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Simonini M, Bologna A, Vezzoli G. Is denosumab an efficient and safe drug for osteoporosis in dialysis patients? Considerations and state of the art about its use in this setting. Int Urol Nephrol 2024; 56:3285-3293. [PMID: 38856936 DOI: 10.1007/s11255-024-04110-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 06/02/2024] [Indexed: 06/11/2024]
Abstract
PURPOSE In patients with chronic kidney disease (CKD), renal osteodystrophy may be associated with a progressive bone mass loss that increases fracture risk. Denosumab, a monoclonal antibody inhibiting osteoclast activity, is an antiresorptive medication used for the treatment osteoporosis. METHODS Its efficacy and safety were initially established in the FREEDOM study, showing a significant reduction in incident fractures in osteoporotic women treated with denosumab. Subsequent post hoc analyses showed its efficacy in patients stratified by kidney function, but these analyses did not include patients with advanced stages of CKD. The capability of denosumab in improving bone mineral density in uremic patients was evaluated in 12 studies including 461 dialysis patients with low bone mineral density. The improvement of bone mineral density was the final end point in these studies assessed during a follow-up of 6-60 months. Nine of these studies did not have hyperparathyroidism among criteria for patient inclusion and their participants may have low-turnover bone disease. Despite current recommendations, no patients underwent bone biopsy before denosumab therapy. RESULTS Overall, findings in these studies suggest that denosumab is a viable option for promoting bone mass recovery in patients with advanced stages of CKD having either high or low serum levels of PTH. However, the increase of bone mineral density was lower in patients with low serum markers of bone turnover at baseline. These studies also highlighted the need for calcium and vitamin D supplementation to prevent hypocalcemia that remains a serious concern. CONCLUSIONS Denosumab emerges as a potentially safe and effective option for enhancing bone health in CKD patients.
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Affiliation(s)
- Marco Simonini
- IRCCS San Raffaele Scientific Institute, Nephrology and Dialysis Unit, Milan, Italy
| | - Arianna Bologna
- IRCCS San Raffaele Scientific Institute, Nephrology and Dialysis Unit, Milan, Italy
- Università Vita Salute San Raffaele, Milan, Italy
| | - Giuseppe Vezzoli
- IRCCS San Raffaele Scientific Institute, Nephrology and Dialysis Unit, Milan, Italy.
- Università Vita Salute San Raffaele, Milan, Italy.
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Rougereau G, Bourdier JA, Langlais T, Boisrenoult P, Pujol N. Is there a femoral morphology at risk of a cervical or pertrochanteric fracture? Description and validation of the "Neck shaft ratio" and the "Intertrochanteric distal ratio" after analyzing a continuous cohort of 126 bilateral fractures of the proximal femur. Orthop Traumatol Surg Res 2024; 110:103874. [PMID: 38556208 DOI: 10.1016/j.otsr.2024.103874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/24/2023] [Accepted: 02/07/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND Proximal femur fractures constitute a public health concern given their high frequency and the aging population. The frequency of a contralateral fracture occurring can reach up to 15% of cases. Certain historical or demographic factors constitute risk factors for refracture, but the type of fracture, either of the femoral neck (FN) or pertrochanteric (PT), cannot be predicted. The objectives of this retrospective study were: firstly, to analyze several anatomical markers in order to determine whether they predispose to a certain type of fracture in the event of contralateral refracture, and secondly, to determine the predictive power of these possible radiological markers for the type of contralateral fracture. HYPOTHESIS The hypothesis was that the "Neck shaft ratio" (NSR) and the "Intertrochanteric distal ratio" (ITDR) made it possible to determine a proximal femoral morphology at risk of FN and/or PT fracture in the event of a second fracture. MATERIAL AND METHODS This continuous retrospective single-center series from January 2011 to December 2019 of patients who presented with bilateral fractures of the proximal femurs was analyzed. Radiographs, taken after the first fracture, of the contralateral femur were studied. Morphological measurements previously described in the literature were carried out as well as the NSR (ratio of the medial cortical thicknesses of the femoral neck at its narrowest and basicervical level) and the ITDR (ratio of the medial diaphyseal cortical thicknesses at 5mm and 20mm from the distal portion of the lesser trochanter). One hundred and twenty-six patients were included: 46/126 (36.5%) had bilateral FN, 50/126 (39.7%) bilateral PT and 30/126 (23.8%) one of each. RESULTS Only NSR and ITDR were significant predictive measures for FN or PT fracture type [0.54±0.11 vs. 0.81±0.16 (p<0.0001) and 0. 85±0.1 vs. 0.68±0.1 (p<0.0001), respectively]. These two ratios had an excellent predictive value for the type of fracture occurring on the contralateral side [NSR: AUC ROC = 0.91 (95% CI; 0.86-0.96); ITDR: AUC ROC = 0.81 (95% CI; %, 0.74-0.89)]. The NSR had excellent intra- and inter-observer reproducibility with an interclass correlation coefficient of 0.93 [95% CI: 0.86-0.97] and 0.91 [95% CI: 0.82-0.96] respectively, the same also applied for the ITDR with interclass correlation coefficient values of 0.93 [95% CI: 0.87-0.97] and 0.86 [95% CI: 0.73-0.93] respectively. DISCUSSION The NSR and ITDR ratios offer a simple and reproducible means to predict a morphological predisposition to a certain fracture type, respectively an FN and PT on the side contralateral to an initial osteoporotic proximal femur fracture. A prospective cohort study would be useful in defining a possible prognostic nature on the occurrence and/or time until refracture. LEVEL OF EVIDENCE III; retrospective control case.
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Affiliation(s)
- Grégoire Rougereau
- Service de chirurgie orthopédique et traumatologique, Hôpital Mignot, Université Versailles Saint-Quentin-en-Yvelines, Centre hospitalier de Versailles, 177, rue de Versailles, 78150 Le Chesnay-Rocquencourt, France; Service de chirurgie orthopédique, Université Sorbonne, Hôpital de la Pitié Salpêtrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France.
| | - Jean-Arthur Bourdier
- Service de chirurgie orthopédique et traumatologique, Hôpital Mignot, Université Versailles Saint-Quentin-en-Yvelines, Centre hospitalier de Versailles, 177, rue de Versailles, 78150 Le Chesnay-Rocquencourt, France
| | - Tristan Langlais
- Service de chirurgie orthopédique, Université de Toulouse, Hôpital des enfants Purpan, 330, avenue de Grande Bretagne, 31300 Toulouse, France
| | - Philippe Boisrenoult
- Service de chirurgie orthopédique et traumatologique, Hôpital Mignot, Université Versailles Saint-Quentin-en-Yvelines, Centre hospitalier de Versailles, 177, rue de Versailles, 78150 Le Chesnay-Rocquencourt, France
| | - Nicolas Pujol
- Service de chirurgie orthopédique et traumatologique, Hôpital Mignot, Université Versailles Saint-Quentin-en-Yvelines, Centre hospitalier de Versailles, 177, rue de Versailles, 78150 Le Chesnay-Rocquencourt, France
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Surowiec RK, Reul ON, Chowdhury NN, Rai RK, Segvich D, Tomaschke AA, Damrath J, Jacobson AM, Allen MR, Wallace JM. Combining raloxifene and mechanical loading improves bone composition and mechanical properties in a murine model of chronic kidney disease (CKD). Bone 2024; 183:117089. [PMID: 38575047 PMCID: PMC11210703 DOI: 10.1016/j.bone.2024.117089] [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: 01/26/2024] [Revised: 03/19/2024] [Accepted: 03/26/2024] [Indexed: 04/06/2024]
Abstract
INTRODUCTION Patients with chronic kidney disease (CKD) are at an alarming risk of fracture compared to age and sex-matched non-CKD individuals. Clinical and preclinical data highlight two key factors in CKD-induced skeletal fragility: cortical porosity and reduced matrix-level properties including bone hydration. Thus, strategies are needed to address these concerns to improve mechanical properties and ultimately lower fracture risk in CKD. We sought to evaluate the singular and combined effects of mechanical and pharmacological interventions on modulating porosity, bone hydration, and mechanical properties in CKD. METHODS Sixteen-week-old male C57BL/6J mice underwent a 10-week CKD induction period via a 0.2 % adenine-laced casein-based diet (n = 48) or remained as non-CKD littermate controls (Con, n = 48). Following disease induction (26 weeks of age), n = 7 CKD and n = 7 Con were sacrificed (baseline cohort) to confirm a steady-state CKD state was achieved prior to the initiation of treatment. At 27 weeks of age, all remaining mice underwent right tibial loading to a maximum tensile strain of 2050 μƐ 3× a week for five weeks with the contralateral limb as a non-loaded control. Half of the mice (equal number CKD and Con) received subcutaneous injections of 0.5 mg/kg raloxifene (RAL) 5× a week, and the other half remained untreated (UN). Mice were sacrificed at 31 weeks of age. Serum biochemistries were performed, and bi-lateral tibiae were assessed for microarchitecture, whole bone and tissue level mechanical properties, and composition including bone hydration. RESULTS Regardless of intervention, BUN and PTH were higher in CKD animals throughout the study. In CKD, the combined effects of loading and RAL were quantified as lower cortical porosity and improved mechanical, material, and compositional properties, including higher matrix-bound water. Loading was generally responsible for positive impacts in cortical geometry and structural mechanical properties, while RAL treatment improved some trabecular outcomes and material-level mechanical properties and was responsible for improvements in several compositional parameters. While control animals responded positively to loading, their bones were less impacted by the RAL treatment, showing no deformation, toughness, or bound water improvements which were all evident in CKD. Serum PTH levels were negatively correlated with matrix-bound water. DISCUSSION An effective treatment program to improve fracture risk in CKD ideally focuses on the cortical bone and considers both cortical porosity and matrix properties. Loading-induced bone formation and mechanical improvements were observed across groups, and in the CKD cohort, this included lower cortical porosity. This study highlights that RAL treatment superimposed on active bone formation may be ideal for reducing skeletal complications in CKD by forming new bone with enhanced matrix properties.
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Affiliation(s)
- Rachel K Surowiec
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, United States of America; Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN, United States of America; Department of Biomedical Engineering, Indiana University Purdue University Indianapolis, Indianapolis, IN, United States of America.
| | - Olivia N Reul
- Department of Biomedical Engineering, Indiana University Purdue University Indianapolis, Indianapolis, IN, United States of America.
| | - Nusaiba N Chowdhury
- Department of Biomedical Engineering, Indiana University Purdue University Indianapolis, Indianapolis, IN, United States of America.
| | - Ratan K Rai
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, IN, United States of America.
| | - Dyann Segvich
- Department of Biomedical Engineering, Indiana University Purdue University Indianapolis, Indianapolis, IN, United States of America.
| | - Andrew A Tomaschke
- Department of Biomedical Engineering, Indiana University Purdue University Indianapolis, Indianapolis, IN, United States of America.
| | - John Damrath
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, United States of America.
| | - Andrea M Jacobson
- Department of Biomedical Engineering, Indiana University Purdue University Indianapolis, Indianapolis, IN, United States of America.
| | - Matthew R Allen
- Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, IN, United States of America; Roudebush Veterans Administration Medical Center, Indianapolis, IN, United States of America.
| | - Joseph M Wallace
- Department of Biomedical Engineering, Indiana University Purdue University Indianapolis, Indianapolis, IN, United States of America.
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Khairallah P, Cherasard J, Sung J, Agarwal S, Aponte MA, Bucovsky M, Fusaro M, Silberzweig J, Frumkin GN, El Hachem K, Schulman L, McMahon D, Allen MR, Metzger CE, Surowiec RK, Wallace J, Nickolas TL. Changes in Bone Quality after Treatment with Etelcalcetide. Clin J Am Soc Nephrol 2023; 18:1456-1465. [PMID: 37574661 PMCID: PMC10637456 DOI: 10.2215/cjn.0000000000000254] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 07/31/2023] [Indexed: 08/15/2023]
Abstract
INTRODUCTION Secondary hyperparathyroidism is associated with osteoporosis and fractures. Etelcalcetide is an intravenous calcimimetic for the control of hyperparathyroidism in patients on hemodialysis. Effects of etelcalcetide on the skeleton are unknown. METHODS In a single-arm, open-label, 36-week prospective trial, we hypothesized that etelcalcetide improves bone quality and strength without damaging bone-tissue quality. Participants were 18 years or older, on hemodialysis ≥1 year, without calcimimetic exposure within 12 weeks of enrollment. We measured pretreatment and post-treatment areal bone mineral density by dual-energy X-ray absorptiometry, central skeleton trabecular microarchitecture by trabecular bone score, and peripheral skeleton volumetric bone density, geometry, microarchitecture, and estimated strength by high-resolution peripheral quantitative computed tomography. Bone-tissue quality was assessed using quadruple-label bone biopsy in a subset of patients. Paired t tests were used in our analysis. RESULTS Twenty-two participants were enrolled; 13 completed follow-up (mean±SD age 51±14 years, 53% male, and 15% White). Five underwent bone biopsy (mean±SD age 52±16 years and 80% female). Over 36 weeks, parathyroid hormone levels declined 67%±9% ( P < 0.001); areal bone mineral density at the spine, femoral neck, and total hip increased 3%±1%, 7%±2%, and 3%±1%, respectively ( P < 0.05); spine trabecular bone score increased 10%±2% ( P < 0.001); and radius stiffness and failure load trended to a 7%±4% ( P = 0.05) and 6%±4% increase ( P = 0.06), respectively. Bone biopsy demonstrated a decreased bone formation rate (mean difference -25±4 µ m 3 / µ m 2 per year; P < 0.01). CONCLUSIONS Treatment with etelcalcetide for 36 weeks was associated with improvements in central skeleton areal bone mineral density and trabecular quality and lowered bone turnover without affecting bone material properties. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER The Effect of Etelcalcetide on CKD-MBD (Parsabiv-MBD), NCT03960437.
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Affiliation(s)
| | - Jenna Cherasard
- City University of New York School of Medicine, New York, New York
| | - Joshua Sung
- Columbia University Irving Medical Center, New York, New York
| | | | | | | | | | | | - Gail N. Frumkin
- Rogosin Institute, NewYork-Presbyterian Hospital, New York, New York
| | - Karim El Hachem
- Rogosin Institute, NewYork-Presbyterian Hospital, New York, New York
| | - Linda Schulman
- Rogosin Institute, NewYork-Presbyterian Hospital, New York, New York
| | - Donald McMahon
- Columbia University Irving Medical Center, New York, New York
| | | | | | | | - Joseph Wallace
- Indiana University School of Medicine, Indianapolis, Indiana
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Fusaro M, Pereira L, Bover J. Current and Emerging Markers and Tools Used in the Diagnosis and Management of Chronic Kidney Disease-Mineral and Bone Disorder in Non-Dialysis Adult Patients. J Clin Med 2023; 12:6306. [PMID: 37834950 PMCID: PMC10573159 DOI: 10.3390/jcm12196306] [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: 08/02/2023] [Revised: 09/19/2023] [Accepted: 09/27/2023] [Indexed: 10/15/2023] Open
Abstract
Chronic kidney disease (CKD) is a significant public health concern associated with significant morbidity and has become one of the foremost global causes of death in recent years. A frequent comorbidity of CKD is secondary hyperparathyroidism (SHPT), exemplified by high serum parathyroid hormone (PTH) levels. The mineral metabolism disturbances resulting from CKD and progression to SHPT are currently considered part of the definition of chronic kidney disease-mineral and bone disorder (CKD-MBD). However, CKD-MBD does not only include abnormalities in laboratory-measured parameters; it is a complex condition characterized by dysregulation of bone turnover, mineralization, growth and strength, accompanied by vascular or another soft-tissue calcification. Together, this increases the risk of bone fractures, cardiovascular disease, and overall mortality in CKD-MBD patients. Monitoring serum markers is essential in diagnosing SHPT and CKD-MBD, and there are several recognized indicators for prognosis, optimal clinical management and treatment response in late-stage kidney disease patients receiving dialysis. However, far fewer markers have been established for patients with non-dialysis CKD. This review provides an overview of current and emerging markers and tools used in the diagnosis and management of CKD-MBD in non-dialysis adult patients.
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Affiliation(s)
- Maria Fusaro
- National Research Council (CNR)—Institute of Clinical Physiology (IFC), Via G. Moruzzi 1, 56124 Pisa, Italy
- Department of Medicine, University of Padova, Via Giustiniani, 2, 35128 Padova, Italy
| | - Luciano Pereira
- Institute of Investigation and Innovation in Health, University of Porto, 4200-135 Porto, Portugal
- INEB—National Institute of Biomedical Engineering, University of Porto, 4150-180 Porto, Portugal
- DaVita Kidney Care, 4200-448 Porto, Portugal
- Faculty of Medicine, University of Porto, 4200-250 Porto, Portugal
| | - Jordi Bover
- Nephrology Department, University Hospital Germans Trias i Pujol (HGiTP), 08916 Barcelona, Spain
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Surowiec RK, Saldivar R, Rai RK, Metzger CE, Jacobson AM, Allen MR, Wallace JM. Ex vivo exposure to calcitonin or raloxifene improves mechanical properties of diseased bone through non-cell mediated mechanisms. Bone 2023; 173:116805. [PMID: 37196853 PMCID: PMC10330631 DOI: 10.1016/j.bone.2023.116805] [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: 03/15/2023] [Revised: 05/01/2023] [Accepted: 05/12/2023] [Indexed: 05/19/2023]
Abstract
Raloxifene (RAL) reduces clinical fracture risk despite modest effects on bone mass and density. This reduction in fracture risk may be due to improved material level-mechanical properties through a non-cell mediated increase in bone hydration. Synthetic salmon calcitonin (CAL) has also demonstrated efficacy in reducing fracture risk with only modest bone mass and density improvements. This study aimed to determine if CAL could modify healthy and diseased bone through cell-independent mechanisms that alter hydration similar to RAL. 26-week-old male C57BL/6 mice induced with chronic kidney disease (CKD) beginning at 16 weeks of age via 0.2 % adenine-laced casein-based (0.9 % P, 0.6 % C) chow, and their non-CKD control littermates (Con), were utilized. Upon sacrifice, right femora were randomly assigned to the following ex vivo experimental groups: RAL (2 μM, n = 10 CKD, n = 10 Con), CAL (100 nM, n = 10 CKD, n = 10 Con), or Vehicle (VEH; n = 9 CKD, n = 9 Con). Bones were incubated in PBS + drug solution at 37 °C for 14 days using an established ex vivo soaking methodology. Cortical geometry (μCT) was used to confirm a CKD bone phenotype, including porosity and cortical thinning, at sacrifice. Femora were assessed for mechanical properties (3-point bending) and bone hydration (via solid state nuclear magnetic resonance spectroscopy with magic angle spinning (ssNMR)). Data were analyzed by two-tailed t-tests (μCT) or 2-way ANOVA for main effects of disease, treatment, and their interaction. Tukey's post hoc analyses followed a significant main effect of treatment to determine the source of the effect. Imaging confirmed a cortical phenotype reflective of CKD, including lower cortical thickness (p < 0.0001) and increased cortical porosity (p = 0.02) compared to Con. In addition, CKD resulted in weaker, less deformable bones. In CKD bones, ex vivo exposure to RAL or CAL improved total work (+120 % and +107 %, respectively; p < 0.05), post-yield work (+143 % and +133 %), total displacement (+197 % and +229 %), total strain (+225 % and +243 %), and toughness (+158 % and +119 %) vs. CKD VEH soaked bones. Ex vivo exposure to RAL or CAL did not impact any mechanical properties in Con bone. Matrix-bound water by ssNMR showed CAL treated bones had significantly higher bound water compared to VEH treated bones in both CKD and Con cohorts (p = 0.001 and p = 0.01, respectively). RAL positively modulated bound water in CKD bone compared to VEH (p = 0.002) but not in Con bone. There were no significant differences between bones soaked with CAL vs. RAL for any outcomes measured. RAL and CAL improve important post-yield properties and toughness in a non-cell mediated manner in CKD bone but not in Con bones. While RAL treated CKD bones had higher matrix-bound water content in line with previous reports, both Con and CKD bones exposed to CAL had higher matrix-bound water. Therapeutic modulation of water, specifically the bound water fraction, represents a novel approach to improving mechanical properties and potentially reducing fracture risk.
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Affiliation(s)
- Rachel K Surowiec
- Department of Biomedical Engineering, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA; Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Rosario Saldivar
- Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, IN, USA; Department of Epidemiology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ratan K Rai
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Corinne E Metzger
- Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Andrea M Jacobson
- Department of Biomedical Engineering, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA.
| | - Matthew R Allen
- Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, IN, USA; Roudebush Veterans Administration Medical Center, Indianapolis, IN, USA.
| | - Joseph M Wallace
- Department of Biomedical Engineering, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA.
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Newman CL, Surowiec RK, Swallow EA, Metzger CE, Kim J, Tomaschke AA, Chen NX, Allen MR, Wallace JM, Moe SM, Wu YC, Niziolek PJ. Assessing cortical bone porosity with MRI in an animal model of chronic kidney disease. Bone 2023; 173:116808. [PMID: 37207990 PMCID: PMC11167728 DOI: 10.1016/j.bone.2023.116808] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 05/07/2023] [Accepted: 05/15/2023] [Indexed: 05/21/2023]
Abstract
Chronic kidney disease (CKD) is characterized by secondary hyperparathyroidism and an increased risk of hip fractures predominantly related to cortical porosity. Unfortunately, bone mineral density measurements and high-resolution peripheral computed tomography (HR-pQCT) imaging have shortcomings that limit their utility in these patients. Ultrashort echo time magnetic resonance imaging (UTE-MRI) has the potential to overcome these limitations by providing an alternative assessment of cortical porosity. The goal of the current study was to determine if UTE-MRI could detect changes in porosity in an established rat model of CKD. Cy/+ rats (n = 11), an established animal model of CKD-MBD, and their normal littermates (n = 12) were imaged using microcomputed tomography (microCT) and UTE-MRI at 30 and 35 weeks of age (which approximates late-stage kidney disease in humans). Images were obtained at the distal tibia and the proximal femur. Cortical porosity was assessed using the percent porosity (Pore%) calculated from microCT imaging and the porosity index (PI) calculated from UTE-MRI. Correlations between Pore% and PI were also calculated. Cy/+ rats had higher Pore% than normal rats at both skeletal sites at 35 weeks (tibia = 7.13 % +/- 5.59 % vs. 0.51 % +/- 0.09 %, femur = 19.99 % +/- 7.72 % vs. 2.72 % +/- 0.32 %). They also had greater PI at the distal tibia at 30 weeks of age (0.47 +/- 0.06 vs. 0.40 +/- 0.08). However, Pore% and PI were only correlated in the proximal femur at 35 weeks of age (ρ = 0.929, Spearman). These microCT results are consistent with prior studies in this animal model utilizing microCT imaging. The UTE-MRI results were inconsistent, resulting in variable correlations with microCT imaging, which may be related to suboptimal bound and pore water discrimination at higher magnetic field strengths. Nevertheless, UTE-MRI may still provide an additional clinical tool to assess fracture risk without using ionizing radiation in CKD patients.
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Affiliation(s)
- Christopher L Newman
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN, United States of America.
| | - Rachel K Surowiec
- Department of Biomedical Engineering, Indiana University-Purdue University, Indianapolis, Indianapolis, IN, United States of America
| | | | - Corinne E Metzger
- Wu Tsai Neurosciences Institute, Stanford University, Stanford, CA, United States of America
| | - Jieun Kim
- Wu Tsai Neurosciences Institute, Stanford University, Stanford, CA, United States of America
| | - Andrew A Tomaschke
- Department of Biomedical Engineering, Indiana University-Purdue University, Indianapolis, Indianapolis, IN, United States of America
| | - Neal X Chen
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Matthew R Allen
- Department of Biomedical Engineering, Indiana University-Purdue University, Indianapolis, Indianapolis, IN, United States of America; Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, IN, United States of America; Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Joseph M Wallace
- Department of Biomedical Engineering, Indiana University-Purdue University, Indianapolis, Indianapolis, IN, United States of America
| | - Sharon M Moe
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Yu-Chien Wu
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Paul J Niziolek
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN, United States of America
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8
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Heilbronner AK, Koff MF, Breighner R, Kim HJ, Cunningham M, Lebl DR, Dash A, Clare S, Blumberg O, Zaworski C, McMahon DJ, Nieves JW, Stein EM. Opportunistic Evaluation of Trabecular Bone Texture by MRI Reflects Bone Mineral Density and Microarchitecture. J Clin Endocrinol Metab 2023; 108:e557-e566. [PMID: 36800234 PMCID: PMC10516518 DOI: 10.1210/clinem/dgad082] [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: 10/31/2022] [Revised: 01/13/2023] [Accepted: 02/08/2023] [Indexed: 02/18/2023]
Abstract
CONTEXT Many individuals at high risk for fracture are never evaluated for osteoporosis and subsequently do not receive necessary treatment. Utilization of magnetic resonance imaging (MRI) is burgeoning, providing an ideal opportunity to use MRI to identify individuals with skeletal deficits. We previously reported that MRI-based bone texture was more heterogeneous in postmenopausal women with a history of fracture compared to controls. OBJECTIVE The present study aimed to identify the microstructural characteristics that underlie trabecular texture features. METHODS In a prospective cohort, we measured spine volumetric bone mineral density (vBMD) by quantitative computed tomography (QCT), peripheral vBMD and microarchitecture by high-resolution peripheral QCT (HRpQCT), and areal BMD (aBMD) by dual-energy x-ray absorptiometry. Vertebral trabecular bone texture was analyzed using T1-weighted MRIs. A gray level co-occurrence matrix was used to characterize the distribution and spatial organization of voxelar intensities and derive the following texture features: contrast (variability), entropy (disorder), angular second moment (ASM; uniformity), and inverse difference moment (IDM; local homogeneity). RESULTS Among 46 patients (mean age 64, 54% women), lower peripheral vBMD and worse trabecular microarchitecture by HRpQCT were associated with greater texture heterogeneity by MRI-higher contrast and entropy (r ∼ -0.3 to 0.4, P < .05), lower ASM and IDM (r ∼ +0.3 to 0.4, P < .05). Lower spine vBMD by QCT was associated with higher contrast and entropy (r ∼ -0.5, P < .001), lower ASM and IDM (r ∼ +0.5, P < .001). Relationships with aBMD were less pronounced. CONCLUSION MRI-based measurements of trabecular bone texture relate to vBMD and microarchitecture, suggesting that this method reflects underlying microstructural properties of trabecular bone. Further investigation is required to validate this methodology, which could greatly improve identification of patients with skeletal fragility.
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Affiliation(s)
- Alison K Heilbronner
- Division of Endocrinology/Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY 10021, USA
| | - Matthew F Koff
- Department of Radiology and Imaging—MRI, Hospital for Special Surgery, New York, NY 10021, USA
| | - Ryan Breighner
- Department of Radiology and Imaging—MRI, Hospital for Special Surgery, New York, NY 10021, USA
| | - Han Jo Kim
- Spine Service, Hospital for Special Surgery, New York, NY 10021, USA
| | | | - Darren R Lebl
- Spine Service, Hospital for Special Surgery, New York, NY 10021, USA
| | - Alexander Dash
- Division of Endocrinology/Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY 10021, USA
| | - Shannon Clare
- Division of Endocrinology/Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY 10021, USA
| | - Olivia Blumberg
- Division of Endocrinology/Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY 10021, USA
| | - Caroline Zaworski
- Division of Endocrinology/Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY 10021, USA
| | - Donald J McMahon
- Division of Endocrinology/Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY 10021, USA
| | - Jeri W Nieves
- Division of Endocrinology/Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY 10021, USA
- Mailman School of Public Health and Institute of Human Nutrition, Columbia University, New York, NY 10032, USA
| | - Emily M Stein
- Division of Endocrinology/Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY 10021, USA
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9
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Levy RV, McMahon DJ, Agarwal S, Dempster D, Zhou H, Misof BM, Guo X, Kamanda-Kosseh M, Aponte MA, Reidy K, Kumar J, Fusaro M, Brown DD, Melamed ML, Nickolas TL. Comprehensive Associations between Acidosis and the Skeleton in Patients with Kidney Disease. J Am Soc Nephrol 2023; 34:668-681. [PMID: 36749125 PMCID: PMC10103353 DOI: 10.1681/asn.0000000000000085] [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: 12/22/2022] [Accepted: 01/10/2023] [Indexed: 02/08/2023] Open
Abstract
SIGNIFICANCE STATEMENT Renal osteodystrophy (ROD) contributes substantially to morbidity in CKD, including increased fracture risk. Metabolic acidosis (MA) contributes to the development of ROD, but an up-to-date skeletal phenotype in CKD-associated acidosis has not been described. We comprehensively studied associations between acidosis and bone in patients with CKD using advanced methods to image the skeleton and analyze bone-tissue, along with biochemical testing. Cross-sectionally, acidosis was associated with higher markers of bone remodeling and female-specific impairments in cortical and trabecular bone quality. Prospectively, acidosis was associated with cortical expansion and trabecular microarchitectural deterioration. At the bone-tissue level, acidosis was associated with deficits in bone mineral content. Future work investigating acidosis correction on bone quality is warranted. BACKGROUND Renal osteodystrophy is a state of impaired bone quality and strength. Metabolic acidosis (MA) is associated with alterations in bone quality including remodeling, microarchitecture, and mineralization. No studies in patients with CKD have provided a comprehensive multimodal skeletal phenotype of MA. We aim to describe the structure and makeup of bone in patients with MA in the setting of CKD using biochemistry, noninvasive imaging, and histomorphometry. METHODS The retrospective cross-sectional analyses included 180 patients with CKD. MA was defined as bicarbonate ≤22 mEq/L. We evaluated circulating bone turnover markers and skeletal imaging with dual energy x-ray absorptiometry and high-resolution peripheral computed tomography. A subset of 54 participants had follow-up. We assessed associations between baseline and change in bicarbonate with change in bone outcomes. Histomorphometry, microCT, and quantitative backscatter electron microscopy assessed bone biopsy outcomes in 22 participants. RESULTS The mean age was 68±10 years, 54% of participants were male, and 55% were White. At baseline, acidotic subjects had higher markers of bone turnover, lower areal bone mineral density at the radius by dual energy x-ray absorptiometry, and lower cortical and trabecular volumetric bone mineral density and impaired trabecular microarchitecture. Over time, acidosis was associated with opposing cortical and trabecular effects: cortical expansion but trabecular deterioration. Bone-tissue analyses showed reduced tissue mineral density with increased heterogeneity of calcium distribution in acidotic participants. CONCLUSIONS MA is associated with multiple impairments in bone quality. Future work should examine whether correction of acidosis improves bone quality and strength in patients with CKD.
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Affiliation(s)
- Rebecca V. Levy
- Nephrology, Department of Medicine, University of Rochester Medical Center Rochester, New York, USA
- Pediatric Nephrology, Department of Pediatrics, University of Rochester Medical Center, Rochester, New York, USA
| | | | | | - David Dempster
- Columbia University Irving Medical Center, New York, USA
| | - Hua Zhou
- Columbia University Irving Medical Center, New York, USA
| | - Barbara M. Misof
- Ludwig Boltzmann Institute for Osteology at the Hanusch Hospital of OEGK and AUVA Trauma Centre Meidling, 1st Medical Department, Hanusch Hospital, Vienna, Austria
| | - X.E. Guo
- Columbia University Biomedical Engineering, New York, New York, USA
| | | | | | - Kimberly Reidy
- Nephrology, Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
| | - Juhi Kumar
- Nephrology, Department of Pediatrics, Weill-Cornell Medical Center, New York, New York
| | - Maria Fusaro
- National Research Council (CNR), Institute of Clinical Physiology (IFC), Pisa, Italy
- Department of Medicine, University of Padova, Padova, Padua, Italy
| | - Denver D. Brown
- Division of Nephrology, Children's National Hospital, Washington, DC
| | - Michal L. Melamed
- Nephrology, Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
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10
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Mouse Models of Mineral Bone Disorders Associated with Chronic Kidney Disease. Int J Mol Sci 2023; 24:ijms24065325. [PMID: 36982400 PMCID: PMC10048881 DOI: 10.3390/ijms24065325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 02/27/2023] [Accepted: 03/03/2023] [Indexed: 03/14/2023] Open
Abstract
Patients with chronic kidney disease (CKD) inevitably develop mineral and bone disorders (CKD–MBD), which negatively impact their survival and quality of life. For a better understanding of underlying pathophysiology and identification of novel therapeutic approaches, mouse models are essential. CKD can be induced by surgical reduction of a functional kidney mass, by nephrotoxic compounds and by genetic engineering specifically interfering with kidney development. These models develop a large range of bone diseases, recapitulating different types of human CKD–MBD and associated sequelae, including vascular calcifications. Bones are usually studied by quantitative histomorphometry, immunohistochemistry and micro-CT, but alternative strategies have emerged, such as longitudinal in vivo osteoblast activity quantification by tracer scintigraphy. The results gained from the CKD–MBD mouse models are consistent with clinical observations and have provided significant knowledge on specific pathomechanisms, bone properties and potential novel therapeutic strategies. This review discusses available mouse models to study bone disease in CKD.
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11
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Haarhaus M, Aaltonen L, Cejka D, Cozzolino M, de Jong RT, D'Haese P, Evenepoel P, Lafage-Proust MH, Mazzaferro S, McCloskey E, Salam S, Skou Jørgensen H, Vervloet M. Management of fracture risk in CKD-traditional and novel approaches. Clin Kidney J 2023; 16:456-472. [PMID: 36865010 PMCID: PMC9972845 DOI: 10.1093/ckj/sfac230] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Indexed: 11/13/2022] Open
Abstract
The coexistence of osteoporosis and chronic kidney disease (CKD) is an evolving healthcare challenge in the face of increasingly aging populations. Globally, accelerating fracture incidence causes disability, impaired quality of life and increased mortality. Consequently, several novel diagnostic and therapeutic tools have been introduced for treatment and prevention of fragility fractures. Despite an especially high fracture risk in CKD, these patients are commonly excluded from interventional trials and clinical guidelines. While management of fracture risk in CKD has been discussed in recent opinion-based reviews and consensus papers in the nephrology literature, many patients with CKD stages 3-5D and osteoporosis are still underdiagnosed and untreated. The current review addresses this potential treatment nihilism by discussing established and novel approaches to diagnosis and prevention of fracture risk in patients with CKD stages 3-5D. Skeletal disorders are common in CKD. A wide variety of underlying pathophysiological processes have been identified, including premature aging, chronic wasting, and disturbances in vitamin D and mineral metabolism, which may impact bone fragility beyond established osteoporosis. We discuss current and emerging concepts of CKD-mineral and bone disorders (CKD-MBD) and integrate management of osteoporosis in CKD with current recommendations for management of CKD-MBD. While many diagnostic and therapeutic approaches to osteoporosis can be applied to patients with CKD, some limitations and caveats need to be considered. Consequently, clinical trials are needed that specifically study fracture prevention strategies in patients with CKD stages 3-5D.
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Affiliation(s)
- Mathias Haarhaus
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
- Diaverum Sweden, Malmö, Sweden
| | - Louise Aaltonen
- Turku University Hospital, Kidney Center, Department of Medicine, Turku, Finland
| | - Daniel Cejka
- Department of Medicine III – Nephrology, Hypertension, Transplantation, Rheumatology, Geriatrics, Ordensklinikum Linz - Elisabethinen Hospital, Linz, Austria
| | - Mario Cozzolino
- Department of Health Sciences, Renal Division, University of Milan, ASST Santi Paolo e Carlo, Milan, Italy
| | - Renate T de Jong
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Internal Medicine and Endocrinology, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism Institute, Amsterdam, The Netherlands
| | - Patrick D'Haese
- Laboratory of Pathophysiology, Department of Biomedical Sciences, University of Antwerp, Antwerp, Belgium
| | - Pieter Evenepoel
- Department of Nephrology, University Hospitals Leuven, Leuven, Belgium
- Department of Microbiology Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven-University of Leuven, Leuven, Belgium
| | | | - Sandro Mazzaferro
- Nephrology Unit at Policlinico Umberto I Hospital and Department of Translation and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Eugene McCloskey
- Academic Unit of Bone Metabolism, Centre for Integrated research in Musculoskeletal Ageing, Mellanby Centre for Musculoskeletal Research, Department of Oncology & Metabolism, University of Sheffield, Sheffield, UK
| | - Syazrah Salam
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK and Sheffield Kidney Institute, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Hanne Skou Jørgensen
- Department of Microbiology Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven-University of Leuven, Leuven, Belgium
- Aarhus University Hospital, Department of Kidney Diseases, Aarhus,Denmark
- Aarhus University, Department of Clinical Medicine, Aarhus,Denmark
| | - Marc Vervloet
- Department of Nephrology, Amsterdam University Medical Center, VU University Amsterdam, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, Amsterdam, The Netherlands
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12
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Aleksova J, Ebeling PR, Milat F, Elder GJ. DXA-derived advanced hip analysis and the trabecular bone score in end-stage kidney disease secondary to type 1 diabetes. Eur J Endocrinol 2022; 187:883-892. [PMID: 36315195 DOI: 10.1530/eje-22-0687] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 10/31/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Patients with end-stage kidney disease (ESKD) caused by type 1 diabetes mellitus (T1DM) have a heightened fracture risk. Bone mineral density (BMD) may predict fracture less accurately in ESKD than in patients with chronic kidney disease (CKD) stages 1-3b or the general population. Alternate, readily available imaging modalities are needed to improve ESKD fracture risk assessment. This study aimed to assess dual-energy X-ray absorptiometry (DXA)-derived BMD, the trabecular bone score (TBS) and advanced hip analysis parameters in patients with ESKD due to T1DM and to compare their results with those of patients with ESKD from other causes. METHODS We compared the DXA-derived TBS, hip cortical thickness (CT) and femoral neck (FN) buckling ratio (BR), an index of FN stability, of patients with T1DM and ESKD undergoing simultaneous pancreas kidney transplantation, patients with ESKD from other causes receiving kidney transplants and population reference ranges. RESULTS Of 227 patients with ESKD, 28% had T1DM and 65% were male. Compared with other ESKD patients, patients with T1DM were younger (42 ± 7.7 vs 51 ± 13.8 years), had shorter dialysis duration (24.4 ± 21 vs 42.6 ± 40 months), had higher HbA1c (7.9 ± 1.57% vs 5.4 ± 0.95%) and had lower BMI (25 ± 6 vs 27 ± 5 kg/m2). They had lower spine, hip and UD radius BMD Z-scores (all P ≤ 0.001), TBS (1.33 ± 0.12 vs 1.36 ± 0.12; P = 0.05), CT at the FN (P = 0.03), calcar (P = 0.006) and shaft (P < 0.001) and higher BR (10.1±7.1 vs 7.7±4; P = 0.006). All ESKD parameters were lower than population-based reference ranges (P < 0.001). Adjusting for age, sex, dialysis vintage and weight, prevalent vertebral fractures in patients with T1DM and ESKD were associated with higher BR (odds ratio (OR): 3.27 (95% CI: 1.19-8.92), P = 0.002) and lower FN CT (OR: 3.70 (95% CI: 1.13-12.50)). CONCLUSION Patients with ESKD and T1DM have reduced TBS, reduced CT and increased BR compared with other ESKD patients. Prospective study of these parameters is warranted to determine their utility in fracture risk prediction and management. SIGNIFICANCE STATEMENT Patients with ESKD and T1DM have an elevated fracture risk due to decreased bone strength. As an adjunct to BMD, evaluating dual-energy X-ray absorptiometry parameters that incorporate structural change may have greater value in patients with ESKD and T1DM than in the general population. In this study, patients with ESKD due to T1DM had lower BMD, lower trabecular bone scores, more severe loss of CT and higher BR than other patients with ESKD and people from the general population. Both lower CT and higher BR were associated with prevalent vertebral fractures in patients with T1DM and ESKD. Changes to these parameters should be evaluated for incident fracture prediction.
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Affiliation(s)
- Jasna Aleksova
- Hudson Institute for Medical Research
- Department of Medicine, Monash University
- Department of Endocrinology, Monash Health
| | - Peter R Ebeling
- Department of Medicine, Monash University
- Department of Endocrinology, Monash Health
| | - Frances Milat
- Hudson Institute for Medical Research
- Department of Medicine, Monash University
- Department of Endocrinology, Monash Health
| | - Grahame J Elder
- Department of Renal Medicine, Westmead Hospital
- Skeletal Biology Program, Garvan Institute of Medical Research
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13
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Cirovic A, Denic A, Clarke BL, Vassallo R, Cirovic A, Landry GM. A hypoxia-driven occurrence of chronic kidney disease and osteoporosis in COPD individuals: New insights into environmental cadmium exposure. Toxicology 2022; 482:153355. [DOI: 10.1016/j.tox.2022.153355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 10/14/2022] [Accepted: 10/15/2022] [Indexed: 11/07/2022]
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14
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Damrath JG, Metzger CE, Allen MR, Wallace JM. A novel murine model of combined insulin-dependent diabetes and chronic kidney disease has greater skeletal detriments than either disease individually. Bone 2022; 165:116559. [PMID: 36116758 PMCID: PMC9798592 DOI: 10.1016/j.bone.2022.116559] [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: 06/24/2022] [Revised: 09/11/2022] [Accepted: 09/13/2022] [Indexed: 12/31/2022]
Abstract
Diabetes and chronic kidney disease (CKD) consistently rank among the top ten conditions in prevalence and mortality in the United States. Insulin-dependent diabetes (IDD) and CKD each increase the risk of skeletal fractures and fracture-related mortality. However, it remains unknown whether these conditions have interactive end-organ effects on the skeleton. We hypothesized that combining IDD and CKD in mice would cause structural and mechanical bone alterations that are more deleterious compared to the single disease states. Female C57BL6/J mice were divided into four groups: 1) N = 12 Control (CTRL), 2) N = 10 Streptozotocin-induced IDD (STZ), 3) N = 10 Adenine diet-induced CKD (AD), and 4) N = 9 Combination (STZ+AD). STZ administration resulted in significantly higher blood glucose, HbA1c (p < 0.0001), and glucose intolerance (p < 0.0001). AD resulted in higher blood urea nitrogen (p = 0.0002) while AD, but not STZ+AD mice, had high serum parathyroid hormone (p < 0.0001) and phosphorus (p = 0.0005). STZ lowered bone turnover (p = 0.001). Trabecular bone volume was lowered by STZ (p < 0.0001) and increased by AD (p = 0.003). Tissue mineral density was lowered by STZ (p < 0.0001) and AD (p = 0.02) in trabecular bone but only lowered by STZ in cortical bone (p = 0.002). Cortical porosity of the proximal tibia was increased by AD, moment of inertia was lower in both disease groups, and most cortical properties were lower in all groups vs CTRL. Ultimate force, stiffness, toughness, and total displacement/strain were lowered by STZ and AD. Fracture toughness was lower by AD (p = 0.003). Importantly, Cohen's D indicated that STZ+AD most strongly lowered bone turnover and mechanical properties. Taken together, structural and material-level bone properties are altered by STZ and AD while their combination resulted in greater detriments, indicating that improving bone health in the combined disease state may require novel interventions.
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Affiliation(s)
- John G Damrath
- Purdue University, Weldon School of Biomedical Engineering, West Lafayette, IN, United States
| | - Corinne E Metzger
- Indiana University School of Medicine, Department of Anatomy and Cell Biology, Indianapolis, IN, United States
| | - Matthew R Allen
- Indiana University School of Medicine, Department of Anatomy and Cell Biology, Indianapolis, IN, United States
| | - Joseph M Wallace
- Indiana University-Purdue University at Indianapolis, Department of Biomedical Engineering, Indianapolis, IN, United States.
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15
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Abdalbary M, Sobh M, Elnagar S, Elhadedy MA, Elshabrawy N, Abdelsalam M, Asadipooya K, Sabry A, Halawa A, El-Husseini A. Management of osteoporosis in patients with chronic kidney disease. Osteoporos Int 2022; 33:2259-2274. [PMID: 35748896 DOI: 10.1007/s00198-022-06462-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 05/31/2022] [Indexed: 12/19/2022]
Abstract
Patients with CKD have a 4-fivefold higher rate of fractures. The incidence of fractures increases with deterioration of kidney function. The process of skeletal changes in CKD patients is characterized by compromised bone strength because of deterioration of bone quantity and/or quality. The fractures lead to a deleterious effect on the quality of life and higher mortality in patients with CKD. The pathogenesis of bone loss and fracture is complex and multi-factorial. Renal osteodystrophy, uremic milieu, drugs, and systemic diseases that lead to renal failure all contribute to bone damage in CKD patients. There is no consensus on the optimal diagnostic method of compromised bone assessment in patients with CKD. Bone quantity and mass can be assessed by dual-energy x-ray absorptiometry (DXA) or quantitative computed tomography (QCT). Bone quality on the other side can be assessed by non-invasive methods such as trabecular bone score (TBS), high-resolution bone imaging methods, and invasive bone biopsy. Bone turnover markers can reflect bone remodeling, but some of them are retained by kidneys. Understanding the mechanism of bone loss is pivotal in preventing fracture in patients with CKD. Several non-pharmacological and therapeutic interventions have been reported to improve bone health. Controlling laboratory abnormalities of CKD-MBD is crucial. Anti-resorptive therapies are effective in improving BMD and reducing fracture risk, but there are uncertainties about safety and efficacy especially in advanced CKD patients. Accepting the prevalent of low bone turnover in patients with advanced CKD, the osteo-anabolics are possibly promising. Parathyroidectomy should be considered a last resort for intractable cases of renal hyperparathyroidism. There is a wide unacceptable gap in osteoporosis management in patients with CKD. This article is focusing on the updated management of CKD-MBD and osteoporosis in CKD patients. Chronic kidney disease deteriorates bone quality and quantity. The mechanism of bone loss mainly determines pharmacological treatment. DXA and QCT provide information about bone quantity, but assessing bone quality, by TBS, high-resolution bone imaging, invasive bone biopsy, and bone turnover markers, can guide us about the mechanism of bone loss.
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Affiliation(s)
- M Abdalbary
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, 800 Rose Street, Room MN-560, Lexington, KY, 40536-0298, USA
| | - M Sobh
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - S Elnagar
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - M A Elhadedy
- Nephrology and Transplantation Unit, Mansoura Urology and Nephrology Center, Mansoura, Egypt
| | - N Elshabrawy
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - M Abdelsalam
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - K Asadipooya
- Division of Endocrinology, University of Kentucky, Lexington, USA
| | - A Sabry
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - A Halawa
- Sheffield Teaching Hospital, University of Liverpool, Liverpool, UK
| | - A El-Husseini
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, 800 Rose Street, Room MN-560, Lexington, KY, 40536-0298, USA.
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16
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Bobillier A, Wagner P, Whittier DE, Ecochard R, Boyd SK, Chapurlat R, Szulc P. Association of Vitamin D and Parathyroid Hormone Status With the Aging-Related Decline of Bone Microarchitecture in Older Men: The Prospective Structure of Aging Men's Bones (STRAMBO) Study. J Bone Miner Res 2022; 37:1903-1914. [PMID: 35880628 DOI: 10.1002/jbmr.4657] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 06/20/2022] [Accepted: 07/21/2022] [Indexed: 11/11/2022]
Abstract
Poor vitamin D status and high parathyroid hormone (PTH) level are associated with impaired bone microarchitecture, but these data are mainly cross-sectional. We studied the association of the baseline PTH and 25-hydroxycholecalciferol (25OHD) levels with the prospectively assessed deterioration of bone microarchitecture and in estimated bone strength in older men. Distal radius and tibia bone microarchitecture was assessed by high-resolution peripheral quantitative computed tomography (HR-pQCT) at baseline, then after 4 and 8 years in 826 men aged 60-87 years. At distal radius, total bone mineral density (Tt.BMD), cortical thickness (Ct.Thd ), cortical area (Ct.Ar), cortical BMD (Ct.BMD), and trabecular BMD (Tb.BMD) decreased, whereas trabecular area (Tb.Ar) increased more rapidly in men with 25OHD ≤20 ng/mL versus the reference group (>30 ng/mL). Men with 25OHD ≤10 ng/mL had faster decrease in reaction force and failure load than men with 25OHD >30 ng/mL. At the distal tibia, Tt.BMD, Ct.Thd , Ct.Ar, Ct.BMD, failure load, and reaction force decreased, whereas Tb.Ar increased more rapidly in men with 25OHD between 10 and 20 ng/mL versus the reference group. The results were similar when 12 ng/mL was used as a threshold of severe vitamin D deficiency. At distal radius, men with PTH levels above the median (>44 pg/mL) had more rapid decrease in Tt.BMD, Ct.Ar, Ct.BMD, Ct.Thd , reaction force, and failure load, and more rapid increase in Tb.Ar versus the lowest quartile (≤34 pg/mL). At the distal tibia, men in the highest PTH quartile had faster decrease in Tt.BMD, Ct.Thd , Ct.Ar, Ct.BMD, reaction force, and failure load and faster increase in Tb.Ar versus the lowest quartile. The results were similar in men with glomerular filtration rate >60 mL/min. The results were similar in men who took no vitamin D or calcium supplements for 8 years. In summary, vitamin D deficiency and secondary hyperparathyroidism are associated with more rapid prospectively assessed cortical and trabecular bone decline in older men. © 2022 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Audrey Bobillier
- Institut National de la Santé et de la Recherche Médicale (INSERM) Unité Mixtes de Recherche (UMR) 1033, University of Lyon, Hôpital Edouard Herriot, Lyon, France
| | - Philippe Wagner
- Institut National de la Santé et de la Recherche Médicale (INSERM) Unité Mixtes de Recherche (UMR) 1033, University of Lyon, Hôpital Edouard Herriot, Lyon, France
| | - Danielle E Whittier
- McCaig Institute for Bone and Joint Health, Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - René Ecochard
- Department of Biostatistics, University of Lyon, Lyon, France
| | - Steven K Boyd
- McCaig Institute for Bone and Joint Health, Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Roland Chapurlat
- Institut National de la Santé et de la Recherche Médicale (INSERM) Unité Mixtes de Recherche (UMR) 1033, University of Lyon, Hôpital Edouard Herriot, Lyon, France
| | - Pawel Szulc
- Institut National de la Santé et de la Recherche Médicale (INSERM) Unité Mixtes de Recherche (UMR) 1033, University of Lyon, Hôpital Edouard Herriot, Lyon, France
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17
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Sharma S, Mehta P, Patil A, Gupta SK, Rajender S, Chattopadhyay N. Meta-analyses of the quantitative computed tomography data in dialysis patients show differential impacts of renal failure on the trabecular and cortical bones. Osteoporos Int 2022; 33:1521-1533. [PMID: 35249146 DOI: 10.1007/s00198-022-06366-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 02/24/2022] [Indexed: 10/18/2022]
Abstract
UNLABELLED Dialysis patients have compromised bone health that increases their fracture risk due to low bone mass and deterioration in bone microarchitecture. Through meta-analyses of published studies, we conclude that dialysis patients suffer from impaired compartmental bone parameters compared with healthy controls. INTRODUCTION We performed meta-analyses to determine the effect of chronic kidney disease (CKD) patients under dialysis on the trabecular and cortical parameters of radius and tibia. METHODS This is a meta-analysis of cross-sectional and prospective clinical studies. PubMed, Web of Science, Google Scholar, and Scopus were searched using various permutation combinations. Dialysis patients were compared with non-CKD healthy controls using quantitative computed tomography. High-resolution peripheral quantitative computed tomography (HR-pQCT) and pQCT data of dialysis patients were dissected from eligible studies for pooled analysis of each parameter. RESULTS Ten studies met the inclusion criteria that included data from 457 dialysis patients and 2134 controls. Pooled analysis showed a significant decrease (a) in total vBMD at distal radius [standard deviation of the mean (SDM) = -0.842, p = 0.000] and tibia (SMD = -0.705, p = 0.000) and (b) in cortical vBMD (SDM = -1.037, p = 0.000) at radius of dialysis patients compared with control. There were strong correlations between total vBMD and microarchitecture parameters at tibia in dialysis patients. CONCLUSIONS At radius and tibia, bone mass, microarchitecture, and geometry at trabecular and cortical envelopes displayed impairments in dialysis patients compared with control. Tibial vBMD may have diagnostic value in dialysis. HR-pQCT and pQCT may be used to further understand the compartmental bones response to CKD-induced loss at different stages of CKD.
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Affiliation(s)
- S Sharma
- Division of Endocrinology and Centre for Research in Anabolic Skeletal Targets in Health and Illness (ASTHI), CSIR-Central Drug Research Institute, Sector 10, Jankipuram Extension, Sitapur Road, Lucknow, 226031, India
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, 201002, India
| | - P Mehta
- Division of Endocrinology and Centre for Research in Anabolic Skeletal Targets in Health and Illness (ASTHI), CSIR-Central Drug Research Institute, Sector 10, Jankipuram Extension, Sitapur Road, Lucknow, 226031, India
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, 201002, India
| | - A Patil
- Division of Endocrinology and Centre for Research in Anabolic Skeletal Targets in Health and Illness (ASTHI), CSIR-Central Drug Research Institute, Sector 10, Jankipuram Extension, Sitapur Road, Lucknow, 226031, India
| | - S K Gupta
- Department of Endocrinology, Sanjay Gandhi Post-graduate Institute of Medical Sciences, Lucknow, India
| | - S Rajender
- Division of Endocrinology and Centre for Research in Anabolic Skeletal Targets in Health and Illness (ASTHI), CSIR-Central Drug Research Institute, Sector 10, Jankipuram Extension, Sitapur Road, Lucknow, 226031, India.
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, 201002, India.
| | - N Chattopadhyay
- Division of Endocrinology and Centre for Research in Anabolic Skeletal Targets in Health and Illness (ASTHI), CSIR-Central Drug Research Institute, Sector 10, Jankipuram Extension, Sitapur Road, Lucknow, 226031, India.
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, 201002, India.
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18
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Pichone A, Gomes CP, Lima LFC, Moreira CA, Paranhos-Neto FDP, Madeira M, Lopes RT, Farias MLF, Leite Jr. M. Assessment of trabecular and cortical parameters using high-resolution peripheral quantitative computed tomography, histomorphometry and microCT of iliac crest bone core in hemodialysis patients. Bone Rep 2022; 16:101173. [PMID: 35198659 PMCID: PMC8850668 DOI: 10.1016/j.bonr.2022.101173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/03/2022] [Accepted: 02/04/2022] [Indexed: 11/28/2022] Open
Abstract
Patients with end-stage renal disease develop changes in bone quality and quantity, which can be assessed using different methods. This study aimed to compare and to correlate bone parameters obtained in vivo using high-resolution peripheral quantitative computed tomography (HR-pQCT) with those obtained by bone biopsy using histomorphometry and microcomputed tomography (microCT) analysis of the iliac crest core, and to evaluate if HR-pQCT is helpful in aiding with categorization of those with high turnover. Twenty hemodialysis patients, 13 females (7 postmenopausal), underwent bone biopsy from 2018 to 2020. The mean age was 48.5 ± 10.6 years, and the mean hemodialysis vintage was 15 years. Histomorphometry identified mineralization defects, low turnover, and high turnover in 65%, 45%, and 35% of the patients, respectively. The highest values of trabecular bone volume (BV/TV) were obtained by histomorphometry, while the highest values of cortical thickness (Ct.Th) were obtained by HR-pQCT at the distal tibia. Moderate correlations were found between BV/TV values obtained by microCT of the bone core and HR-pQCT at the distal radius (r = 0.531, p = 0.016) and at the distal tibia (r = 0.536, p = 0.015). BV/TV values obtained from the bone core by histomorphometry and microCT were also significantly correlated (r = 0.475, p = 0.04). Regarding Ct.Th, there was a strong correlation between the radius and tibia HR-pQCT (r = 0.800, p < 0.001), between bone core microCT and the distal radius HR-pQCT (r = 0.610, p < 0.01), as between histomorphometry and microCT (r = 0.899, p < 0.01). In groups classified by bone turnover, patients with high turnover presented lower BV/TV, Tb.N, Tb.Th, and Ct.Th than those with low turnover in peripheral sites using HR-pQCT. By this method, it was possible to identify low turnover from tibia BV/TV > 12,4% plus Tb.Sp ≤ 0.667 mm (AUC 0.810, 95% CI 0.575 to 0.948) and high turnover from total bone mineral density (BMD) ≤ 154.2 mg HA/cm3 (AUC 0.860, 95% CI 0.633 to 0.982, p < 0.001) and cortical BMD ≤ 691.6 mg HA/cm3 (AUC 0.840, 95% CI 0.609 to 0.963, p < 0.001). In conclusion, HR-pQCT had significant correlation with iliac crest bone in BV/TV and Ct.Th, which are known to provide bone strength. This method is quick and non-invasive and may be helpful in categorizing those with high versus low turnover in hemodialysis patients. Bone structure in hemodialysis patients can be assessed using different methods. There was correlation of BV/TV and Ct.Th between histomorphometry and bone core microCT. BV/TV and Ct.Th values obtained by radius HR-pQCT and bone core microCT were correlated. High turnover patients had lower BV/TV, Tb.N, Tb.Th, and Ct.Th by HR-pQCT. HR-pQCT was able to discriminate low and high turnover in hemodialysis patients.
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Affiliation(s)
- Alinie Pichone
- Division of Nephrology, HUCFF, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- Corresponding author at: Hospital Universitario Clementino Fraga Filho – Universidade Federal do Rio de Janeiro, Rua Professor Rodolpho Paulo Rocco, 255/Serviço de nefrologia - sétimo andar, Rio de Janeiro, RJ 21941-617, Brazil.
| | - Carlos Perez Gomes
- Division of Nephrology, HUCFF, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Luis Felipe Cardoso Lima
- Laboratory of Nuclear Instrumentation, COPPE, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Carolina Aguiar Moreira
- Division of Endocrinology (SEMPR), Internal Medicine Department of Federal University of Parana & Academic Research Center of Pro Renal Institute, Curitiba, Brazil
| | | | - Miguel Madeira
- Division of Endocrinology, HUCFF, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Ricardo Tadeu Lopes
- Laboratory of Nuclear Instrumentation, COPPE, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Maurilo Leite Jr.
- Division of Nephrology, HUCFF, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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19
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Alkaline Phosphatase: An Old Friend as Treatment Target for Cardiovascular and Mineral Bone Disorders in Chronic Kidney Disease. Nutrients 2022; 14:nu14102124. [PMID: 35631265 PMCID: PMC9144546 DOI: 10.3390/nu14102124] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/12/2022] [Accepted: 05/17/2022] [Indexed: 11/17/2022] Open
Abstract
Alkaline phosphatase (ALP) is an evolutionary conserved enzyme and widely used biomarker in clinical practice. Tissue-nonspecific alkaline phosphatase (TNALP) is one of four human isozymes that are expressed as distinct TNALP isoforms after posttranslational modifications, mainly in bone, liver, and kidney tissues. Beyond the well-known effects on bone mineralization, the bone ALP (BALP) isoforms (B/I, B1, B1x, and B2) are also involved in the pathogenesis of ectopic calcification. This narrative review summarizes the recent clinical investigations and mechanisms that link ALP and BALP to inflammation, metabolic syndrome, vascular calcification, endothelial dysfunction, fibrosis, cardiovascular disease, and mortality. The association between ALP, vitamin K, bone metabolism, and fracture risk in patients with chronic kidney disease (CKD) is also discussed. Recent advances in different pharmacological strategies are highlighted, with the potential to modulate the expression of ALP directly and indirectly in CKD–mineral and bone disorder (CKD-MBD), e.g., epigenetic modulation, phosphate binders, calcimimetics, vitamin D, and other anti-fracture treatments. We conclude that the significant evidence for ALP as a pathogenic factor and risk marker in CKD-MBD supports the inclusion of concrete treatment targets for ALP in clinical guidelines. While a target value below 120 U/L is associated with improved survival, further experimental and clinical research should explore interventional strategies with optimal risk–benefit profiles. The future holds great promise for novel drug therapies modulating ALP.
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20
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Sobh MM, Abdalbary M, Elnagar S, Nagy E, Elshabrawy N, Abdelsalam M, Asadipooya K, El-Husseini A. Secondary Osteoporosis and Metabolic Bone Diseases. J Clin Med 2022; 11:2382. [PMID: 35566509 PMCID: PMC9102221 DOI: 10.3390/jcm11092382] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/17/2022] [Accepted: 04/20/2022] [Indexed: 02/04/2023] Open
Abstract
Fragility fracture is a worldwide problem and a main cause of disability and impaired quality of life. It is primarily caused by osteoporosis, characterized by impaired bone quantity and or quality. Proper diagnosis of osteoporosis is essential for prevention of fragility fractures. Osteoporosis can be primary in postmenopausal women because of estrogen deficiency. Secondary forms of osteoporosis are not uncommon in both men and women. Most systemic illnesses and organ dysfunction can lead to osteoporosis. The kidney plays a crucial role in maintaining physiological bone homeostasis by controlling minerals, electrolytes, acid-base, vitamin D and parathyroid function. Chronic kidney disease with its uremic milieu disturbs this balance, leading to renal osteodystrophy. Diabetes mellitus represents the most common secondary cause of osteoporosis. Thyroid and parathyroid disorders can dysregulate the osteoblast/osteoclast functions. Gastrointestinal disorders, malnutrition and malabsorption can result in mineral and vitamin D deficiencies and bone loss. Patients with chronic liver disease have a higher risk of fracture due to hepatic osteodystrophy. Proinflammatory cytokines in infectious, autoimmune, and hematological disorders can stimulate osteoclastogenesis, leading to osteoporosis. Moreover, drug-induced osteoporosis is not uncommon. In this review, we focus on causes, pathogenesis, and management of secondary osteoporosis.
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Affiliation(s)
- Mahmoud M. Sobh
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt; (M.M.S.); (M.A.); (S.E.); (E.N.); (N.E.); (M.A.)
| | - Mohamed Abdalbary
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt; (M.M.S.); (M.A.); (S.E.); (E.N.); (N.E.); (M.A.)
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY 40506, USA
| | - Sherouk Elnagar
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt; (M.M.S.); (M.A.); (S.E.); (E.N.); (N.E.); (M.A.)
| | - Eman Nagy
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt; (M.M.S.); (M.A.); (S.E.); (E.N.); (N.E.); (M.A.)
| | - Nehal Elshabrawy
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt; (M.M.S.); (M.A.); (S.E.); (E.N.); (N.E.); (M.A.)
| | - Mostafa Abdelsalam
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt; (M.M.S.); (M.A.); (S.E.); (E.N.); (N.E.); (M.A.)
| | - Kamyar Asadipooya
- Division of Endocrinology, University of Kentucky, Lexington, KY 40506, USA;
| | - Amr El-Husseini
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY 40506, USA
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21
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Ebeling PR, Nguyen HH, Aleksova J, Vincent AJ, Wong P, Milat F. Secondary Osteoporosis. Endocr Rev 2022; 43:240-313. [PMID: 34476488 DOI: 10.1210/endrev/bnab028] [Citation(s) in RCA: 100] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Indexed: 02/07/2023]
Abstract
Osteoporosis is a global public health problem, with fractures contributing to significant morbidity and mortality. Although postmenopausal osteoporosis is most common, up to 30% of postmenopausal women, > 50% of premenopausal women, and between 50% and 80% of men have secondary osteoporosis. Exclusion of secondary causes is important, as treatment of such patients often commences by treating the underlying condition. These are varied but often neglected, ranging from endocrine to chronic inflammatory and genetic conditions. General screening is recommended for all patients with osteoporosis, with advanced investigations reserved for premenopausal women and men aged < 50 years, for older patients in whom classical risk factors for osteoporosis are absent, and for all patients with the lowest bone mass (Z-score ≤ -2). The response of secondary osteoporosis to conventional anti-osteoporosis therapy may be inadequate if the underlying condition is unrecognized and untreated. Bone densitometry, using dual-energy x-ray absorptiometry, may underestimate fracture risk in some chronic diseases, including glucocorticoid-induced osteoporosis, type 2 diabetes, and obesity, and may overestimate fracture risk in others (eg, Turner syndrome). FRAX and trabecular bone score may provide additional information regarding fracture risk in secondary osteoporosis, but their use is limited to adults aged ≥ 40 years and ≥ 50 years, respectively. In addition, FRAX requires adjustment in some chronic conditions, such as glucocorticoid use, type 2 diabetes, and HIV. In most conditions, evidence for antiresorptive or anabolic therapy is limited to increases in bone mass. Current osteoporosis management guidelines also neglect secondary osteoporosis and these existing evidence gaps are discussed.
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Affiliation(s)
- Peter R Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia
| | - Hanh H Nguyen
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Department of Endocrinology and Diabetes, Western Health, Victoria 3011, Australia
| | - Jasna Aleksova
- Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
| | - Amanda J Vincent
- Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Monash Centre for Health Research and Implementation, School of Public Health and Preventative Medicine, Monash University, Clayton, Victoria 3168, Australia
| | - Phillip Wong
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
| | - Frances Milat
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
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22
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Zaworski C, Cheah J, Koff MF, Breighner R, Lin B, Harrison J, Donnelly E, Stein EM. MRI-based Texture Analysis of Trabecular Bone for Opportunistic Screening of Skeletal Fragility. J Clin Endocrinol Metab 2021; 106:2233-2241. [PMID: 33999148 DOI: 10.1210/clinem/dgab342] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Indexed: 11/19/2022]
Abstract
CONTEXT Many individuals at high risk for osteoporosis and fragility fracture are never screened by traditional methods. Opportunistic use of imaging obtained for other clinical purposes is required to foster identification of these patients. OBJECTIVE The aim of this pilot study was to evaluate texture features as a measure of bone fragility, by comparing clinically acquired magnetic resonance imaging (MRI) scans from individuals with and without a history of fragility fracture. METHODS This study retrospectively investigated 100 subjects who had lumbar spine MRI performed at our institution. Cases (n = 50) were postmenopausal women with osteoporosis and a confirmed history of fragility fracture. Controls (n = 50) were age- and race-matched postmenopausal women with no known fracture history. Trabecular bone from the lumbar vertebrae was segmented to create regions of interest within which a gray level co-occurrence matrix was used to quantify the distribution and spatial organization of voxel intensity. Heterogeneity in the trabecular bone texture was assessed by several features, including contrast (variability), entropy (disorder), and angular second moment (homogeneity). RESULTS Texture analysis revealed that trabecular bone was more heterogeneous in fracture patients. Specifically, fracture patients had greater texture variability (+76% contrast; P = 0.005), greater disorder (+10% entropy; P = 0.005), and less homogeneity (-50% angular second moment; P = 0.005) compared with controls. CONCLUSIONS MRI-based textural analysis of trabecular bone discriminated between patients with known osteoporotic fractures and controls. Further investigation is required to validate this promising methodology, which could greatly expand the number of patients screened for skeletal fragility.
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Affiliation(s)
- Caroline Zaworski
- Department of Medicine, Endocrinology and Metabolic Bone Service, Hospital for Special Surgery, NY, NY 10021, USA
| | - Jonathan Cheah
- Department of Medicine, Endocrinology and Metabolic Bone Service, Hospital for Special Surgery, NY, NY 10021, USA
| | - Matthew F Koff
- Department of Radiology and Imaging - MRI, Hospital for Special Surgery, NY, NY 10021, USA
| | - Ryan Breighner
- Department of Radiology and Imaging - MRI, Hospital for Special Surgery, NY, NY 10021, USA
| | - Bin Lin
- Department of Radiology and Imaging - MRI, Hospital for Special Surgery, NY, NY 10021, USA
| | - Jonathan Harrison
- Department of Medicine, Endocrinology and Metabolic Bone Service, Hospital for Special Surgery, NY, NY 10021, USA
| | - Eve Donnelly
- Materials Science and Engineering, Cornell University, Ithaca NY 14853, USA
| | - Emily M Stein
- Department of Medicine, Endocrinology and Metabolic Bone Service, Hospital for Special Surgery, NY, NY 10021, USA
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23
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Asadipooya K, Abdalbary M, Ahmad Y, Kakani E, Monier-Faugere MC, El-Husseini A. Bone Quality in CKD Patients: Current Concepts and Future Directions - Part I. KIDNEY DISEASES (BASEL, SWITZERLAND) 2021; 7:268-277. [PMID: 34395542 PMCID: PMC8314761 DOI: 10.1159/000515534] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 02/26/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND There is ample evidence that patients with CKD have an increased risk of osteoporotic fractures. Bone fragility is not only influenced by low bone volume and mass but also by poor microarchitecture and tissue quality. More emphasis has been given to the quantitative rather than qualitative assessment of bone health, both in general population and CKD patients. Although bone mineral density (BMD) is a very useful clinical tool in assessing bone strength, it may underestimate the fracture risk in CKD patients. Serum and urinary bone biomarkers have been found to be reflective of bone activities and predictive of fractures independently of BMD in CKD patients. Bone quality and fracture risk in CKD patients can be better assessed by utilizing new technologies such as trabecular bone score and high-resolution imaging studies. Additionally, invasive assessments such as bone histology and micro-indentation are useful counterparts in the evaluation of bone quality. SUMMARY A precise diagnosis of the underlying skeletal abnormalities in CKD patients is crucial to prevent further bone loss and fractures. We must consider bone quantity and quality abnormalities for management of CKD patients. Here in this part I, we are focusing on advances in bone quality diagnostics that are expected to help in proper understanding of the bone health in CKD patients. KEY MESSAGES Assessment of bone quality and quantity in CKD patients is essential. Both noninvasive and invasive techniques for the assessment of bone quality are available.
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Affiliation(s)
- Kamyar Asadipooya
- Division of Endocrinology, University of Kentucky, Lexington, Kentucky, USA
| | - Mohamed Abdalbary
- Division of Nephrology & Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
- Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - Yahya Ahmad
- Division of Nephrology & Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
| | - Elijah Kakani
- Division of Nephrology & Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
| | | | - Amr El-Husseini
- Division of Nephrology & Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
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24
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Damrath JG, Creecy A, Wallace JM, Moe SM. The impact of advanced glycation end products on bone properties in chronic kidney disease. Curr Opin Nephrol Hypertens 2021; 30:411-417. [PMID: 33928911 PMCID: PMC8154706 DOI: 10.1097/mnh.0000000000000713] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE OF REVIEW Chronic kidney disease (CKD) affects over 15% of Americans and results in an increased risk of skeletal fractures and fracture-related mortality. However, there remain great challenges in estimating fracture risk in CKD patients, as conventional metrics such as bone density assess bone quantity without accounting for the material quality of the bone tissue. The purpose of this review is to highlight the detrimental effects of advanced glycation end products (AGEs) on the structural and mechanical properties of bone, and to demonstrate the importance of including bone quality when assessing fracture risk in CKD patients. RECENT FINDINGS Increased oxidative stress and inflammation drive the production of AGEs in CKD patients that form nonenzymatic crosslinks between type I collagen fibrils in the bone matrix. Nonenzymatic crosslinks stiffen and embrittle the bone, reducing its ability to absorb energy and resist fracture. Clinical measurement of AGEs is typically indirect and fails to distinguish the identity and properties of the various AGEs. SUMMARY Accounting for the impact of AGEs on the skeleton in CKD patients may improve our estimation of overall bone quality, fracture risk, and treatments to improve both bone quantity and quality by reducing AGEs in patients with CKD merit investigation in order to improve our understanding of the etiology of increased fracture risk.
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Affiliation(s)
- John G. Damrath
- Purdue University Weldon School of Biomedical Engineering, West Lafayette, IN, United States
| | - Amy Creecy
- Indiana University – Purdue University at Indianapolis Department of Biomedical Engineering, Indianapolis, IN, United States
| | - Joseph M. Wallace
- Indiana University – Purdue University at Indianapolis Department of Biomedical Engineering, Indianapolis, IN, United States
| | - Sharon M. Moe
- Indiana University School of Medicine, Division of Nephrology, Indianapolis, IN, United States
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25
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Aleksova J, Milat F, Kotowicz MA, Pasco JA, Schultz C, Wong P, Ebeling PR, Elder GJ. Patients with end-stage kidney disease have markedly abnormal cortical hip parameters by dual-energy X-ray absorptiometry. Nephrol Dial Transplant 2021; 36:543-550. [PMID: 31697355 DOI: 10.1093/ndt/gfz195] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 08/01/2019] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Patients with end-stage kidney disease (ESKD) have higher fracture rates and post-fracture mortality than the general population, but bone mineral density by dual-energy X-ray absorptiometry (DXA) is less predictive of fracture in this patient group. Bone biopsy and high-resolution imaging indicate that cortical thickness (CT) is reduced and cortical porosity is increased in ESKD. The aim of this study was to assess cortical parameters using DXA in patients with ESKD. It was hypothesized that these parameters would show deterioration and be associated with fracture. METHODS Using advanced hip analysis, normal age-related ranges were determined from 752 female and 861 male femur scans and were compared with scans of 226 patients with ESKD at the time of transplantation. RESULTS Compared with controls, female patients had lower mean±SD CT (mms) at the femoral neck (FN) (2.59 ± 1.42 versus 5.23 ± 1.85), calcar (3.46 ± 1.07 versus 5.09 ± 1.30) and shaft (4.42 ± 1.21 versus 7.44 ± 2.07; P < 0.001 for each), and buckling ratios were higher (8.21 ± 4.6 versus 3.63 ± 1.42; P < 0.001), indicating greater FN instability. All findings were similar for men. Prevalent fracture was documented in 28.8% of patients; 12.4% vertebral only, 8.4% non-vertebral only and 8% vertebral plus non-vertebral. In adjusted models, each 1 SD reduction in FN CT and increase in the buckling ratio was associated with a respective 1.73 (1.22-2.46)- and 1.82 (1.49-2.86)-fold increase in the risk of prevalent vertebral fracture. CONCLUSIONS In patients with ESKD, DXA-derived cortical parameters are markedly abnormal compared with age- and sex-matched controls. These parameters should be assessed for incident fracture prediction and targeting treatment.
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Affiliation(s)
- Jasna Aleksova
- Hudson Institute for Medical Research, Clayton, Australia.,Department of Medicine, Monash University, Clayton, Australia.,Department of Endocrinology, Monash Health, Clayton, Australia
| | - Frances Milat
- Hudson Institute for Medical Research, Clayton, Australia.,Department of Medicine, Monash University, Clayton, Australia.,Department of Endocrinology, Monash Health, Clayton, Australia
| | - Mark A Kotowicz
- Deakin University, Geelong, Australia.,Barwon Health, University Hospital, Geelong, Australia.,Department of Medicine-Western Health, University of Melbourne, St Albans, Australia
| | - Julie A Pasco
- Deakin University, Geelong, Australia.,Barwon Health, University Hospital, Geelong, Australia.,Department of Medicine-Western Health, University of Melbourne, St Albans, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Chris Schultz
- Department of Nuclear Medicine, PET and Bone Densitometry, Royal Adelaide Hospital, Adelaide, Australia
| | - Phillip Wong
- Hudson Institute for Medical Research, Clayton, Australia.,Department of Medicine, Monash University, Clayton, Australia.,Department of Endocrinology, Monash Health, Clayton, Australia
| | - Peter R Ebeling
- Department of Medicine, Monash University, Clayton, Australia.,Department of Endocrinology, Monash Health, Clayton, Australia
| | - Grahame J Elder
- Department of Renal Medicine, Westmead Hospital, Sydney, Australia.,Osteoporosis and Bone Biology Division, Garvan Institute of Medical Research, Sydney, Australia
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26
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Elder GJ. Radiographic absorptiometry: a step in solving the CKD fracture puzzle. Kidney Int 2020; 98:826-828. [PMID: 32998811 DOI: 10.1016/j.kint.2020.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 05/06/2020] [Indexed: 11/20/2022]
Abstract
Patients on dialysis are highly prone to fracture, and radiographic absorptiometry can be used to measure their bone mineral density and assess fracture risk. However, to determine its place in management, radiographic absorptiometry should be compared with dual-energy X-ray absorptiometry, and with fracture risk assessment tools such as FRAX, tests of muscle strength, biomarkers, and newer dual-energy X-ray absorptiometry techniques. The convenience, accessibility, and cost of radiographic absorptiometry may contribute to its utility in a number of clinical settings.
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Affiliation(s)
- Grahame J Elder
- Osteoporosis and Bone Biology Division, Garvan Institute of Medical Research, Darlinghurst, New South Wales, Australia; Faculty of Medicine, University of Notre Dame, Sydney, New South Wales, Australia; Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia.
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27
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Benillouche E, Ostertag A, Marty C, Ureña Torres P, Cohen-Solal M. Cortical Bone Microarchitecture in Dialysis Patients. Am J Nephrol 2020; 51:833-838. [PMID: 32911468 DOI: 10.1159/000510064] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 07/08/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND The incidence of skeletal fractures is high in dialysis patients. Current available tools are insufficient to predict bone fragility. We analyzed the microarchitecture in patients on dialysis therapy using bone biopsies and peripheral microcomputed tomography. METHODS We analyzed 12 trans-iliac bone biopsies of patients with recent fractures. Bone microarchitecture was assessed in the bone cores by histology (2D-), microcomputed tomography (3D-µCT), and high-resolution peripheral quantitative computed tomography (HR-pQCT) at the tibia. RESULTS Trabecular bone volume/tissue volume was similar in 2D histology and 3D-µCT (p = 0.40), while lower in HR-pQCT (p < 0.01). There was no correlation in trabecular microarchitectural indices between 2-histology and 3D-µCT, or HR-pQCT. The 3D-µCT cortical thickness (Ct.Th) were positively correlated with 2D (p < 0.05), but with HR-pQCT (p = 0.33). Ct.Th was lower in patients with ≥2 vertebral fractures than with one fracture. CONCLUSIONS 3D-µCT is a reliable method for the measurement of cortical bone in bone biopsies. Prospective studies are awaited to address its value in discriminating fracture risk.
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Affiliation(s)
- Eva Benillouche
- Department of Rheumatology, Lariboisière Hospital, Paris, France
| | - Agnes Ostertag
- INSERM U1132, Université de Paris, Hôpital Lariboisière (APHP), Paris, France
| | - Caroline Marty
- INSERM U1132, Université de Paris, Hôpital Lariboisière (APHP), Paris, France
| | | | - Martine Cohen-Solal
- Department of Rheumatology, Lariboisière Hospital, Paris, France,
- INSERM U1132, Université de Paris, Hôpital Lariboisière (APHP), Paris, France,
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Costa LR, Carvalho AB, Bittencourt AL, Rochitte CE, Canziani MEF. Cortical unlike trabecular bone loss is not associated with vascular calcification progression in CKD patients. BMC Nephrol 2020; 21:121. [PMID: 32252657 PMCID: PMC7137513 DOI: 10.1186/s12882-020-01756-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 03/05/2020] [Indexed: 11/17/2022] Open
Abstract
Background Vascular calcification progression has been associated with the loss of trabecular bone in chronic kidney disease (CKD) patients. There are few data evaluating the relationship between cortical bone loss and vascular calcification in this population. The aim of this study was to prospectively evaluate the association between changes in cortical bone density and coronary artery calcification (CAC) progression in non-dialyzed CKD patients. Methods Changes of cortical and trabecular bone, and changes of calcium score, were analyzed using vertebral tomographic images from a prospective study. Automatic delineation of the cortical bone layer was performed by Image J software, and trabecular bone was determined by selecting a region of interest using Vitrea 2® software. Cortical and trabecular bone density (BD) were expressed in Hounsfield Units (HU), and coronary artery calcium score in Agatston Units (AU). Results Seventy asymptomatic patients [57.8 ± 10.2 years, 63% males, 20% diabetic, estimated glomerular filtration rate (eGFR) = 37.3 (24.8–51.3) mL/min/1.73m2] were followed for 24 months. The mean cortical and trabecular BD did not change over time. While 49 patients lost either bone, 29 (41%) patients lost cortical [− 4.4%/year (ranging from − 7.15 to − 0.5)] and 39 (56%) lost trabecular bone [− 3.15%/year (− 13.7 to − 0.25)]. There was no association between cortical and trabecular BD changes (p = 0.12). CAC was observed in 33 (46%) patients at baseline, and 30 (91%) of them showed CAC progression. While an inverse correlation between trabecular bone and calcium score changes was observed (p = 0.001), there was no correlation between cortical bone and calcium score changes (p = 0.34). Conclusion CKD patients experience either cortical or trabecular bone loss over time, but these changes do not take place simultaneously in all patients. Cortical, unlike trabecular bone loss, is not associated with vascular calcification progression in these patients.
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Affiliation(s)
- Larissa R Costa
- Nephrology Division of Federal University of São Paulo, Rua Pedro de Toledo, 282 - Vila Clementino, São Paulo, SP, 04039-000, Brazil.
| | - Aluizio B Carvalho
- Nephrology Division of Federal University of São Paulo, Rua Pedro de Toledo, 282 - Vila Clementino, São Paulo, SP, 04039-000, Brazil
| | - Amandha L Bittencourt
- Nephrology Division of Federal University of São Paulo, Rua Pedro de Toledo, 282 - Vila Clementino, São Paulo, SP, 04039-000, Brazil
| | - Carlos E Rochitte
- Heart Institute of the University of São Paulo, Av. Dr. Enéas Carvalho de Aguiar, 44 - Pacaembu, São Paulo, SP, 05403-900, Brazil
| | - Maria Eugênia F Canziani
- Nephrology Division of Federal University of São Paulo, Rua Pedro de Toledo, 282 - Vila Clementino, São Paulo, SP, 04039-000, Brazil
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29
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Holloway-Kew KL, Rufus-Membere P, Anderson KB, Betson A, Gaston J, Kotowicz MA, Diez-Perez A, Hyde NK, Pasco JA. Bone material strength index is associated with prior fracture in men with and without moderate chronic kidney disease. Bone 2020; 133:115241. [PMID: 31954850 DOI: 10.1016/j.bone.2020.115241] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 01/13/2020] [Accepted: 01/15/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) are at high risk for fracture. The ability of bone mineral density (BMD) to predict fractures in CKD patients has been inconsistent. Other measures such as trabecular bone score (TBS) and impact microindentation (IMI) may be more useful in this group. This study aimed to determine if TBS or IMI values differed between men with and without CKD and examine associations between prior fracture, TBS and IMI values. METHODS Men (n = 343, age 33-96 yr) from the Geelong Osteoporosis Study were included. Femoral neck (FNBMD) and lumbar spine BMD (LSBMD) were measured using DXA (Lunar ProdigyPro). TBS was determined from lumbar spine scans (TBS iNsight software Version 2.2). IMI values (bone material strength index; BMSi) were measured using an OsteoProbe. CKD was defined as an eGFR<60 mL/min/1.73m2 (n = 53). Prior low trauma fractures (n = 37) were ascertained from radiological reports. Associations were examined using binary logistic regression, adjusting for potential confounders. Interaction terms were tested in all models. RESULTS Men with CKD tended to have a higher likelihood of prior fracture (adjusted OR 2.27, 95%CI 1.02-5.01). Higher BMSi was associated with a lower likelihood of prior fracture (adjusted OR for 1SD increase: 0.70; 95%CI 0.51-0.97). This association was sustained after adjustment for FNBMD (OR 0.68; 95%CI 0.49-0.96) or LSBMD (OR 0.69; 95%CI 0.49-0.95). No interaction was detected between BMSi and CKD (p = 0.898). No associations were detected between FNBMD, LSBMD or TBS and prior fracture in either population and there were no interactions with CKD for FNBMD, LSBMD or TBS. CONCLUSIONS BMSi was associated with prior fracture in men with and without CKD, however, FNBMD, LSBMD and TBS were not. Lack of an interaction term suggests that BMSi performed similarly in identifying the likelihood of prior fracture, regardless of CKD status. IMI may have clinical utility for assessing fracture risk in patients with CKD.
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Affiliation(s)
| | | | | | | | | | - Mark A Kotowicz
- Deakin University, Geelong, Australia; Barwon Health, Geelong, Australia; Melbourne Medical School - Western Campus, Department of Medicine, The University of Melbourne, St Albans, Australia
| | - Adolfo Diez-Perez
- Department of Internal Medicine, Hospital del Mar-IMIM, Autonomous University of Barcelona, CIBERFES, Instituto Carlos III, Spain
| | | | - Julie A Pasco
- Deakin University, Geelong, Australia; Barwon Health, Geelong, Australia; Melbourne Medical School - Western Campus, Department of Medicine, The University of Melbourne, St Albans, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
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30
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Gardinier JD, Daly-Seiler CS, Zhang C. Osteocytes' expression of the PTH/PTHrP receptor has differing effects on endocortical and periosteal bone formation during adenine-induced CKD. Bone 2020; 133:115186. [PMID: 31987988 DOI: 10.1016/j.bone.2019.115186] [Citation(s) in RCA: 1] [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: 08/14/2019] [Revised: 12/03/2019] [Accepted: 12/04/2019] [Indexed: 12/01/2022]
Abstract
Osteocytes play a key role in the pathophysiology of chronic kidney disease (CKD). However, the extent to which osteocytes contribute to abnormalities in bone turnover due to excessive levels of parathyroid hormone (PTH) remains poorly understood. The purpose of this study was to determine the extent to which bone formation and tissue strength during the progression of CKD is modified through osteocytes' response to PTH. Conditional knockout mice targeting osteocytes' expression of the PTH/PTH-related protein type 1 receptor (PPR) were subjected to adenine-induced CKD. After 6-weeks of treatment, adenine-induced CKD was found to reduce bone formation at the periosteal and endocortical surfaces of the tibia. The loss in bone mass corresponded with a significant decrease in structural-level mechanical properties. In knockout mice, the loss of PPR expression in osteocytes further exacerbated the loss in bone formation at the endocortical surface, but inhibited bone loss at the periosteal surface. In general, the effects of adenine-induced CKD were not as extensive in female mice. Collectively, these findings demonstrate that osteocytes' response to PTH under adenine-induced CKD has a unique impact on bone turnover that is specific to the periosteal and endocortical surfaces.
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Affiliation(s)
| | | | - Chunbin Zhang
- Bone and Joint Center, Henry Ford Hospital, Detroit, MI 48202, USA
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31
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Nickolas TL, Chen N, McMahon DJ, Dempster D, Zhou H, Dominguez J, Aponte MA, Sung J, Evenepoel P, D'Haese PC, Mac-Way F, Moyses R, Moe S. A microRNA Approach to Discriminate Cortical Low Bone Turnover in Renal Osteodystrophy. JBMR Plus 2020; 4:e10353. [PMID: 32490328 PMCID: PMC7254487 DOI: 10.1002/jbm4.10353] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 01/31/2020] [Accepted: 02/18/2020] [Indexed: 01/03/2023] Open
Abstract
A main obstacle to diagnose and manage renal osteodystrophy (ROD) is the identification of intracortical bone turnover type (low, normal, high). The gold standard, tetracycline‐labeled transiliac crest bone biopsy, is impractical to obtain in most patients. The Kidney Disease Improving Global Outcomes Guidelines recommend PTH and bone‐specific alkaline phosphatase (BSAP) for the diagnosis of turnover type. However, PTH and BSAP have insufficient diagnostic accuracy to differentiate low from non‐low turnover and were validated for trabecular turnover. We hypothesized that four circulating microRNAs (miRNAs) that regulate osteoblast (miRNA‐30b, 30c, 125b) and osteoclast development (miRNA‐155) would provide superior discrimination of low from non‐low turnover than biomarkers in clinical use. In 23 patients with CKD 3‐5D, we obtained tetracycline‐labeled transiliac crest bone biopsy and measured circulating levels of intact PTH, BSAP, and miRNA‐30b, 30c, 125b, and 155. Spearman correlations assessed relationships between miRNAs and histomorphometry and PTH and BSAP. Diagnostic test characteristics for discriminating low from non‐low intracortical turnover were determined by receiver operator curve analysis; areas under the curve (AUC) were compared by χ2 test. In CKD rat models of low and high turnover ROD, we performed histomorphometry and determined the expression of bone tissue miRNAs. Circulating miRNAs moderately correlated with bone formation rate and adjusted apposition rate at the endo‐ and intracortical envelopes (ρ = 0.43 to 0.51; p < 0.05). Discrimination of low versus non‐low turnover was 0.866, 0.813, 0.813, and 0.723 for miRNA‐30b, 30c, 125b, and 155, respectively, and 0.509 and 0.589 for PTH and BSAP, respectively. For all four miRNAs combined, the AUC was 0.929, which was superior to that of PTH and BSAP alone and together (p < 0.05). In CKD rats, bone tissue levels of the four miRNAs reflected the findings in human serum. These data suggest that a panel of circulating miRNAs provide accurate noninvasive identification of bone turnover in ROD. © 2020 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Thomas L Nickolas
- Department of Medicine Columbia University Medical Center New York NY USA
| | - Neal Chen
- Division of Nephrology Indiana University School of Medicine Indianapolis IN USA
| | - Donald J McMahon
- Department of Medicine Columbia University Medical Center New York NY USA
| | - David Dempster
- Department of Pathology and Cell Biology Columbia University New York NY USA.,Regional Bone Center Helen Hayes Hospital New York NY USA
| | - Hua Zhou
- Regional Bone Center Helen Hayes Hospital New York NY USA
| | - James Dominguez
- Division of Nephrology Indiana University School of Medicine Indianapolis IN USA
| | - Maria A Aponte
- Department of Medicine Columbia University Medical Center New York NY USA
| | - Joshua Sung
- Department of Medicine Columbia University Medical Center New York NY USA
| | - Pieter Evenepoel
- Department of Microbiology and Immunology, Laboratory of Nephrology Katholieke Universiteit Leuven, University of Leuven Leuven Belgium
| | - Patrick C D'Haese
- Department of Biomedical Sciences, Laboratory of Pathophysiology Antwerp University Wilrijk Belgium
| | - Fabrice Mac-Way
- CHU de Québec Research Center, L'Hôtel-Dieu de Québec Hospital, Endocrinology and Nephrology Axis, Faculty and Department of Medicine Université Laval Quebec City Canada
| | - Rosa Moyses
- Laboratório de Investigação Médica 16 Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo Sao Paulo Brazil
| | - Sharon Moe
- Division of Nephrology Indiana University School of Medicine Indianapolis IN USA.,Department of Medicine Roudebush Veterans Administration Medical Center Indianapolis IN USA
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32
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Allen MR, Wallace J, McNerney E, Nyman J, Avin K, Chen N, Moe S. N-acetylcysteine (NAC), an anti-oxidant, does not improve bone mechanical properties in a rat model of progressive chronic kidney disease-mineral bone disorder. PLoS One 2020; 15:e0230379. [PMID: 32203558 PMCID: PMC7089527 DOI: 10.1371/journal.pone.0230379] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 02/27/2020] [Indexed: 01/17/2023] Open
Abstract
Individuals with chronic kidney disease have elevated levels of oxidative stress and are at a significantly higher risk of skeletal fracture. Advanced glycation end products (AGEs), which accumulate in bone and compromise mechanical properties, are known to be driven in part by oxidative stress. The goal of this study was to study effects of N-acetylcysteine (NAC) on reducing oxidative stress and improving various bone parameters, most specifically mechanical properties, in an animal model of progressive CKD. Male Cy/+ (CKD) rats and unaffected littermates were untreated (controls) or treated with NAC (80 mg/kg, IP) from 30 to 35 weeks of age. Endpoint measures included serum biochemistries, assessments of systemic oxidative stress, bone morphology, and mechanical properties, and AGE levels in the bone. CKD rats had the expected phenotype that included low kidney function, elevated parathyroid hormone, higher cortical porosity, and compromised mechanical properties. NAC treatment had mixed effects on oxidative stress markers, significantly reducing TBARS (a measure of lipid peroxidation) while not affecting 8-OHdG (a marker of DNA oxidation) levels. AGE levels in the bone were elevated in CKD animals and were reduced with NAC although this did not translate to a benefit in bone mechanical properties. In conclusion, NAC failed to significantly improve bone architecture/geometry/mechanical properties in our rat model of progressive CKD.
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Affiliation(s)
- Matthew R. Allen
- Department of Anatomy, Cell Biology and Physiology, Indiana University School of Medicine, Indianapolis, IN, United States of America
- Department of Biomedical Engineering, Indiana University—Purdue University, Indianapolis, IN, United States of America
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
- Roudebush VA Medical Center, Indianapolis, IN, United States of America
| | - Joseph Wallace
- Department of Biomedical Engineering, Indiana University—Purdue University, Indianapolis, IN, United States of America
| | - Erin McNerney
- Department of Anatomy, Cell Biology and Physiology, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Jeffry Nyman
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Keith Avin
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Neal Chen
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Sharon Moe
- Department of Anatomy, Cell Biology and Physiology, Indiana University School of Medicine, Indianapolis, IN, United States of America
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
- Roudebush VA Medical Center, Indianapolis, IN, United States of America
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33
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Bone Mineral Density in Relation to Chronic Kidney Disease After Heart Transplantation: A Retrospective Single-center Study at Skåne University Hospital in Lund 1988-2016. Transplant Direct 2020; 6:e537. [PMID: 32195328 PMCID: PMC7056280 DOI: 10.1097/txd.0000000000000981] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 11/26/2019] [Accepted: 12/11/2019] [Indexed: 12/14/2022] Open
Abstract
Background. Our aim was to investigate the bone mineral density (BMD) evolution and incidence of osteoporosis in relation to chronic kidney disease (CKD) up to 10 years after heart transplantation (HT). Methods. A retrospective analysis was performed on 159 HT patients at Skåne University Hospital in Lund 1988–2016. Results. The median follow-up time was 6.1 years (interquartile range = 7.5 y). HT patients with CKD stage <3 or normal kidney function before HT exhibited a greater mean BMD loss in the lumbar spine, compared to patients with CKD stage ≥3 before HT, at the first (−6.6% versus −2.5%, P = 0.029), second (−3.7% versus 2.1%, P = 0.018), and third (−2.0% versus 4.1%, P = 0.047) postoperative years, respectively. All included HT patients exhibited a BMD loss in the femoral neck at the first postoperative year (−8.8% [−10.3 to −7.3] in patients with CKD stage <3 or normal kidney function and −9.3% [−13.2 to −5.5] in patients with CKD stage ≥3 before HT), which was not fully reversed up to 10 years after HT. In adjusted models, CKD stage <3 before HT did not predict osteopenia and osteoporosis in the lumbar spine or femoral neck. Conclusions. CKD before HT did not predict BMD loss or osteoporosis development after HT. The study is, however, limited by a lack of data on fractures, and further studies on the relationship between CKD and postoperative bone strength are encouraged.
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34
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Mikolajewicz N, Bishop N, Burghardt AJ, Folkestad L, Hall A, Kozloff KM, Lukey PT, Molloy-Bland M, Morin SN, Offiah AC, Shapiro J, van Rietbergen B, Wager K, Willie BM, Komarova SV, Glorieux FH. HR-pQCT Measures of Bone Microarchitecture Predict Fracture: Systematic Review and Meta-Analysis. J Bone Miner Res 2020; 35:446-459. [PMID: 31643098 DOI: 10.1002/jbmr.3901] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 09/19/2019] [Accepted: 10/13/2019] [Indexed: 12/13/2022]
Abstract
High-resolution peripheral quantitative computed tomography (HR-pQCT) is a noninvasive imaging modality for assessing volumetric bone mineral density (vBMD) and microarchitecture of cancellous and cortical bone. The objective was to (1) assess fracture-associated differences in HR-pQCT bone parameters; and (2) to determine if HR-pQCT is sufficiently precise to reliably detect these differences in individuals. We systematically identified 40 studies that used HR-pQCT (39/40 used XtremeCT scanners) to assess 1291 to 3253 and 3389 to 10,687 individuals with and without fractures, respectively, ranging in age from 10.9 to 84.7 years with no comorbid conditions. Parameters describing radial and tibial bone density, microarchitecture, and strength were extracted and percentage differences between fracture and control subjects were estimated using a random effects meta-analysis. An additional meta-analysis of short-term in vivo reproducibility of bone parameters assessed by XtremeCT was conducted to determine whether fracture-associated differences exceeded the least significant change (LSC) required to discern measured differences from precision error. Radial and tibial HR-pQCT parameters, including failure load, were significantly altered in fracture subjects, with differences ranging from -2.6% (95% confidence interval [CI] -3.4 to -1.9) in radial cortical vBMD to -12.6% (95% CI -15.0 to -10.3) in radial trabecular vBMD. Fracture-associated differences reported by prospective studies were consistent with those from retrospective studies, indicating that HR-pQCT can predict incident fracture. Assessment of study quality, heterogeneity, and publication biases verified the validity of these findings. Finally, we demonstrated that fracture-associated deficits in total and trabecular vBMD and certain tibial cortical parameters can be reliably discerned from HR-pQCT-related precision error and can be used to detect fracture-associated differences in individual patients. Although differences in other HR-pQCT measures, including failure load, were significantly associated with fracture, improved reproducibility is needed to ensure reliable individual cross-sectional screening and longitudinal monitoring. In conclusion, our study supports the use of HR-pQCT in clinical fracture prediction. © 2019 American Society for Bone and Mineral Research.
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Affiliation(s)
- Nicholas Mikolajewicz
- Research Center, Shriners Hospital for Children, Montreal, Canada.,Department of Dentistry, McGill University, Montreal, Canada
| | - Nick Bishop
- Department of Oncology & Metabolism, University of Sheffield, Sheffield, UK
| | - Andrew J Burghardt
- Department of Radiology & Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA
| | - Lars Folkestad
- Department of Clinical Research, Odense University Hospital, Odense, Denmark
| | | | - Kenneth M Kozloff
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
| | | | | | | | - Amaka C Offiah
- Department of Oncology & Metabolism, University of Sheffield, Sheffield, UK
| | - Jay Shapiro
- Department of Bone and Osteogenesis Imperfecta, Kennedy Krieger Institute, Baltimore, MD, USA
| | - Bert van Rietbergen
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | | | - Bettina M Willie
- Research Center, Shriners Hospital for Children, Montreal, Canada.,Department of Pediatric Surgery, McGill University, Montreal, Canada
| | - Svetlana V Komarova
- Research Center, Shriners Hospital for Children, Montreal, Canada.,Department of Dentistry, McGill University, Montreal, Canada
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35
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Assessment of Renal Osteodystrophy via Computational Analysis of Label-free Raman Detection of Multiple Biomarkers. Diagnostics (Basel) 2020; 10:diagnostics10020079. [PMID: 32023980 PMCID: PMC7168928 DOI: 10.3390/diagnostics10020079] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 01/27/2020] [Accepted: 01/29/2020] [Indexed: 01/19/2023] Open
Abstract
Accurate clinical evaluation of renal osteodystrophy (ROD) is currently accomplished using invasive in vivo transiliac bone biopsy, followed by in vitro histomorphometry. In this study, we demonstrate that an alternative method for ROD assessment is through a fast, label-free Raman recording of multiple biomarkers combined with computational analysis for predicting the minimally required number of spectra for sample classification at defined accuracies. Four clinically relevant biomarkers: the mineral-to-matrix ratio, the carbonate-to-matrix ratio, phenylalanine, and calcium contents were experimentally determined and simultaneously considered as input to a linear discriminant analysis (LDA). Additionally, sample evaluation was performed with a linear support vector machine (LSVM) algorithm, with a 300 variable input. The computed probabilities based on a single spectrum were only marginally different (~80% from LDA and ~87% from LSVM), both providing an unacceptable classification power for a correct sample assignment. However, the Type I and Type II assignment errors confirm that a relatively small number of independent spectra (7 spectra for Type I and 5 spectra for Type II) is necessary for a p < 0.05 error probability. This low number of spectra supports the practicality of future in vivo Raman translation for a fast and accurate ROD detection in clinical settings.
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36
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Khairallah P, Nickolas TL, Fusaro M. How and when to assess bone mineral density and bone quality in chronic kidney disease patients? Nephrol Dial Transplant 2019; 36:774-776. [PMID: 31665427 DOI: 10.1093/ndt/gfz198] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Indexed: 01/26/2023] Open
Affiliation(s)
- Pascale Khairallah
- Division of Nephrology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Thomas L Nickolas
- Division of Nephrology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Maria Fusaro
- National Research Council (CNR), Institute of Clinical Physiology (IFC), Pisa, Italy.,Department of Medicine, University of Padova, Padova, Italy
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37
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Leonard MB, Wehrli FW, Ziolkowski SL, Billig E, Long J, Nickolas TL, Magland JF, Nihtianova S, Zemel BS, Herskovitz R, Rajapakse CS. A multi-imaging modality study of bone density, bone structure and the muscle - bone unit in end-stage renal disease. Bone 2019; 127:271-279. [PMID: 31158505 DOI: 10.1016/j.bone.2019.05.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 05/16/2019] [Accepted: 05/16/2019] [Indexed: 01/10/2023]
Abstract
End stage renal disease (ESRD) is associated with sarcopenia and skeletal fragility. The objectives of this cross-sectional study were to (1) characterize body composition, bone mineral density (BMD) and bone structure in hemodialysis patients compared with controls, (2) assess whether DXA areal BMD (aBMD) correlates with peripheral quantitative CT (pQCT) measures of volumetric BMD (vBMD), cortical dimensions and MRI measures of trabecular microarchitecture, and (3) determine the magnitude of bone deficits in ESRD after adjustment for muscle mass. Thirty ESRD participants, ages 25 to 64 years, were compared with 403 controls for DXA and pQCT outcomes and 104 controls for MRI outcomes; results were expressed as race- and sex- specific Z-scores relative to age. DXA appendicular lean mass index (ALMI kg/m2) and total hip, femoral neck, ultradistal and 1/3rd radius aBMD were significantly lower in ESRD, vs. controls (all p < 0.01). pQCT trabecular vBMD (p < 0.01), cortical vBMD (p < 0.001) and cortical thickness (due to a greater endosteal circumference, p < 0.02) and MRI measures of trabecular number, trabecular thickness, and whole bone stiffness were lower (all p < 0.01) in ESRD, vs. controls. ALMI was positively associated with total hip, femoral neck, ultradistal radius and 1/3rd radius aBMD and with tibia cortical thickness (R = 0.46 to 0.64). Adjustment for ALMI significantly attenuated bone deficits at these sites: e.g. mean femoral neck aBMD was 0.79 SD lower in ESRD, compared with controls and this was attenuated to 0.33 with adjustment for ALMI. In multivariate models within the dialysis participants, pQCT trabecular vBMD and cortical area Z-scores were significant and independently (all p < 0.02) associated with DXA femoral neck, total hip, and ultradistal radius aBMD Z-scores. Cortical vBMD (p = 0.01) and cortical area (p < 0.001) Z-scores were significantly and independently associated with 1/3rd radius areal aBMD Z-scores (R2 = 0.62). These data demonstrate that DXA aBMD captures deficits in trabecular and cortical vBMD and cortical area. The strong associations with ALMI, as an index of skeletal muscle, highlight the importance of considering the role of sarcopenia in skeletal fragility in patients with ESRD.
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Affiliation(s)
- Mary B Leonard
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States of America; Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States of America.
| | - Felix W Wehrli
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Susan L Ziolkowski
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Erica Billig
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Jin Long
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Thomas L Nickolas
- Department of Medicine, Columbia University, New York, NY, United States of America
| | - Jeremy F Magland
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Snejana Nihtianova
- Susanne M. Glasscock School of Continuing Studies, Rice University, Houston, TX, United States of America
| | - Babette S Zemel
- Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Rita Herskovitz
- Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Chamith S Rajapakse
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, United States of America; Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, United States of America
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38
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McNerny EMB, Buening DT, Aref MW, Chen NX, Moe SM, Allen MR. Time course of rapid bone loss and cortical porosity formation observed by longitudinal μCT in a rat model of CKD. Bone 2019; 125:16-24. [PMID: 31059864 PMCID: PMC6581598 DOI: 10.1016/j.bone.2019.05.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 04/29/2019] [Accepted: 05/02/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND Rodent studies of bone in chronic kidney disease have primarily relied on end-point examinations of bone microarchitecture. This study used longitudinal in vivo microcomputed tomography (in vivo μCT) to characterize the onset and progression of bone loss, specifically cortical porosity, in the Cy/+ rat of model of CKD. METHODS Male CKD rats and normal littermates were studied. In vivo μCT scans of the right distal tibia repeated at 25, 30, and 35 weeks were analyzed for longitudinal changes in cortical and trabecular bone morphometry. In vitro μCT scans of the tibia and femur identified spatial patterns of bone loss across distal, midshaft and proximal sites. RESULTS CKD animals had reduced BV/TV and cortical BV at all time points but developed cortical porosity and thinning between 30 and 35 weeks. Cortical pore formation was localized near the endosteal surface. The severity of bone loss was variable across bone sites, but the distal tibia was representative of both cortical and trabecular changes. CONCLUSIONS The distal tibia was found to be a sensitive suitable site for longitudinal imaging of both cortical and trabecular bone changes in the CKD rat. CKD trabecular bone loss progressed through ~30 weeks followed by a sudden acceleration in cortical bone catabolism. These changes varied in timing and severity across individuals, and cortical bone loss and porosity progressed rapidly once initiated. The inclusion of longitudinal μCT in future studies will be important for both reducing the number of required animals and to track individual responses to treatment.
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Affiliation(s)
- Erin M B McNerny
- Department of Anatomy and Cell Biology, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Dorothy T Buening
- Department of Anatomy and Cell Biology, Indiana University School of Medicine, Indianapolis, IN, United States; Alma College, Alma, MI, United States
| | - Mohammad W Aref
- Department of Anatomy and Cell Biology, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Neal X Chen
- Department of Medicine, Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Sharon M Moe
- Department of Medicine, Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, United States; Roudebush Veterans Administration Medical Center, Indianapolis, IN, United States
| | - Matthew R Allen
- Department of Anatomy and Cell Biology, Indiana University School of Medicine, Indianapolis, IN, United States; Department of Medicine, Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, United States; Department of Biomedical Engineering, Indiana University Purdue University of Indianapolis, Indianapolis, IN, United States; Roudebush Veterans Administration Medical Center, Indianapolis, IN, United States.
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Iseri K, Watanabe M, Lee XP, Yamada M, Ryu K, Iyoda M, Uchida N, Sato K, Shibata T. Elimination of intravenous alendronate by hemodialysis: A kinetic study. Hemodial Int 2019; 23:466-471. [PMID: 31328884 DOI: 10.1111/hdi.12773] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 06/20/2019] [Accepted: 06/23/2019] [Indexed: 12/22/2022]
Abstract
INTRODUCTION The potential utility of intravenous alendronate for the treatment of osteoporosis in hemodialysis patients was recently reported. However, the pharmacokinetics of intravenous alendronate in patients on hemodialysis is not clear. METHODS Six hemodialysis patients (mean age, 80.5 years) with osteoporosis who had received intravenous alendronate prior to the study were enrolled. The participants received a 30-min infusion of 900-μg alendronate intravenously at the beginning of the dialysis session. The blood flow rate (Qb) and dialysate flow rate (Qd) were set at 200 mL/min and 500 mL/min, respectively. All patients used the same dialyzer (1.5-m2 polysulfone membrane). At the completion of administration, plasma and dialysate samples were collected, and alendronate concentrations were determined using metal-free high-performance liquid chromatography (HPLC)-tandem mass spectrometry (MS/MS). RESULTS The plasma arterial alendronate concentration was 150.9 ± 46.09 ng/mL. It decreased through the dialyzer to 76.1 ± 34.1 ng/mL (venous alendronate concentration). Mean alendronate clearance was 113.9 ± 25.6 mL/min. Mean alendronate removal by hemodialysis, measured by the difference in arterial-venous concentrations, was 51.8%. CONCLUSIONS Fifty percent of intravenous alendronate was removed by hemodialysis, which is nearly equal to elimination of alendronate in patients with normal renal function. The elimination by hemodialysis would decrease the risk of excessive accumulation in bone. UMIN 000027182.
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Affiliation(s)
- Ken Iseri
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan.,Nephrology Center, Makita General Hospital, Tokyo, Japan
| | - Makoto Watanabe
- Nephrology Center, Makita General Hospital, Tokyo, Japan.,Department of Pharmacology, Showa University School of Medicine, Tokyo, Japan
| | - Xiao-Pen Lee
- Department of Legal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Miho Yamada
- Department of Legal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Kakei Ryu
- Clinial Research Institute of Clinical Pharmacology and Therapeutics, Showa University, Tokyo, Japan
| | - Masayuki Iyoda
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Naoki Uchida
- Department of Pharmacology, Showa University School of Medicine, Tokyo, Japan.,Clinial Research Institute of Clinical Pharmacology and Therapeutics, Showa University, Tokyo, Japan
| | - Keizo Sato
- Department of Legal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Takanori Shibata
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
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Osteoclast-Released Wnt-10b Underlies Cinacalcet Related Bone Improvement in Chronic Kidney Disease. Int J Mol Sci 2019; 20:ijms20112800. [PMID: 31181716 PMCID: PMC6600662 DOI: 10.3390/ijms20112800] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 05/29/2019] [Accepted: 06/06/2019] [Indexed: 12/18/2022] Open
Abstract
Secondary hyperparathyroidism (SHPT) relates to high turnover bone loss and is responsible for most bone fractures among chronic kidney disease (CKD) patients. Changes in the Wingless/beta-catenin signaling (Wnt/β-catenin) pathway and Wnt inhibitors have been found to play a critical role in CKD related bone loss. A calcimimetic agent, cinacalcet, is widely used for SHPT and found to be similarly effective for parathyroidectomy clinically. A significant decrease in hip fracture rates is noted among US hemodialysis Medicare patients since 2004, which is probably related to the cinacalcet era. In our previous clinical study, it was proven that cinacalcet improved the bone mineral density (BMD) even among severe SHPT patients. In this study, the influence of cinacalcet use on bone mass among CKD mice was determined. Cinacalcet significantly reduced the cortical porosity in femoral bones of treated CKD mice. It also improved the whole-bone structural properties through increased stiffness and maximum load. Cinacalcet increased femoral bone wingless 10b (Wnt10b) expression in CKD mice. In vitro studies revealed that cinacalcet decreased osteoclast bone resorption and increased Wnt 10b release from osteoclasts. Cinacalcet increased bone mineralization when culturing the osteoblasts with cinacalcet treated osteoclast supernatant. In conclusion, cinacalcet increased bone quantity and quality in CKD mice, probably through increased bone mineralization related with osteoclast Wnt 10b secretion.
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Wakolbinger R, Muschitz C, Scheriau G, Bodlaj G, Kocijan R, Feichtinger X, Schanda JE, Haschka J, Resch H, Pietschmann P. Bone microarchitecture and bone turnover in hepatic cirrhosis. Osteoporos Int 2019; 30:1195-1204. [PMID: 30788527 PMCID: PMC6546655 DOI: 10.1007/s00198-019-04870-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 01/21/2019] [Indexed: 02/06/2023]
Abstract
UNLABELLED Liver cirrhosis leads to bone loss. To date, information on bone quality (three-dimensional microarchitecture) and, thus, bone strength is scarce. We observed decreased bone quality at both assessed sites, independent of disease severity. Therefore, all patients should undergo early-stage screening for osteoporosis. INTRODUCTION Recent studies found low bone mineral density in cirrhosis, but data on bone microstructure are scarce. This study assessed weight-bearing and non-weight-bearing bones in patients with cirrhosis and healthy controls. The primary objective was to evaluate trabecular and cortical microarchitecture. METHODS This was a single-center study in patients with recently diagnosed hepatic cirrhosis. Thirty-two patients and 32 controls participated in this study. After determining the type of cirrhosis, the parameters of bone microarchitecture were assessed by high-resolution peripheral quantitative computed tomography. RESULTS Both cortical and trabecular microarchitectures showed significant alterations. At the radius, trabecular bone volume fraction was 17% lower (corrected p = 0.028), and, at the tibia, differences were slightly more pronounced. Trabecular bone volume fraction was 19% lower (p = 0.024), cortical bone mineral density 7% (p = 0.007), and cortical thickness 28% (p = 0.001), while cortical porosity was 32% higher (p = 0.023), compared to controls. Areal bone mineral density was lower (lumbar spine - 13%, total hip - 11%, total body - 9%, radius - 17%, and calcaneus - 26%). There was no correlation between disease severity and microarchitecture. Areal bone mineral density (aBMD) measured by dual-energy X-ray absorptiometry (DXA) correlated well with parameters of cortical and trabecular microarchitecture. CONCLUSIONS Hepatic cirrhosis deteriorates both trabecular and cortical microarchitecture, regardless of disease severity. Areal bone mineral density is diminished at all sites as a sign of generalized affection. In patients with hepatic cirrhosis, regardless of its origin or disease severity, aBMD measurements are an appropriate tool for osteologic screening.
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Affiliation(s)
- R Wakolbinger
- Medical Department II-The VINFORCE Study Group, St. Vincent Hospital, Academic Teaching Hospital of the Medical University of Vienna, Stumpergasse 13, A-1060, Vienna, Austria
- Department of Physical Medicine and Rehabilitation, Danube Hospital-Social Medical Center East, Academic Teaching Hospital of the Medical University of Vienna, Langobardenstraße 122, A-1220, Vienna, Austria
| | - C Muschitz
- Medical Department II-The VINFORCE Study Group, St. Vincent Hospital, Academic Teaching Hospital of the Medical University of Vienna, Stumpergasse 13, A-1060, Vienna, Austria.
| | - G Scheriau
- Medical Department II-The VINFORCE Study Group, St. Vincent Hospital, Academic Teaching Hospital of the Medical University of Vienna, Stumpergasse 13, A-1060, Vienna, Austria
| | - G Bodlaj
- Medical Department II-The VINFORCE Study Group, St. Vincent Hospital, Academic Teaching Hospital of the Medical University of Vienna, Stumpergasse 13, A-1060, Vienna, Austria
| | - R Kocijan
- Medical Department II-The VINFORCE Study Group, St. Vincent Hospital, Academic Teaching Hospital of the Medical University of Vienna, Stumpergasse 13, A-1060, Vienna, Austria
| | - X Feichtinger
- Medical Department II-The VINFORCE Study Group, St. Vincent Hospital, Academic Teaching Hospital of the Medical University of Vienna, Stumpergasse 13, A-1060, Vienna, Austria
- AUVA Trauma Center Meidling, Kundratstraße 37, A-1120, Vienna, Austria
| | - J E Schanda
- Medical Department II-The VINFORCE Study Group, St. Vincent Hospital, Academic Teaching Hospital of the Medical University of Vienna, Stumpergasse 13, A-1060, Vienna, Austria
- AUVA Trauma Center Meidling, Kundratstraße 37, A-1120, Vienna, Austria
| | - J Haschka
- Medical Department II-The VINFORCE Study Group, St. Vincent Hospital, Academic Teaching Hospital of the Medical University of Vienna, Stumpergasse 13, A-1060, Vienna, Austria
| | - H Resch
- Medical Department II-The VINFORCE Study Group, St. Vincent Hospital, Academic Teaching Hospital of the Medical University of Vienna, Stumpergasse 13, A-1060, Vienna, Austria
| | - P Pietschmann
- Department of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Währinger Gürtel 18-20, A-1090, Vienna, Austria
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Yin MT, RoyChoudhury A, Bucovsky M, Colon I, Ferris DC, Olender S, Agarwal S, Sharma A, Zeana C, Zingman B, Shane E. A Randomized Placebo-Controlled Trial of Low- Versus Moderate-Dose Vitamin D3 Supplementation on Bone Mineral Density in Postmenopausal Women With HIV. J Acquir Immune Defic Syndr 2019; 80:342-349. [PMID: 30531305 PMCID: PMC6375749 DOI: 10.1097/qai.0000000000001929] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Prevalence of osteoporosis and fracture is increased among older people with HIV. We compared the effects of low (1000 IU) vs moderate (3000 IU) vitamin D3 (VitD) supplementation on areal bone mineral density (aBMD) and volumetric bone mineral density (vBMD) in African American and Hispanic postmenopausal women with HIV on antiretroviral therapy. METHODS We performed a 12-month prospective, randomized, double-blind, placebo-controlled study with primary outcomes of change in aBMD by dual-energy X-ray absorptiometry (DXA) and secondary outcomes of change in vBMD by quantitative computed tomography and bone turnover markers. An intent-to-treat analysis was performed on 85 randomized subjects (43 low and 42 moderate) for primary DXA outcomes, and complete case analysis was performed for secondary outcomes. RESULTS Mean age was 56 ± 5 years, median CD4 count was 722 cells/mm, and 74% had HIV RNA ≤ 50 copies/mL. Serum 25-OHD was higher in the moderate than low VitD group at 6 months (33.1 ± 10.3 vs 27.8 ± 8.1 ng/mL, P = 0.03) and 12 months, but parathyroid hormone levels remained similar. Percent change in aBMD, vBMD, and bone turnover markers did not differ between low and moderate VitD groups before or after adjustment for baseline aBMD. CONCLUSIONS VitD supplementation at 3000 IU daily increased mean total 25-OHD levels in postmenopausal women with HIV, but we did not find evidence of an effect on BMD beyond those observed with 1000 IU daily. Future studies are necessary to determine whether VitD supplementation is beneficial in this patient population, and if so, what dose is optimal for skeletal health.
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Affiliation(s)
- Michael T Yin
- Department of Medicine, Columbia University Medical Center, New York, NY
| | - Arindam RoyChoudhury
- Division of Biostatistics and Epidemiology, Department of Healthcare Policy and Research, Weill Cornell Medical College, Cornell University, New York, NY
| | - Mariana Bucovsky
- Department of Medicine, Columbia University Medical Center, New York, NY
| | - Ivelisse Colon
- Department of Medicine, Columbia University Medical Center, New York, NY
| | - David C Ferris
- Department of Medicine, Mt. Sinai St. Luke's and Mt. Sinai West, New York, NY
- Department of Medicine, Bronx-Lebanon Hospital Center, Bronx, NY
| | - Susan Olender
- Department of Medicine, Columbia University Medical Center, New York, NY
| | - Sanchita Agarwal
- Department of Medicine, Columbia University Medical Center, New York, NY
| | - Anjali Sharma
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Cosmina Zeana
- Department of Medicine, Bronx-Lebanon Hospital Center, Bronx, NY
| | - Barry Zingman
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Elizabeth Shane
- Department of Medicine, Columbia University Medical Center, New York, NY
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Bisson SK, Ung RV, Picard S, Valade D, Agharazii M, Larivière R, Mac-Way F. High calcium, phosphate and calcitriol supplementation leads to an osteocyte-like phenotype in calcified vessels and bone mineralisation defect in uremic rats. J Bone Miner Metab 2019; 37:212-223. [PMID: 29603070 DOI: 10.1007/s00774-018-0919-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 02/20/2018] [Indexed: 11/26/2022]
Abstract
A link between vascular calcification and bone anomalies has been suggested in chronic kidney disease (CKD) patients with low bone turnover disease. We investigated the vascular expression of osteocyte markers in relation to bone microarchitecture and mineralization defects in a model of low bone turnover CKD rats with vascular calcification. CKD with vascular calcification was induced by 5/6 nephrectomy followed by high calcium and phosphate diet, and vitamin D supplementation (Ca/P/VitD). CKD + Ca/P/VitD group (n = 12) was compared to CKD + normal diet (n = 12), control + normal diet (n = 8) and control + Ca/P/VitD supplementation (n = 8). At week 6, tibia, femurs and the thoracic aorta were analysed by Micro-Ct, histomorphometry and for expression of osteocyte markers. High Ca/P/VitD treatment induced vascular calcification only in CKD rats, suppressed serum parathyroid hormone levels and led to higher sclerostin, DKK1 and FGF23 serum levels. Expression of sclerostin, DKK1 and DMP1 but not FGF23 were increased in calcified vessels from CKD + Ca/P/VitD rats. Despite low parathyroid hormone levels, tibia bone cortical thickness was significantly lower in CKD + Ca/P/VitD rats as compared to control rats fed a normal diet, which is likely the result of radial growth impairment. Finally, Ca/P/VitD treatment in CKD rats induced a bone mineralization defect, which is likely explained by the high calcitriol dose. In conclusion, Ca/P/VitD supplementation in CKD rats induces expression of osteocyte markers in vessels and bone mineralisation anomalies. Further studies should evaluate the mechanisms of high dose calcitriol-induced bone mineralisation defects in CKD.
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Affiliation(s)
- Sarah-Kim Bisson
- Endocrinology and Nephrology Axis, Faculty and Department of Medicine, L'Hôtel-Dieu de Québec Hospital, CHU de Québec Research Center, Université Laval, 10 McMahon, Quebec City, QC, G1R 2J6, Canada
| | - Roth-Visal Ung
- Endocrinology and Nephrology Axis, Faculty and Department of Medicine, L'Hôtel-Dieu de Québec Hospital, CHU de Québec Research Center, Université Laval, 10 McMahon, Quebec City, QC, G1R 2J6, Canada
| | - Sylvain Picard
- Endocrinology and Nephrology Axis, Faculty and Department of Medicine, L'Hôtel-Dieu de Québec Hospital, CHU de Québec Research Center, Université Laval, 10 McMahon, Quebec City, QC, G1R 2J6, Canada
| | - Danika Valade
- Endocrinology and Nephrology Axis, Faculty and Department of Medicine, L'Hôtel-Dieu de Québec Hospital, CHU de Québec Research Center, Université Laval, 10 McMahon, Quebec City, QC, G1R 2J6, Canada
| | - Mohsen Agharazii
- Endocrinology and Nephrology Axis, Faculty and Department of Medicine, L'Hôtel-Dieu de Québec Hospital, CHU de Québec Research Center, Université Laval, 10 McMahon, Quebec City, QC, G1R 2J6, Canada
| | - Richard Larivière
- Endocrinology and Nephrology Axis, Faculty and Department of Medicine, L'Hôtel-Dieu de Québec Hospital, CHU de Québec Research Center, Université Laval, 10 McMahon, Quebec City, QC, G1R 2J6, Canada
| | - Fabrice Mac-Way
- Endocrinology and Nephrology Axis, Faculty and Department of Medicine, L'Hôtel-Dieu de Québec Hospital, CHU de Québec Research Center, Université Laval, 10 McMahon, Quebec City, QC, G1R 2J6, Canada.
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Pediatric bone evaluation with HR-pQCT: A comparison between standard and height-adjusted positioning protocols in a cohort of teenagers with chronic kidney disease. Arch Pediatr 2019; 26:151-157. [PMID: 30827777 DOI: 10.1016/j.arcped.2019.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 12/07/2018] [Accepted: 02/03/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND High-resolution peripheral quantitative computed tomography (HR-pQCT) evaluates different components of bone fragility. The positioning and length of the region of interest (ROI) in growing populations remain to be defined. METHODS Using HR-pQCT at the ultradistal tibia, we compared a single-center cohort of 28 teenagers with chronic kidney disease (CKD) at a median age of 13.6 (range, 10.2-19.9) years to local age-, gender-, and puberty-matched healthy peers. Because of the potential impact of short stature, bone parameters were assessed on two different leg-length-adjusted ROIs in comparison to the standard analysis, namely the one applied in adults. The results are presented as median (range). RESULTS After matching, SDS height was -0.9 (-3.3;1.6) and 0.3 (-1.4;2.0) in patients and controls, respectively (P<0.001). In younger children (e.g., prepubertal, n=11), bone texture parameters and bone strength were not different using standard analysis. However, using a height-adjusted ROI enabled better characterization of cortical bone structure. In older patients (e.g., pubertal, n=17), there were no differences for height between patients and controls: with the standard evaluation, cortical bone area and cortical thickness were significantly lower in CKD patients: 85 (50-124) vs. 108 (67-154) mm2 and 0.89 (0.46-1.31) vs 1.09 (0.60-1.62) mm, respectively (both P<0.05). CONCLUSIONS Adapting the ROI to leg length enables better assessment of bone structure, especially when height discrepancies exist between controls and patients. Larger cohorts are required to prospectively validate this analytic HR-pQCT technique.
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Han SG, Oh J, Jeon HJ, Park C, Cho J, Shin DH. Kidney Stones and Risk of Osteoporotic Fracture in Chronic Kidney Disease. Sci Rep 2019; 9:1929. [PMID: 30760766 PMCID: PMC6374417 DOI: 10.1038/s41598-018-38191-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 12/20/2018] [Indexed: 01/19/2023] Open
Abstract
Osteoporotic fracture associated with calcium dysregulation is more common in patients with kidney stones. However, little is known about the association of kidney stones and bone health status in patients with chronic kidney disease (CKD). This retrospective medical record-based study included 2282 patients with stable stage 3–4 CKD between 2007 and 2017. Of these, 113 patients were diagnosed with kidney stones. Propensity score matching for 226 patients with and without kidney stones showed that osteoporotic fracture occurred more often in patients with kidney stones (33, 29.2%) than in patients without kidney stones (16, 14.2%), resulting in rates of 5.56 and 2.63/100 patient-years, respectively (p < 0.01). In particular, Cox proportional hazard analysis revealed that kidney stones were significantly associated with osteoporotic fracture, even after adjusting for age, sex, body mass index, kidney stones, estimated glomerular filtration rate, excessive alcohol consumption, current smoking, and steroid use in patients with CKD stage 3–4 (hazard ratio, 2.32, 95% CI 1.24–4.34, p = 0.01). This study showed that the presence of kidney stones was a significant predictor for osteoporotic fracture in patients with CKD, suggesting that it should be considered as a clinical risk factor for osteoporotic fracture in them.
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Affiliation(s)
- Seung Gyu Han
- Department of Internal Medicine, Kang Dong Dr. Han medical clinic, 156, Seongan-ro, Gangdong-gu, Seoul, 05355, Korea
| | - Jieun Oh
- Department of Internal Medicine, College of Medicine, Hallym University, Kandong Sacred Heart Hospital, 150, Seongan-ro, Gangdong-gu, Seoul, 05355, Korea
| | - Hee Jung Jeon
- Department of Internal Medicine, College of Medicine, Hallym University, Kandong Sacred Heart Hospital, 150, Seongan-ro, Gangdong-gu, Seoul, 05355, Korea
| | - Chan Park
- Department of Internal Medicine, College of Medicine, Hallym University, Kandong Sacred Heart Hospital, 150, Seongan-ro, Gangdong-gu, Seoul, 05355, Korea
| | - Jeonghwan Cho
- Department of Internal Medicine, College of Medicine, Hallym University, Kandong Sacred Heart Hospital, 150, Seongan-ro, Gangdong-gu, Seoul, 05355, Korea
| | - Dong Ho Shin
- Department of Internal Medicine, College of Medicine, Hallym University, Kandong Sacred Heart Hospital, 150, Seongan-ro, Gangdong-gu, Seoul, 05355, Korea.
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Aleksova J, Rodriguez AJ, McLachlan R, Kerr P, Milat F, Ebeling PR. Gonadal Hormones in the Pathogenesis and Treatment of Bone Health in Patients with Chronic Kidney Disease: a Systematic Review and Meta-Analysis. Curr Osteoporos Rep 2018; 16:674-692. [PMID: 30328552 DOI: 10.1007/s11914-018-0483-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW Patients with chronic kidney disease (CKD) have a greatly increased fracture risk compared with the general population. Gonadal hormones have an important influence on bone mineral density (BMD) and fracture risk, and hormone therapies can significantly improve these outcomes. Gonadal dysfunction is a frequent finding in patients with CKD; yet, little is known about the impact of gonadal hormones in the pathogenesis and treatment of bone health in patients with CKD. This systematic review and meta-analysis aimed to examine the effects of gonadal hormones and hormone therapies on bone outcomes in men and women with CKD. METHODS EMBASE, MEDLINE, SCOPUS, and clinical trial registries were systematically searched from inception to February 14, 2018 for studies that assessed gonadal hormones or hormone treatments with bone outcomes in patients with CKD stage 3-5D. Two independent reviewers screened the titles and abstracts of search results according to inclusion criteria and assessed study quality and risk of bias using validated assessment tools. RECENT FINDINGS Thirteen studies met the inclusion criteria. Six moderate-to-high quality observational studies showed inconsistent association between any gonadal hormone and bone outcomes, limited by significant study heterogeneity. Five moderate-high risk of bias interventional studies examined treatment with selective oestrogen receptor modulators in post-menopausal women (four using raloxifene and one bazedoxifene) and demonstrated variable effects on BMD and fracture outcomes. Meta-analysis of raloxifene treatment in post-menopausal women demonstrated improvement in lumbar spine (SMD 3.30; 95% CI 3.21-3.38) and femoral neck (SMD 3.29; 95% CI 3.21-3.36) BMD compared with placebo. Transdermal oestradiol/norethisterone in pre-menopausal women receiving dialysis (n = 1 study), demonstrated BMD improvement over 12 months. Testosterone treatment for 6 months in dialysis-dependant men (n = 1 study) did not improve BMD. There is evidence that raloxifene treatment may be beneficial in improving BMD in post-menopausal women with CKD. There is insufficient evidence for other hormone treatments in men or women. Despite high fracture rates and frequent gonadal dysfunction in patients with CKD, significant evidence gaps exist, and well-designed studies are required to specifically assess the impact of gonadal status in the pathogenesis of CKD-related bone fragility and its treatment.
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Affiliation(s)
- Jasna Aleksova
- Department of Endocrinology, Monash Health, 246 Clayton Rd. Clayton, Melbourne, Victoria, 3168, Australia.
- Hudson Institute of Medical Reearch, Clayton, Melbourne, Australia.
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Australia.
| | - Alexander J Rodriguez
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Australia
- Bone & Muscle Health Research Group, Department of Medicine, Monash University, Melbourne, Australia
| | - Robert McLachlan
- Department of Endocrinology, Monash Health, 246 Clayton Rd. Clayton, Melbourne, Victoria, 3168, Australia
- Hudson Institute of Medical Reearch, Clayton, Melbourne, Australia
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Australia
| | - Peter Kerr
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Australia
- Department of Nephrology, Monash Health, Melbourne, Australia
| | - Frances Milat
- Department of Endocrinology, Monash Health, 246 Clayton Rd. Clayton, Melbourne, Victoria, 3168, Australia
- Hudson Institute of Medical Reearch, Clayton, Melbourne, Australia
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Australia
| | - Peter R Ebeling
- Department of Endocrinology, Monash Health, 246 Clayton Rd. Clayton, Melbourne, Victoria, 3168, Australia
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Australia
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Abstract
PURPOSE OF REVIEW Despite metabolic improvements following kidney transplantation, transplant recipients still often suffer from complex mineral and bone disease after transplantation. RECENT FINDINGS The pathophysiology of post-transplant disease is unique, secondary to underlying pre-transplant mineral and bone disease, immunosuppression, and changing kidney function. Changes in modern immunosuppression regimens continue to alter the clinical picture. Modern management includes reducing cumulative steroid exposure and correcting the biochemical abnormalities in mineral metabolism. While bone mineral density screening appears to help predict fracture risk and anti-osteoporotic therapy appears to have a positive effect on bone mineral density, more data regarding specific treatment is necessary. Patients with mineral and bone disease after kidney transplantation require special care in order to properly manage and mitigate their mineral and bone disease. Recent changes in clinical management of transplant patients may also be changing the implications on patients' mineral and bone disease.
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Affiliation(s)
- Ariella M Altman
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Stuart M Sprague
- Division of Nephrology and Hypertension, NorthShore University HealthSystem, University of Chicago Medical School, 2650 Ridge Avenue, Evanston, IL, 60201, USA.
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48
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Abstract
PURPOSE OF REVIEW Chronic kidney disease (CKD) is associated with bone loss and fractures. The purpose of this review is to provide clinicians with an overview of the underlying pathogenesis of CKD-associated osteoporosis, and a summary of the current diagnostic and therapeutic approaches to this disease. RECENT FINDINGS In 2017, the Kidney Disease Improving Global Outcomes Committee on Bone Quality updated their guidelines to include screening for osteoporosis and fracture risk by dual energy X-ray absorptiometry in patients with CKD. Once a diagnosis of osteoporosis and/or fracture risk is established, it is not clear how nephrologists should manage their patients. Patients with CKD should be screened for CKD-associated osteoporosis and considered for strategies that prevent bone loss and fractures. Assessment of bone turnover via imaging, biochemical testing, or bone biopsy can help guide the choice of therapy. Randomized controlled trials are needed to assess safety and efficacy of treatments to prevent bone loss and fractures.
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Affiliation(s)
- Pascale Khairallah
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, 622 West 168th Street, PH2-124, New York City, NY, 10032, USA
| | - Thomas L Nickolas
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, 622 West 168th Street, PH2-124, New York City, NY, 10032, USA.
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49
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Damasiewicz MJ, Nickolas TL. Rethinking Bone Disease in Kidney Disease. JBMR Plus 2018; 2:309-322. [PMID: 30460334 PMCID: PMC6237213 DOI: 10.1002/jbm4.10117] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 09/05/2018] [Accepted: 10/03/2018] [Indexed: 12/17/2022] Open
Abstract
Renal osteodystrophy (ROD) is the bone component of chronic kidney disease mineral and bone disorder (CKD-MBD). ROD affects bone quality and strength through the numerous hormonal and metabolic disturbances that occur in patients with kidney disease. Collectively these disorders in bone quality increase fracture risk in CKD patients compared with the general population. Fractures are a serious complication of kidney disease and are associated with higher morbidity and mortality compared with the general population. Furthermore, at a population level, fractures are at historically high levels in patients with end-stage kidney disease (ESKD), whereas in contrast the general population has experienced a steady decline in fracture incidence rates. Based on these findings, it is clear that a paradigm shift is needed in our approach to diagnosing and managing ROD. In clinical practice, our ability to diagnose ROD and initiate antifracture treatments is impeded by the lack of accurate noninvasive methods that identify ROD type. The past decade has seen advances in the noninvasive measurement of bone quality and strength that have been studied in kidney disease patients. Below we review the current literature pertaining to the epidemiology, pathology, diagnosis, and management of ROD. We aim to highlight the pressing need for a greater awareness of this condition and the need for the implementation of strategies that prevent fractures in kidney disease patients. Research is needed for more accurate noninvasive assessment of ROD type, clinical studies of existing osteoporosis therapies in patients across the spectrum of kidney disease, and the development of CKD-specific treatments. © 2018 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of the American Society for Bone and Mineral Research.
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Affiliation(s)
- Matthew J Damasiewicz
- Department of NephrologyMonash HealthClaytonAustralia
- Department of MedicineMonash UniversityClaytonAustralia
| | - Thomas L Nickolas
- Columbia University Medical CenterDepartment of MedicineDivision of NephrologyNew YorkNYUSA
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50
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Ramalho J, Marques IDB, Hans D, Dempster D, Zhou H, Patel P, Pereira RMR, Jorgetti V, Moyses RMA, Nickolas TL. The trabecular bone score: Relationships with trabecular and cortical microarchitecture measured by HR-pQCT and histomorphometry in patients with chronic kidney disease. Bone 2018; 116:215-220. [PMID: 30098418 DOI: 10.1016/j.bone.2018.08.006] [Citation(s) in RCA: 37] [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: 05/15/2018] [Revised: 08/06/2018] [Accepted: 08/07/2018] [Indexed: 10/28/2022]
Abstract
The trabecular bone score (TBS) is a novel tool using grayscale variograms of the lumbar spine bone mineral density (BMD) to assess trabecular bone microarchitecture. Studies in patients with chronic kidney disease (CKD) suggest it may be helpful in assessing fracture risk. However, TBS has not been validated as a measure of trabecular architecture against transiliac bone biopsy with histomorphometry in CKD patients. We hypothesized that TBS would reflect trabecular architecture at the iliac crest in CKD patients. We obtained tetracycline double labeled transiliac crest bone biopsy, areal BMD of the spine, total hip, femoral neck (FN) and spine TBS by dual energy X-ray absorptiometry (DXA), and cortical and trabecular volumetric density and microarchitecture by high resolution peripheral quantitative computed tomography (HR-pQCT) in CKD patients from two centers: twenty-two patients from Columbia University Medical Center, USA and thirty patients from Hospital das Clinicas - Universidade de São Paulo, Brazil. Two patients were excluded for outlier status. Univariate and multivariate relationships between TBS and measures from DXA, HR-pQCT and histomorphometry were determined. Patients were 50.2 ± 15.8 years old, 23 (46%) were men, and 33 (66%) were on dialysis. TBS was <1.31 in 21 (42%) patients and 22%, 14% and 10% had T-scores ≤ -2.5 at spine, FN and total hip respectively. In univariate regression, TBS was significantly associated with trabecular bone volume (BV/TV), trabecular width (Tb.Wi), trabecular spacing, cortical width but not with trabecular number or cortical porosity. FN Z-score and height were also associated with cancellous BV/TV and Tb.Wi, In multivariate analysis, TBS remained an independent predictor of BV/TV and Tb.Wi. There were no relationships between TBS and dynamic parameters from histomorphometry. These data suggest that TBS reflected trabecular microarchitecture and cortical width measured by bone biopsy in CKD patients. Future studies should address its utility in the identification of CKD patients who may benefit from fracture prevention strategies.
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Affiliation(s)
- J Ramalho
- Laboratório de Investigação Médica 16, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, SP, Brazil
| | - I D B Marques
- Laboratório de Investigação Médica 16, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, SP, Brazil
| | - Didier Hans
- Center of bone Diseases, Bone & Joint Department, Lausanne University Hospital, Lausanne, Switzerland
| | - David Dempster
- Department of Pathology and Cell Biology, Columbia University, New York, NY, USA; Regional Bone Center, Helen Hayes Hospital, West Haverstraw, New York, NY, USA
| | - Hua Zhou
- Regional Bone Center, Helen Hayes Hospital, West Haverstraw, New York, NY, USA
| | - Parth Patel
- Columbia University College of Physicians & Surgeons, New York, NY, USA
| | - R M R Pereira
- Bone Laboratory Metabolism, Rheumatology Division, Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - V Jorgetti
- Laboratório de Investigação Médica 16, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, SP, Brazil; Hospital Samaritano Americas Serviços Médicos, Sao Paulo, SP, Brazil
| | - R M A Moyses
- Laboratório de Investigação Médica 16, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, SP, Brazil; Universidade Nove de Julho, São Paulo, SP, Brazil
| | - Thomas L Nickolas
- Department of Medicine, Columbia University Medical Center, New York, NY, USA.
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