin levels in children with subclinical hypothyroidism. Acta Paediatr 2020; 109:2770-2774. [PMID: 32259306 DOI: 10.1111/apa.15291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 03/23/2020] [Accepted: 03/30/2020] [Indexed: 11/27/2022]
Abstract
AIM In this study, we investigated the osteoprotegerin (OPG) and soluble receptor activator of nuclear factor-kappa Β ligand (sRANKL) serum levels in association with thyroid function in children with subclinical hypothyroidism. METHODS In 143 children and adolescents with subclinical hypothyroidism and 343 with normal thyroid function, age, height, weight and pubertal status were recorded and TSH, free thyroxine (FT4), anti-thyroid antibodies, OPG and sRANKL were measured in serum. Multiple linear regression was used for the statistical analysis with P < .05. RESULTS Children with subclinical hypothyroidism had higher TSH and lower FT4 serum levels than the control group (P < .05). Both groups had similar BMI Z-score, OPG and sRANKL serum levels. After multiple regression analysis, in children with subclinical hypothyroidism, OPG was negatively associated with FT4 (P < .05) whilst no association was observed between OPG and sRANKL, as well as between FT4 serum levels and RANKL. CONCLUSION Osteoprotegerin levels in children with subclinical hypothyroidism do not differ from those of euthyroid children. However, there is a negative association between FT4 and OPG levels observed only in the SH group. Considering the link between vascular dysfunction and alterations in osteoprotegerin levels, further research is needed to establish the role of childhood subclinical hypothyroidism in the long-term cardiovascular risk.
Collapse
Affiliation(s)
- Aristeidis Giannakopoulos
- Division of Endocrinology Department of Pediatrics Medical School University of Patras Patras Greece
| | - Elena Katsantoni
- Department of Internal Medicine Medical School University of Patras Patras Greece
| | - Dimitra Kritikou
- Division of Endocrinology Department of Pediatrics Medical School University of Patras Patras Greece
| | - Dionisios Chrysis
- Division of Endocrinology Department of Pediatrics Medical School University of Patras Patras Greece
| |
Collapse
|
4
|
Kose E, Wakabayashi H. Rehabilitation pharmacotherapy: A scoping review. Geriatr Gerontol Int 2020; 20:655-663. [PMID: 32691925 DOI: 10.1111/ggi.13975] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 05/15/2020] [Accepted: 06/01/2020] [Indexed: 12/15/2022]
Abstract
Many patients in rehabilitation facilities are affected by polypharmacy. Polypharmacy is associated with rehabilitation outcomes and functional recovery. Consequently, a combination of rehabilitation and pharmacotherapy may improve the outcomes of older people undergoing rehabilitation. A recent report described the concept of rehabilitation pharmacotherapy. The concept envisages helping frail older people and people with disabilities to achieve the highest possible body function, activity level and quality of life. There are two key tenets of rehabilitation pharmacotherapy: "pharmacotherapy in consideration of rehabilitation" and "rehabilitation in consideration of pharmacotherapy." "Pharmacotherapy in consideration of rehabilitation" includes use of drugs to treat impairment, activity limitation and participation restriction based on the International Classification of Functioning, Disability, and Health. "Rehabilitation in consideration of pharmacotherapy" refers to tailoring of rehabilitation considering the content of pharmacotherapy. With respect to drugs and motor dysfunction, anticholinergic drugs are associated with dysphagia and fractures. Increased use of potentially inappropriate medications may adversely affect the nutritional status. With respect to activities of daily living, polypharmacy and use of potentially inappropriate medications negatively affect the improvement in motor function during rehabilitation. Potent anticholinergic drugs are more likely to impede the improvement in cognitive function. In this review, we address the concept of rehabilitation pharmacotherapy and discuss its importance from the perspective of polypharmacy, the effect of drugs on disability and disease, nutritional status and activities of daily living. Geriatr Gerontol Int 2020; 20: -.
Collapse
Affiliation(s)
- Eiji Kose
- Department of Pharmacy, Teikyo University School of Medicine University Hospital, Tokyo, Japan
| | - Hidetaka Wakabayashi
- Department of Rehabilitation Medicine, Tokyo Women's Medical University Hospital, Tokyo, Japan
| |
Collapse
|
5
|
El-Adawy EH, Shaker GA, Seleem A. Relationship between subclinical hypothyroidism and serum osteoprotegerin level in type 2 diabetic patients. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2017. [DOI: 10.4103/ejim.ejim_40_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
6
|
Konca Degertekin C, Turhan Iyidir O, Aktas Yılmaz B, Elbeg S, Pasaoglu OT, Pasaoglu H, Cakır N, Arslan M. RANKL/Osteoprotegerin System and Bone Turnover in Hashimoto Thyroiditis. Calcif Tissue Int 2016; 99:365-72. [PMID: 27328677 DOI: 10.1007/s00223-016-0163-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 06/09/2016] [Indexed: 11/29/2022]
Abstract
Hypothyroidism is associated with changes in bone metabolism. The impact of hypothyroidism and the associated autoimmunity on the mediators of bone turnover in Hashimoto's thyroiditis (HT) is not known. In this study, we assessed the levels of OPG, RANKL, and IL-6 along with markers of bone formation as osteocalcin (OC) and markers of bone resorption as type 1 collagen C telopeptide (CTX) and tartrate-resistant acid phosphatase isoform 5b (TRAcP 5b) in 30 hypothyroid and 30 euthyroid premenopausal HT patients and 20 healthy premenopausal controls. We found that TRAcP 5b (p = 0.006), CTX (p = 0.01), OC (p = 0.017), and IL-6 (p < 0.001) levels were lower in the hypothyroid group compared to euthyroid HT patients and controls. OPG levels were higher (p < 0.001) and RANKL levels were lower (p = 0.021) in hypothyroid and euthyroid HT patients compared to controls. TSH was negatively correlated with IL-6 (rho = -0.434, p < 0.001), OC (rho = -0.313, p = 0.006), TRAcP 5b (rho = -0.335, p = 0.003), and positively correlated with OPG (rho = 0.248, p = 0.029). RANKL/OPG ratio was independently associated with the presence of HT. In conclusion, bone turnover is slowed down by hypothyroidism in premenopausal patients with HT. Thyroid autoimmunity might have a unique impact on OPG/RANKL levels apart from the resultant hypothyroidism.
Collapse
Affiliation(s)
- Ceyla Konca Degertekin
- Department of Endocrinology and Metabolism, Endokrinoloji ve Metabolizma BD, Gazi University Faculty of Medicine, Gazi Üniversitesi Hastanesi, 06100, Beşevler, Ankara, Turkey.
| | - Ozlem Turhan Iyidir
- Department of Endocrinology and Metabolism, Endokrinoloji ve Metabolizma BD, Gazi University Faculty of Medicine, Gazi Üniversitesi Hastanesi, 06100, Beşevler, Ankara, Turkey
| | - Banu Aktas Yılmaz
- Department of Endocrinology and Metabolism, Endokrinoloji ve Metabolizma BD, Gazi University Faculty of Medicine, Gazi Üniversitesi Hastanesi, 06100, Beşevler, Ankara, Turkey
| | - Sehri Elbeg
- Department of Biochemistry, Biyokimya AD, Gazi University Faculty of Medicine, Gazi Üniversitesi Hastanesi, 06100, Beşevler, Ankara, Turkey
| | - Ozge Tugce Pasaoglu
- Department of Biochemistry, Biyokimya AD, Gazi University Faculty of Medicine, Gazi Üniversitesi Hastanesi, 06100, Beşevler, Ankara, Turkey
| | - Hatice Pasaoglu
- Department of Biochemistry, Biyokimya AD, Gazi University Faculty of Medicine, Gazi Üniversitesi Hastanesi, 06100, Beşevler, Ankara, Turkey
| | - Nuri Cakır
- Department of Endocrinology and Metabolism, Endokrinoloji ve Metabolizma BD, Gazi University Faculty of Medicine, Gazi Üniversitesi Hastanesi, 06100, Beşevler, Ankara, Turkey
| | - Metin Arslan
- Department of Endocrinology and Metabolism, Endokrinoloji ve Metabolizma BD, Gazi University Faculty of Medicine, Gazi Üniversitesi Hastanesi, 06100, Beşevler, Ankara, Turkey
| |
Collapse
|
7
|
Zhang H, Yang Z, Zhang W, Niu Y, Li X, Qin L, Su Q. HIGHER SERUM OSTEOPROTEGERIN LEVELS IN SUBJECTS WITH THYROID NODULES. Endocr Pract 2015; 22:412-9. [PMID: 26595513 DOI: 10.4158/ep15994.or] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE A recent study demonstrated that osteoprotegerin (OPG) could be expressed both in benign and malignant thyroid tissue. However, epidemiologic studies investigating the association between serum OPG and thyroid nodules are not available. The objective of this study was to determine whether serum OPG is associated with thyroid nodules. METHODS We measured serum OPG, total triiodothyronine, total thyroxine, free triiodothyronine, free thyroxine, thyrotropin, antithyroid peroxidase antibodies, thyrotropin-receptor antibodies, antithyroglobulin antibodies, and thyroglobulin in 1,120 Chinese participants in a cross-sectional community-based study performed in downtown Shanghai. Thyroid nodule was diagnosed by thyroid ultrasonographic examination. RESULTS The serum OPG levels were significantly increased in nodule-positive subjects compared to nodule-negative subjects (2.8 ± 1.2 ng/mL versus 2.1 ± 1.0 ng/mL; P<.001). After multiple adjustments, the odds ratios were substantially higher for thyroid nodule (odds ratio, 3.09; 95% confidence interval, 1.60 to 5.97) in the highest OPG quartile compared with those in the lowest quartile. These associations remained significant after further adjustment for potential confounders. Multivariate linear regression analysis demonstrated that age (P = .015) and OPG (P = .003) were independently associated with thyroid nodule. CONCLUSION Serum OPG is elevated significantly in subjects with thyroid nodules among middle-aged and elderly individuals.
Collapse
|
8
|
Rhee CM, Brent GA, Kovesdy CP, Soldin OP, Nguyen D, Budoff MJ, Brunelli SM, Kalantar-Zadeh K. Thyroid functional disease: an under-recognized cardiovascular risk factor in kidney disease patients. Nephrol Dial Transplant 2015; 30:724-37. [PMID: 24574542 PMCID: PMC4425477 DOI: 10.1093/ndt/gfu024] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2013] [Accepted: 01/17/2014] [Indexed: 01/07/2023] Open
Abstract
Thyroid functional disease, and in particular hypothyroidism, is highly prevalent among chronic kidney disease (CKD) and end-stage renal disease (ESRD) patients. In the general population, hypothyroidism is associated with impaired cardiac contractility, endothelial dysfunction, atherosclerosis and possibly higher cardiovascular mortality. It has been hypothesized that hypothyroidism is an under-recognized, modifiable risk factor for the enormous burden of cardiovascular disease and death in CKD and ESRD, but this has been difficult to test due to the challenge of accurate thyroid functional assessment in uremia. Low thyroid hormone levels (i.e. triiodothyronine) have been associated with adverse cardiovascular sequelae in CKD and ESRD patients, but these metrics are confounded by malnutrition, inflammation and comorbid states, and hence may signify nonthyroidal illness (i.e. thyroid functional test derangements associated with underlying ill health in the absence of thyroid pathology). Thyrotropin is considered a sensitive and specific thyroid function measure that may more accurately classify hypothyroidism, but few studies have examined the clinical significance of thyrotropin-defined hypothyroidism in CKD and ESRD. Of even greater uncertainty are the risks and benefits of thyroid hormone replacement, which bear a narrow therapeutic-to-toxic window and are frequently prescribed to CKD and ESRD patients. In this review, we discuss mechanisms by which hypothyroidism adversely affects cardiovascular health; examine the prognostic implications of hypothyroidism, thyroid hormone alterations and exogenous thyroid hormone replacement in CKD and ESRD; and identify areas of uncertainty related to the interplay between hypothyroidism, cardiovascular disease and kidney disease requiring further investigation.
Collapse
Affiliation(s)
- Connie M. Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA
| | - Gregory A. Brent
- Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Departments of Medicine and Physiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Csaba P. Kovesdy
- Division of Nephrology, Memphis Veterans Affairs Medical Center, Memphis, TN, USA
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Offie P. Soldin
- Department of Medicine, Georgetown University Medical Center, Washington, DC, USA
| | - Danh Nguyen
- Department of Medicine, University of California Irvine, Orange, CA, USA
| | - Matthew J. Budoff
- Division of Cardiology, LA Biomedical Research Institute, Harbor-UCLA Medical Center, Los Angeles, CA, USA
| | - Steven M. Brunelli
- Division of Nephrology, Brigham and Women's Hospital, Boston, MA, USA
- DaVita Clinical Research, Minneapolis, MN, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA
- Department of Medicine, University of California Irvine, Orange, CA, USA
- Department of Epidemiology, UCLA School of Public Health, Los Angeles, CA, USA
| |
Collapse
|
9
|
Shinkov AD, Borissova AMI, Kovatcheva RD, Atanassova IB, Vlahov JD, Dakovska LN. Age and menopausal status affect osteoprotegerin and osteocalcin levels in women differently, irrespective of thyroid function. CLINICAL MEDICINE INSIGHTS-ENDOCRINOLOGY AND DIABETES 2014; 7:19-24. [PMID: 25125991 PMCID: PMC4125375 DOI: 10.4137/cmed.s15466] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Revised: 06/30/2014] [Accepted: 07/01/2014] [Indexed: 12/23/2022]
Abstract
Osteoprotegerin (OPG) and osteocalcin (OC) are essential bone proteins. Recent studies have demonstrated that they are not secreted solely by bone cells; they play roles in the vascular function and energy metabolism, and they are influenced by multiple factors. The aim of the current study was to investigate the influence of menopause and age on OPG and OC in women with different thyroid-stimulating hormone (TSH) levels.
Collapse
Affiliation(s)
- Alexander D Shinkov
- Medical University of Sofia, University Hospital of Endocrinology, Clinic of Thyroid and Metabolic Bone Disorders, Sofia, Bulgaria
| | - Anna-Maria I Borissova
- Medical University of Sofia, University Hospital of Endocrinology, Clinic of Thyroid and Metabolic Bone Disorders, Sofia, Bulgaria
| | - Roussanka D Kovatcheva
- Medical University of Sofia, University Hospital of Endocrinology, Clinic of Thyroid and Metabolic Bone Disorders, Sofia, Bulgaria
| | - Iliana B Atanassova
- Medical University of Sofia, University Hospital of Endocrinology, Clinic of Thyroid and Metabolic Bone Disorders, Sofia, Bulgaria
| | - Jordan D Vlahov
- Medical University of Sofia, University Hospital of Endocrinology, Clinic of Thyroid and Metabolic Bone Disorders, Sofia, Bulgaria
| | - Lilia N Dakovska
- Medical University of Sofia, University Hospital of Endocrinology, Clinic of Thyroid and Metabolic Bone Disorders, Sofia, Bulgaria
| |
Collapse
|
10
|
Abstract
Accelerated atherosclerosis and arterial stiffness are the two leading causes of increased cardiovascular disease in patients with chronic kidney disease. Dysfunctional thyroid hormone metabolism has been suggested to play a role in atherosclerosis and arterial stiffness. Changes in cardiac contractility and output, myocardial oxygen demand, systemic and peripheral vascular resistance, blood pressure and lipid profile, increased inflammatory burden and endothelial dysfunction may be responsible for thyroid hormone-related cardiovascular disease. This article focuses on the mechanistic insights of this association and provides a concise review of the current literature.
Collapse
|
11
|
Guang-da X, Hui-ling S, Jie H. Changes in endothelial function and its association with plasma osteoprotegerin in hypothyroidism with exercise-induced silent myocardial ischaemia. Clin Endocrinol (Oxf) 2008; 69:799-803. [PMID: 18410551 DOI: 10.1111/j.1365-2265.2008.03263.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Hypothyroidism is associated with an increased risk for cardiovascular disease. Exercise-induced silent myocardial ischaemia (SI) is an early stage of coronary artery disease. Recently, many studies have shown that endothelial dysfunction is an early physiological event in atherosclerosis, and osteoprotegerin (OPG) acts as an important regulatory molecule in the vasculature. The aim of this study was to investigate the alteration of endothelial function and its association with plasma OPG in hypothyroidism with SI. METHODS Forty-eight female postmenopausal hypothyroid patients with normal rest electrocardiography (ECG) were selected. Of these, 19 cases had SI. Twenty healthy females without SI were selected as controls. High-resolution ultrasound was used to measure brachial artery diameter at rest, after reactive hyperaemia and after sublingual glyceryltrinitrate (GTN). Plasma OPG concentration was measured in duplicate by a sandwich enzyme-linked immunosorbent assay (ELISA). RESULTS Flow-mediated arterial dilation (FMD) in the total hypothyroid group, the hypothyroidism with SI group and the hypothyroidism without SI group was 3.51 +/- 0.62%, 3.20 +/- 0.54% and 3.72 +/- 0.60%, respectively, significantly lower than that in the controls (5.08 +/- 0.61%) (P < 0.01). Compared with the hypothyroidism without SI group, FMD in the hypothyroidism with SI group was significantly lower (P < 0.05). Plasma OPG levels in the total hypothyroid group, patients with SI and patients without SI were significantly higher than in the control group (P < 0.05). Compared with patients without SI, OPG levels were significantly higher in patients with SI (P < 0.05). On multiple regression analysis, low density lipoprotein cholesterol (LDL-C), lipoprotein (a) [Lp(a)], C-reactive protein (CRP), OPG, TSH, free T3 (FT3) and thyroid peroxidase antibody (TPO-Ab) were found to be significant factors that were associated with FMD. Logistic analysis also showed that LDL-C, TSH, OPG, CRP and FMD were independently and significantly associated with SI in hypothyroidism. CONCLUSION Impaired endothelial function and increased levels of OPG exist in hypothyroid patients, especially those with SI. These findings support the growing concept that endothelial dysfunction may be associated with vascular disease, and subsequently elevated plasma OPG may have a role in the development of vascular dysfunction in hypothyroid patients.
Collapse
Affiliation(s)
- Xiang Guang-da
- Department of Endocrinology, Wuhan General Hospital of Guangzhou Command, Wuhan, Hubei Province, PR China.
| | | | | |
Collapse
|
12
|
OPG, RANK and RANK ligand expression in thyroid lesions. ACTA ACUST UNITED AC 2008; 148:46-53. [PMID: 18367263 DOI: 10.1016/j.regpep.2008.02.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2007] [Revised: 12/19/2007] [Accepted: 02/13/2008] [Indexed: 11/23/2022]
Abstract
Receptor activator of NF-kappaB (RANK), RANK ligand (RANKL) and osteoprotegerin (OPG) play essential roles in bone metabolism. RANKL binds to RANK, which is expressed by osteoclasts whereas OPG acts as its decoy receptor blocking the RANK-RANKL interaction. OPG/RANK/RANKL are produced by variety of tissues including epithelial and mesenchymal cells. However, the role of RANKL/OPG in thyroid pathophysiology remains unclear. The aim of this study was to determine the expression pattern of RANK/RANKL/OPG in primary neoplastic thyroid lesions and in lymph node metastases. 27 specimens from total thyroidectomy were studied by immunohistochemistry: 9 papillary carcinomas (PC), 9 medullary carcinomas (MC), 9 macrovesicular adenomas (MA). Immunohistochemical evidence of RANKL was found in 30 % of MC, 22% of PC while RANKL has never been detected in PC. The expression of RANK is closely related to RANKL. OPG was restricted to the cytoplasm of epithelial in 1 MA and 1 MC. In contrast to pathological tissues, any expression of OPG/RANK/RANKL was detected in healthy thyroid tissue. This work reveals for the first time that OPG/RANK/RANKL are expressed in the pathological thyroid gland by follicular cells, by malignant parafollicular cells as well as in metastatic lymph node microenvironment. Thus OPG/RANK/RANKL molecular triad might play a role during pathogenesis of follicular and parafollicular tumors.
Collapse
|
13
|
Manfredi E, van Zaane B, Gerdes VEA, Brandjes DPM, Squizzato A. Hypothyroidism and acquired von Willebrand's syndrome: a systematic review. Haemophilia 2008; 14:423-33. [PMID: 18218015 DOI: 10.1111/j.1365-2516.2007.01642.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Acquired von Willebrand's syndrome type I is the supposed main underlying cause of bleeding tendency in hypothyroid patients. The purpose of this systematic review was to summarize the published evidence on the association between hypothyroidism and acquired von Willebrand's syndrome. All published clinical epidemiological and interventional studies, case reports and in vitro studies that investigated the association between hypothyroidism and acquired von Willebrand's syndrome were identified by a computer-assisted search of the MEDLINE and EMBASE electronic databases. A quality assessment was performed for clinical epidemiological studies. A total of 41 papers were included. A total of 22 epidemiological in vivo studies, two in vitro studies and 47 case reports were finally analyzed. No high quality in vivo study was identified. Almost all bleeding episodes described in the case reports were mucocutaneous. von Willebrand factor (VWF) antigen value was available for 23 patients: median value 28 U/dL (range: 4-45); VWF activity was available for 24 patients: median value 28.5 U/dL (range: <3-55); factor VIII activity was available for 16 patients: median value 47 U/dL (range: 9-74). Acquired von Willebrand's syndrome may be the main factor responsible for bleeding diathesis in overt hypothyroid patients. Even if bleeding episodes are mainly mild and mucocutaneous, blood transfusion, drug administration or surgical procedure may be required.
Collapse
Affiliation(s)
- E Manfredi
- Department of Clinical Medicine, University of Insubria, Varese, Italy
| | | | | | | | | |
Collapse
|
14
|
Mikosch P, Kerschan-Schindl K, Woloszczuk W, Stettner H, Kudlacek S, Kresnik E, Gallowitsch HJ, Lind P, Pietschmann P. High cathepsin K levels in men with differentiated thyroid cancer on suppressive L-thyroxine therapy. Thyroid 2008; 18:27-33. [PMID: 18302515 DOI: 10.1089/thy.2007.0186] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Thyroid hormone administration is associated with low bone density in some studies. The aim of the present study was to evaluate the influence L-thyroxine, in doses used to treat patients with a history of thyroid carcinoma, on serum cathepsin K and other markers of bone metabolism. Cathepsin K is thought to have a role in osteoclast mediated bone resorption. METHODS A group of male patients with differentiated thyroid cancer (DTC) on suppressive L-thyroxine therapy (DTC-group; n = 51; mean age 57 years; TSH < 0.1 mU/L) was selected as a model for hyperthyroidism. The results were compared to a group of healthy euthyroid men (control-group; n = 50; mean age 58 years; TSH 1.5 +/- 0.9 mU/L). RESULTS In the DTC-group the median value of cathepsin K was 6.9 pmol/L, in the control group 4.8 pmol/L (p = 0.0052; highly significant [h.s.]). There was a significant negative correlation of cathepsin K with age (r = -0.279, p = 0.028). The analysis of various bone associated parameters revealed an increase of serum crosslaps in the DTC-group versus euthyroid controls (p = 0.03). A significant correlation could be found for cathepsin K and osteoprotegerin (p = 0.002). CONCLUSION Cathepsin K is increased by a suppressive L-thyroxine therapy and decreases with increasing age. The increased cathepsin K levels seen in DTC-patients on suppressive L-thyroxine therapy are likely to contribute to accelerated bone degradation in these patients.
Collapse
Affiliation(s)
- Peter Mikosch
- Department of Internal Medicine II, Klagenfurt State Hospital, Klagenfurt, Austria.
| | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Giusti M, Cecoli F, Fazzuoli L, De Franchis V, Ceresola E, Ferone D, Mussap M, Minuto F. Serum osteoprotegerin and soluble receptor activator of nuclear factor kappaB ligand levels in patients with a history of differentiated thyroid carcinoma: a case-controlled cohort study. Metabolism 2007; 56:699-707. [PMID: 17445547 DOI: 10.1016/j.metabol.2007.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2006] [Accepted: 12/20/2006] [Indexed: 11/28/2022]
Abstract
Overt hyperthyroidism is associated with changes in bone metabolism, whereas the effect of levothyroxine (L-T4) load in patients with differentiated thyroid carcinoma (DTC) is controversial. The aim of our study was to evaluate osteoprotegerin (OPG) and soluble receptor activator of nuclear factor kappaB ligand (RANK-L) in patients with DTC with suppressed endogenous thyrotropin due to L-T4 regimen. A cohort of 80 subjects with DTC (68 women and 12 men; age range, 27-81 years) was studied. A cohort of 55 subjects with a history of partial or total surgery for nonmalignant thyroid pathology served as a control group. Groups were matched for sex, age, and body mass index. Per-week dosage of L-T4 was significantly higher in patients with DTC than in controls (P < .001). More elevated free T(4) concentrations (P < .001) and more suppressed thyrotropin and thyroglobulin levels (P < .001) were found in subjects with DTC than in controls. No difference in serum or urinary parameters related to bone metabolism or dual-energy x-ray absorptiometry was noted between the groups. Overall, OPG levels were similar in both groups but were significantly (P = .03) lower in postmenopausal women with DTC than in postmenopausal control women. Only control women showed lower OPG levels in premenopausal than in postmenopausal (P = .002) conditions. Overall, RANK-L levels were significantly higher (P = .03) in subjects with DTC than in controls. In both groups, OPG and RANK-L levels were unrelated to each other. A significant positive correlation was seen between OPG levels and age in both subjects with DTC (P < .001) and controls (P < .001). Serum RANK-L correlated negatively with age in subjects with DTC (P = .05). Although there were several differences in L-T4 dosages, OPG and RANK-L levels were similar in patients with a history of DTC and those with a history of nonmalignant thyroid diseases. The correlation between circulating OPG and RANK-L levels was not significant. The increase in OPG with age indicates its protective role in bone loss. The cause of bone loss after long-term L-T4 load will be more extensively studied.
Collapse
Affiliation(s)
- Massimo Giusti
- UO Clinica Endocrinologica, Azienda Ospedaliera Universitaria San Martino, Genoa, Italy.
| | | | | | | | | | | | | | | |
Collapse
|
16
|
Nagasaki T, Inaba M, Shirakawa K, Hiura Y, Tahara H, Kumeda Y, Ishikawa T, Ishimura E, Nishizawa Y. Increased levels of C-reactive protein in hypothyroid patients and its correlation with arterial stiffness in the common carotid artery. Biomed Pharmacother 2007; 61:167-72. [PMID: 17383146 DOI: 10.1016/j.biopha.2006.10.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2006] [Revised: 08/08/2006] [Accepted: 10/25/2006] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Hypothyroidism is associated with increased morbidity from cardiovascular disease. The arterial stiffness index beta (stiffness beta) in the common carotid artery (CCA), which is a parameter of arterial stiffening, is known to increase in hypothyroid patients, while normalization of thyroid function for 1 year by levothyroxine (L-T(4)) replacement therapy significantly decreases CCA stiffness beta. Since serum C-reactive protein (CRP) has recently emerged as an independent factor for cardiovascular risk, the present study was designed to examine whether hypothyroidism causes an increase in CRP and whether the serum CRP level is correlated with CCA stiffness beta in hypothyroid patients. PATIENTS AND METHODS Serum CRP levels and CCA stiffness beta were determined in 46 patients with hypothyroidism and in 46 age- and sex-matched normal control subjects. Thirty-five patients were further monitored for change in CCA stiffness beta during 1 year in the euthyroid state induced by L-T(4) therapy. RESULTS Baseline CRP and CCA stiffness beta were both significantly higher in hypothyroid patients than in normal controls [1064.6+/-224.3 vs. 602.1+/-43.3 ng/ml (mean+/-SE), p<0.0001; and 9.25+/-0.84 vs. 8.21+/-0.85, p<0.05, respectively]. Baseline CRP was significantly correlated in a positive manner with baseline values of CCA stiffness beta (r=0.683, p<0.0001). In multivariate analysis, baseline CCA stiffness beta was significantly associated with baseline levels of serum CRP (r=0.740, p<0.0001). During 1 year of L-T(4) replacement therapy, significant decrease in stiffness beta (from 9.25+/-0.84 to 8.57+/-0.58, p<0.0001) to the normal levels was found. Moreover, the change in CCA stiffness beta during L-T(4) replacement therapy was significantly and independently associated in a negative fashion with baseline levels of serum CRP (r=-0.696, p=0.0002). CONCLUSIONS This study suggests that increased serum CRP might have an important independent role in increased arterial stiffening and the measurement of serum CRP is a useful predictor for the degree of improvement of arterial stiffening in hypothyroid patients.
Collapse
Affiliation(s)
- Toshiki Nagasaki
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Kiechl S, Werner P, Knoflach M, Furtner M, Willeit J, Schett G. The osteoprotegerin/RANK/RANKL system: a bone key to vascular disease. Expert Rev Cardiovasc Ther 2007; 4:801-11. [PMID: 17173497 DOI: 10.1586/14779072.4.6.801] [Citation(s) in RCA: 121] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Owing to the common coincidence of osteoporosis and vascular disease, pathophysiological links between both disorders have long been sought. The osteoprotegerin (OPG)/receptor activator of NF-kappaB (RANK)/receptor activator of NF-kappaB ligand (RANKL) cytokine network, a key regulatory system in bone homeostasis, has been implicated recently in vascular calcification, changes in matrix composition and diabetic macroangiopathy, aortic aneurysm development, heart failure and, most importantly, advanced atherosclerosis, plaque destabilization and manifestation of cardiovascular diseases. The concept of an active role of RANKL and OPG in vascular pathophysiology is intriguing and is gaining increasing support from both epidemiological and basic research. OPG serum level is considered to be a stable and reliable indicator of the overall activity of the OPG/RANK/RANKL axis and may find application as a biomarker of vascular risk and prognosis. RANKL in turn may be a suitable target for novel therapies. Pharmacological strategies for specific interference with the OPG/RANK/RANKL axis are currently being developed and evaluated in osteoporosis therapy.
Collapse
Affiliation(s)
- Stefan Kiechl
- Medical University Innsbruck, Department of Neurology, Anichstr. 35, A-6020 Innsbruck, Austria.
| | | | | | | | | | | |
Collapse
|
18
|
Mochizuki Y, Banba N, Hattori Y, Monden T. Correlation between Serum Osteoprotegerin and Biomarkers of Bone Metabolism during Anti-Thyroid Treatment in Patients with Graves’ Disease. Horm Res Paediatr 2006; 66:236-9. [PMID: 16912510 DOI: 10.1159/000095068] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2006] [Accepted: 06/23/2006] [Indexed: 11/19/2022] Open
Abstract
Bone turnover is increased in favor of resorption in hyperthyroid patients. We aimed to examine whether osteoprotegerin (OPG), which has an inhibitory effect on osteoclasts, is correlated with any biomarkers for bone turnover in Graves' disease. Twenty-one patients with Graves' disease were examined in this study, before and after treatment. Briefly, OPG, calcium, phosphorus, PTH, free T3, free T4, TSH, TSH receptor antibody and TSH-stimulating antibody were measured. Elevated serum OPG levels were decreased in accordance with anti-thyroid treatment. This change of OPG level was associated with thyroid hormone free T4 (r = 0.175, p = 0.038) but not with free T3 (r = 0.164, p = 0.052) and TSH (r = 0.046, p = 0.59). Additionally, there was a negative correlation between OPG and PTH (r = -0.37, p = 0.0001). In stepwise regression analysis, the change in serum OPG levels during anti-thyroid treatment was significantly and independently associated with PTH (F ratio = 24.4, p < 0.0001). Our findings suggest that OPG may prevent excessive bone loss in the hyperthyroid state in accordance with the change of biomarkers for bone turnover.
Collapse
Affiliation(s)
- Yasuhiro Mochizuki
- Department of Endocrinology and Metabolism, Dokkyo Medical University School of Medicine, Mibu, Tochigi, Japan
| | | | | | | |
Collapse
|
19
|
Mikosch P, Igerc I, Kudlacek S, Woloszczuk W, Gallowitsch HJ, Kresnik E, Stettner H, Grimm G, Lind P, Pietschmann P. Receptor activator of nuclear factor kappaB ligand and osteoprotegerin in men with thyroid cancer. Eur J Clin Invest 2006; 36:566-73. [PMID: 16893379 DOI: 10.1111/j.1365-2362.2006.01678.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Suppressive thyroid hormone therapy is generally a lifelong treatment for patients with differentiated thyroid cancer (DTC). However, long-standing thyrotropin (TSH) suppression is a risk factor for osteoporosis. Osteoprotegerin (OPG) and receptor activator of nuclear factor kappaB ligand (RANKL) are central regulators of bone turnover. The aim was to analyze the effects of a suppressive thyroid hormone therapy in males with DTC on the OPG/RANKL system and on bone metabolism. PATIENTS AND METHODS The OPG and soluble RANKL (sRANKL) were determined in 40 men (mean age, 53.2 years) with DTC on suppressive thyroid hormone therapy (TSH; 0.053 +/- 0.037 mU L(-1), duration 5.7 +/- 4.4 years) and 120 healthy controls matched for age. The markers of bone metabolism were C-terminal telopeptide of type I collagen in serum (sCTx) and osteocalcin (OC). RESULTS The control group had OPG values (mean +/- SD) of 1.9 +/- 1.0 pmol L(-1) and sRANKL values of 0.40 +/- 0.62 pmol L(-1). In patients with DTC, results for OPG were 3.03 +/- 1.04 pmol L(-1) (P < 0.05) and for sRANKL were 0.13 +/- 0.16 pmol L(-1) (P < 0.05). The control group presented values for sCTx of 2669 +/- 1132 pmol L(-1) and for OC of 17.89 +/- 6.5 ng mL(-1). Patients with DTC on suppressive thyroid hormone therapy had increased sCTx values of 3810 +/- 2020 pmol L(-1) (P = 0.03) but comparable OC values of 19.21 +/- 7.67 ng mL(-1) (NS). CONCLUSIONS Suppressive thyroid hormone therapy in men with DTC increased bone degradation and induced significant changes in the OPG/RANKL system. These changes include, besides the risk of osteoporosis, possible negative effects on the vascular function and an increased risk of cardiovascular disease.
Collapse
Affiliation(s)
- P Mikosch
- Department of Nuclear Medicine and Special Endocrinology, Klagenfurt State Hospital, Klagenfurt, Austria.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Guang-Da X, Hui-Ling S, Zhi-Song C, Lin-Shuang Z. Alteration of plasma concentrations of OPG before and after levothyroxine replacement therapy in hypothyroid patients. J Endocrinol Invest 2005; 28:965-72. [PMID: 16483173 DOI: 10.1007/bf03345333] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Osteoprotegerin (OPG) is a newly identified inhibitor of bone resorption. Recent studies indicate that OPG also acts as an important regulatory molecule in the vasculature. Hypothyroidism is associated with increased morbidity from cardiovascular disease. More recently, one study showed that plasma OPG increases significantly, and decreases markedly with levothyroxine (L-T4) replacement therapy in patients with overt hypothyroidism (oHT). The purpose of this study was to investigate the alteration of plasma OPG concentrations before and after L-T4 replacement therapy, and its association with endothelium-dependent arterial dilation in patients with oHT and subclinical hypothyroidism (sHT). MATERIALS AND METHODS The study subjects included 20 women with oHT, 20 women with sHT, and 20 healthy women. All patients were then given L-T4 therapy individually to maintain all serum free T3 (FT3), free T4 (FT4), and TSH near or within the respective normal ranges. Plasma OPG concentration was measured in duplicate by a sandwich ELISA method. RESULTS Plasma OPG levels in oHT and sHT patients before treatment were 3.13 +/- 0.27 and 2.95 +/- 0.24 ng/l, respectively, which were significantly higher than that in controls (2.42 +/- 0.26 ng/l) (p = 0.000). In multivariate analysis, OPG was significantly associated with TSH (r = 0.306, p < 0.05) and endothelium-dependent arterial dilation (r = -0.675, p < 0.01) at baseline. After normalization of thyroid function, OPG levels in both groups decreased markedly (2.53 +/- 0.28, 2.54 +/- 0.21 ng/l) (p = 0.000), and were very close to that in controls. The absolute changes in OPG showed significant positive correlation with the changes in TSH (p < 0.05) and negative correlation with the changes in endothelium-dependent arterial dilation (p < 0.01), and no significant correlation with other parameters in hypothyroid patients during the course of treatment. CONCLUSION The plasma OPG levels were significantly increased from hypothyroid patients, and were close to those of control subjects after normalization of thyroid function, indicating that OPG acts as an important regulatory molecule in the vasculature and, particularly, that it may be involved in the development of vascular dysfunction in hypothyroid patients.
Collapse
Affiliation(s)
- X Guang-Da
- Department of Endocrinology, Wuhan General Hospital of Guangzhou Command, Wuluo Road 627, Wuhan 430070, Hubei Province, PR China.
| | | | | | | |
Collapse
|
21
|
Guang-da X, Hui-ling S, Zhi-song C, Lin-shuang Z. Changes in plasma concentrations of osteoprotegerin before and after levothyroxine replacement therapy in hypothyroid patients. J Clin Endocrinol Metab 2005; 90:5765-8. [PMID: 16046585 DOI: 10.1210/jc.2005-0562] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Recent study has shown that overt hypothyroidism (oHT) is associated with increased plasma osteoprotegerin (OPG) levels. OBJECTIVE Our objective was to examine the plasma OPG level alteration before and after levothyroxine (L-T4) treatment in oHT and subclinical hypothyroidism (sHT). PATIENTS The study subjects included oHT and sHT patients and healthy individuals (20 subjects in each group). METHODS All patients were given L-T4 therapy to maintain a euthyroid state. Plasma OPG concentration was measured in duplicate by a sandwich ELISA. RESULTS Plasma OPG levels in oHT and sHT before treatment were significantly higher than levels in controls (P < 0.01). After normalization of thyroid function, OPG levels in both groups decreased markedly (P < 0.01). The absolute changes in OPG showed a significant positive correlation with the changes in TSH (P < 0.05) and negative correlation with the changes in endothelium-dependent arterial dilation (P < 0.01) in hypothyroid patients during the course of treatment. CONCLUSION OPG may be involved in the development of vascular dysfunction in hypothyroid patients.
Collapse
Affiliation(s)
- Xiang Guang-da
- Department of Endocrinology, Wuhan General Hospital of Guangzhou Command, Wuluo Road 627, Wuhan 430070, Hubei Province, People's Republic of China.
| | | | | | | |
Collapse
|