Clinical and subclinical cardiovascular disease in female SLE patients: Interplay between body mass index and bone mineral density.

BACKGROUND AND AIMS: Since accelerated atherosclerosis has been reported in systemic lupus erythematosus (SLE), predictive biomarkers of cardiovascular disease (CVD) are needed. Among non-traditional risk factors, bone mineral density (BMD) has been related to CVD. However, its role in SLE remains controversial. This study aims to analyze the associations of subclinical atherosclerosis with traditional and non-traditional CV risk factors. METHODS AND RESULTS: In a cross-sectional study, atherosclerosis burden was compared between 112 female SLE patients and 31 controls. Plaque number and carotid intima-media wall thickness (cIMT) were assessed by ultrasonography. In a retrospective study, BMD determinations obtained 5-years before the ultrasonography assessment were analyzed in a subgroup of 62 patients. Plaque frequency was increased in SLE, even in patients without CV events or carotid wall thickening. cIMT was increased in patients with CVD, positively correlated with body mass index (BMI). Interestingly, a paradoxical effect of BMI on carotid parameters was observed. Whereas underweight patients (BMI < 20) showed increased prevalence of carotid plaques with low cIMT, those with BMI > 30 showed higher cIMT and plaque burden. Overweight patients (25 < BMI<30) exhibited both elevated cIMT and plaque number. BMI was an independent predictor of BMD. In our retrospective study, patients with either clinical or subclinical CVD exhibited lower BMD levels than their CV-free counterparts. A low lumbar spine BMD independently predicted CVD development after adjusting for confounders. CONCLUSION: SLE was associated with a higher subclinical atherosclerosis burden, a bimodal effect being observed for BMI. Decreased BMD can be a CV risk biomarker in SLE.

Association of matrix Gla protein gene functional polymorphisms with loss of bone mineral density and progression of aortic calcification.

UNLABELLED: Two matrix Gla protein (MGP) polymorphisms were associated with progression of aortic calcification and femoral neck bone loss in men. All these findings were also functionally corroborated in two vascular and bone in vitro systems indicating that MGP genetic variations can be partly responsible of higher risk of bone loss and vascular calcification. INTRODUCTION: MGP plays an important role in bone and vascular mineralization as confirmed by MGP-deficient murine model. We therefore aimed to find a genetic association among -138T>C, -7G>A, and Thr83Ala MGP single-nucleotide polymorphisms (SNPs), bone loss, and progression of aortic calcification in a randomly selected general population of 296 individuals who participated in the European Vertebral Osteoporosis Study. METHODS: To evaluate the rate of change in bone mineral density (BMD) and the progression of aortic calcification, dual X-ray absorptiometry and lateral spine X-rays were performed at baseline and after 4 years of follow-up. Genotyping for the three polymorphisms was carried out using polymerase chain reaction and restriction fragment length analysis. In addition, functional studies of MGP-7G>A and Thr83Ala SNPs were performed on transiently transfected osteoblast-like UMR-106 and vascular smooth muscle A7r5 cells. RESULTS: The proportion of men who had lost BMD in the femoral neck was higher among homozygous -7AA and 83Ala-Ala (p = 0.039 and p = 0.009, respectively), and also featured a higher risk of progression of aortic calcifications (OR = 5.6, 95% CI = 1.2-27.8 and OR = 6.8, 95% CI = 1.4-32.3, respectively). No effect was observed in women. The MGP-7A allele produced a reduction in luciferase activity compared to MGP-7G: 47% less in vascular cells and 34% less in bone cells (p = 0.001 and 0.012, respectively). In vascular cells under calcifying conditions, the MGP 83Thr allele showed a slightly higher, although not significant, inhibition than the MGP 83 Ala allele in calcium content suggesting functional differences between both variants. CONCLUSION: These results suggest that MGP genetic variations could predict a higher risk of bone loss and progression of vascular calcification in men.

Low calcidiol levels and risk of progression of aortic calcification.

UNLABELLED: In this observational study, we found a positive relationship between low calcidiol levels and the risk of aortic calcification progression. A 10-ng/mL increase of calcidiol was associated with a decrease in the risk of progression by 44%. This figure was higher than that observed if we increased age by 10 years. INTRODUCTION: The aim of this study was to investigate the relationship between serum calcidiol levels and the onset and progression of aortic calcifications in a community-based sample of ambulatory subjects. METHODS: Three hundred two men and women aged 50 and over underwent two lateral X-rays and were followed up for 4 years. Abdominal aortic calcifications were classified as absent, mild-moderate, and severe. The biochemical measurements of serum calcium, phosphorus, parathyroid hormone, total alkaline phosphatase, tartrate-resistant acid phosphatase, creatinine, calcidiol, calcitriol, and osteocalcin were determined. Subjects who had received anti-osteoporotic treatments were excluded from the analysis. RESULTS: Subjects with progression of aortic calcifications had significantly lower serum calcidiol levels than those without progression. In the multivariate analysis, using the agreed upon serum levels for calcidiol (>30 ng/mL) as the reference, those subjects with calcidiol levels between 10 and 20 ng/mL showed a higher risk of progression of aortic calcification (odds ratio (OR) = 3.95; 95% confidence interval (CI) = 1.16 to 13.40). An even higher OR was observed in subjects with calcidiol values <10 ng/mL (OR = 4.10; 95% CI = 1.12 to 14.99). In addition, an increase by 1 ng/mL in osteocalcin levels was associated with a 17% reduction of the risk of aortic calcification progression. CONCLUSIONS: An increase by 10 ng/mL of calcidiol was associated with a decrease in the risk of aortic calcifications progression by 44%. This figure was even higher than that observed if we increased age by 10 years. Levels of calcidiol higher than 30 ng/mL seem to be desirable to reduce the progression of aortic calcification and to maintain bone turnover.

[The role of calcium, calcitriol and their receptors in parathyroid regulation]. / Papel de calcio, calcitriol y sus receptores en la regulación de la paratiroides.

The mechanism of regulation of Parathyroid hormone (PTH) is complex, and diverse factors are involved: the fundamental ones are calcium, calcitriol and phosphorus. Calcium and calcitriol's mechanism of action takes place through its specific receptors, the calcium-sensing receptor (CaR) and the Vitamin D Receptor (VDR). These two factors have an effect not only on its specific receptors, but also they can modify the other receptor in a positive manner, promoting its actions and demonstrating a cooperative effect between the two. Along with calcium and calcitriol, drugs used in the treatment of Chronic Kidney Disease Mineral Bone Disorders (CKD-MBD) also act directly or indirectly on CaR and VDR and therefore are also responsible for the regulation of the parathyroid gland.

Effects of estradiol, calcitriol and both treatments combined on bone histomorphometry in rats with chronic kidney disease and ovariectomy.

BACKGROUND: The aim of this experimental study was to analyze the histomorphometric changes observed when using different doses of estradiol, calcitriol and both treatments combined, in rats with both chronic kidney disease (CKD) and ovariectomy (OVX). METHODS: Six groups of rats with CKD+OVX were treated for 8 weeks with placebo, with different doses of 17beta-estradiol (E2), with calcitriol or with both treatments combined (E2+calcitriol). Histomorphometric studies were carried out at the proximal tibia segment. RESULTS: All groups that received active treatments showed a trabecular bone volume similar to those of rats with normal ovarian function. Treatment with E2 was effective, E2-10 diminished osteoid and eroded surfaces, and E2-30 was able to achieve a bone remodeling similar to that of the normal group. Calcitriol proved to have a positive effect on bone microarchitecture, achieving normal trabecular connectivity. The combined treatment with E2-30+calcitriol was the most effective treatment as it was not only capable of achieving normal trabecular remodeling and connectivity, but also normal trabecular bone volume. CONCLUSIONS: E2 and calcitriol seem to have independent effects on cancellous bone turnover in rats with CKD+OVX. In rats with chronic kidney disease and ovariectomy, these two agents are able to produce additive effects on bone and offer additional advantages as opposed to the use of both drugs independently.

Genetics and molecular disorders in severe secondary hyperparathyroidism: lessons from rna and microarray studies.

Secondary hyperparathyroidism-related disorders begin in the pre-dialysis period and progressively worsen during dialysis. In a high proportion of cases, therapeutic failure in the control of PTH secretion is related to a late start in medical treatment. This may happen because recovery of the functional control of the parathyroid gland, once some irreversible molecular and genetic changes have occurred, can be only partial. These irreversible changes include promotion of cell proliferation and failure of several pathways affecting the metabolism of DNA, RNA and proteins.

Bone metabolism, vascular calcifications and mortality: associations beyond mere coincidence.

Bone and cardiovascular disorders are common age-related disorders in the general population and also in patients suffering from chronic kidney disease (CKD). Recent studies have shown an association between these two disorders and the rate of mortality. This article addresses some limitations of the concept of osteoporosis in CKD and compares bone and vascular disorders and mortality between non-selected general population and dialysis patients from the same geographic area. In the general population, all metabolic disorders increase with age, as well as vascular calcifications. The progression of vascular calcification was associated with a higher prevalence and incidence of bone fractures. In addition, both vascular calcifications and vertebral fractures were associated with higher mortality. A similar pattern was observed in dialysis patients with no increments in vertebral fractures, although with higher prevalence of vascular calcifications also both associated with higher mortality. Age was the strongest variable associated with all the analysed parameters, but some of the associations remained significant after age adjustment indicating the likely role of other common factors in the pathogenesis of bone and vascular disorders.

A novel mutation in the calcium-sensing receptor responsible for autosomal dominant hypocalcemia in a family with two uncommon parathyroid hormone polymorphisms.

A novel missense activating mutation in the extracellular calcium-sensing receptor (CaSR) is reported in this work. It was identified in three related subjects with the phenotypic features of autosomal dominant hypocalcemia (ADH). The proband, a 27-year-old woman, diagnosed as having hypoparathyroidism at 7 years of age and a history of seizures, showed the highest penetrance of the mutation. The remaining two affected members presented asymptomatic chronic hypocalcemia despite severe hypoparathyroidism associated with high levels of serum phosphate and calcium urinary excretion. The missense mutation (Glu(604)Lys) affected an amino acid residue in the C terminus of the cysteine-rich domain of the extracellular amino-terminal domain, which seems to be required for the coupling of ligand binding to the activation of intracellular signaling pathways. This genetic change cosegregated with hypocalcemia in all the individuals where the mutation was found. As parathyroid hormone (PTH) secretion is the regulatory target of the CaSR, polymorphism analysis of the PTH gene was carried out. PTH polymorphisms were analyzed in the kindred studied. Affected members for the Glu(604)Lys CaSR mutation which also carried the uncommon PTH alleles showed higher penetrance of the mutation, with more severe autosomal dominant hypocalcemia. These results suggested that the PTH gene could act as a modifier locus of ADH, affecting the penetrance of the activating CaSR mutation described.

Use of ultrafiltration and chromatography to assess aluminum speciation in serum after deferoxamine administration.

Deferoxamine effectively chelates aluminum by forming aluminoxamine, a low-molecular-weight compound removable by dialysis. However, aluminum-bound species other than aluminoxamine might be present in serum after the administration of deferoxamine. To study aluminum speciation after the administration of deferoxamine, high-performance liquid chromatography (HPLC) and ultrafiltration techniques were used. Samples of serum were obtained from six dialysis patients 44 hours after the administration of a single dose of deferoxamine. HPLC and ultrafiltration studies were performed. In the HPLC studies, samples underwent ultrafiltration, the filtrate was injected into the chromatographic system, and detection was performed by UV light and atomic absorption spectrometry. Unknown species of aluminum other than aluminoxamine were found in the early elution fractions. In the ultrafiltration studies, the same samples of serum from the six patients underwent ultrafiltration using membranes with different molecular-weight cutoff values from 1 to 30 kd. The percentages of aluminum found by ultrafiltration using membranes with cutoff values of 5, 10, and 30 kd were greater (64.4% +/- 2.5%, 63.5% +/- 3.7%, and 65.6% +/- 4.3%, respectively) than the percentages obtained with membranes with a 1-kd cutoff value (38.7%), suggesting that the unknown species of aluminum have a molecular weight between 1 and 5 kd. The unknown species of aluminum cannot be aluminoxamine because they behaved in a different way with HPLC.

Hormonal replacement therapy in an animal model with chronic renal failure and ovariectomy: biochemical and densitometric study.

BACKGROUND: In spite of estrogen replacement therapy being extensively used in clinical and experimental studies without renal impairment, there are no long-term studies concerning estrogen replacement in chronic renal failure. METHODS: In this experimental study, six groups of nephrectomized and ovariectomized animals were treated with different doses of 17beta-estradiol, alone or in combination with calcitriol, to evaluate the effect of these treatments on bone metabolism. RESULTS: Biochemical results showed that estrogen alone did not have any effect neither on calcium nor on PTH serum levels. By contrast, in the groups treated with calcitriol, the levels of serum calcium were significantly higher, and the levels of iPTH were significantly lower than those observed in the control group. Animals receiving the combined treatment with estrogen and calcitriol showed the greater gain in uterus weight and a better bone mineral density at the lumbar site and the proximal and distal tibia sites. CONCLUSION: The combination of estrogen and calcitriol is the most effective therapy to prevent bone mass loss in animals with chronic renal failure and estrogen deprivation.

Binding of aluminium to plasma proteins: comparative effect of desferrioxamine and deferiprone (L1).

Ultramicrofiltration techniques were used to study both the binding of aluminium to high molecular weight proteins in the presence of different concentrations of desferrioxamine and deferiprone (L1) and the kinetics of aluminium release from human serum proteins. Human serum from healthy volunteers was used in all studies. The serum was spiked with aluminium (100 micrograms/l) and different concentrations of chelators. Ultramicrofiltration was performed with Amicon YMT membranes which had a nominal cut-off of 30,000 Da. Aluminium was measured by graphite furnace atomic absorption spectrometry in total serum and ultrafiltered fluid. Deferiprone shows a higher capability to displace aluminium from serum proteins (80%) than desferrioxamine (60%) at equivalent concentrations of the chelators. The kinetics of the release were also faster for deferiprone, taking 20 min to achieve its maximum effect, whereas, desferrioxamine achieved only 80% of its maximum effect after 2 h. Thus, deferiprone could be an attractive alternative to desferrioxamine, as an aluminium chelator agent.

Management of secondary hyperparathyroidism: the gap between diagnosis and treatment. The Renal Osteodystrophy Multicenter Enquiry.

In mild secondary hyperparathyroidism, small daily doses of oral calcitriol represent the physiological form of replacement of this hormone, but in moderate or severe cases, higher doses of calcitriol are needed to suppress parathyroid gland overactivity. Unfortunately, in chronic renal failure, these 2 different forms of calcitriol prescription are not always adequately selected. This review will focus on the current use of calcitriol in renal failure. It includes data from a recent multicenter trial carried out in Spain in which data was gathered from dialysis patients. This trial was designed to determine the current approach to the prevention, diagnosis, and treatment of renal osteodystrophy, with a special emphasis on the gap found between diagnosis and treatment of secondary hyperparathyroidism. Our main goal should be to achieve an adequate and early management of secondary hyperparathyroidism to decrease the number of patients suffering from irreversible enlargement of the parathyroid glands.

Adynamic bone and chronic renal failure: an overview.

Renal osteodystrophy may present with a wide spectrum of bone lesions, ranging from high bone turnover to low bone turnover. Decreased serum calcium and 1,25-dihydroxy vitamin D synthesis and retention of phosphate are involved in the pathogenesis of high bone turnover. However, several factors may influence the evolution of this disorder. The use of different therapeutic approaches (such as calcium supplements, phosphate binders, vitamin D metabolites, etc.), the type of treatment (either hemodialysis or continuous ambulatory peritoneal dialysis), and also the changes in the type of patients to whom we are offering dialysis (more diabetics and older patients are currently included in dialysis programs) may have introduced changes modifying the form of presentation of the bone metabolic disorders. As a result, recent studies reported a greater prevalence of adynamic forms of renal osteodystrophy. Patients with adynamic bone (with or without aluminum) would have more difficulties in handling and buffering calcium loads; consequently, they would have a higher risk of extraosseous calcifications.

Micellar versus reversed phase liquid chromatography for the determination of desferrioxamine and its chelates with aluminium and iron in uremic serum.

Micellar liquid chromatography with sodium dodecyl sulphate or Brij-35 as surfactants in the mobile phase was evaluated and compared with reversed phase liquid chromatography using conventional acetonitrile-water eluents for the separation and determination of desferrioxamine (DFO) and its complexes with aluminium (AIDFO) and iron (FeDFO) in uremic serum. Reversed phase liquid chromatography proved to be superior in terms of sensitivity and selectivity. The three solutes investigated were separated with a mobile phase of 13% (v/v) acetonitrile/phosphate buffer (5 mM, pH = 3.5) on a C(18) column and detected by ultraviolet absorption at 210 nm (DFO) and 220 nm (AlDFO and FeDFO). Limits of detection of 0.1 mug ml(-1) and relative standard deviation of 3-4% were obtained. The recovery from serum samples after ultramicrofiltration was around 90%. The method was applied to the determination of DFO, AlDFO and FeDFO in uremic serum.

Bone aluminum uptake in uremic rats receiving intraperitoneal iron.

To assess the effect of concomitant iron and aluminum loads on bone aluminum accumulation and on the response to the deferoxamine test in rats with the same aluminum surcharge, Wistar rats with chronic renal failure were divided into three groups: iron-overloaded rats (N = 6) (intraperitoneal iron); iron-depleted rats (N = 6) (blood withdrawal two to three times per week); control rats (N = 4) (no manipulation). All groups received intraperitoneal aluminum simultaneously. After 6 wk, a deferoxamine challenge test was performed. Thereafter, bone aluminum and iron were measured. The iron-overloaded rats showed higher bone iron content (iron overloaded: 147.7+/-55.4 microg/g; iron depleted: 7.9+/-1.0, and controls 13.3+/-9.9 microg/g, p < 0.010) and lower bone aluminum content (iron overloaded: 14.2+/-4.0 microg/g; iron depleted: 70.9+/-35.1 microg/g; controls: 72.7+/-28.3 microg/g p < 0.005). No differences were found between the iron-depleted and control rats. After the deferoxamine infusion, the iron-depleted rats tended to have higher serum aluminum increments (p = NS) and higher urinary aluminum excretion (p < 0.012, p < 0.020) than control rats despite similar amounts of aluminum in bone of the two groups. Aluminum bone accumulation was minor if iron and aluminum loads were given concomitantly. The iron depletion influenced the results of the deferoxamine challenge test in rats with similar bone aluminum burden.

Reference values for trace and ultratrace elements in human serum determined by double-focusing ICP-MS.

Reference values for trace and ultratrace elements concentrations in healthy human serum, measured by double-focusing inductively coupled plasma-mass spectrometry (ICP-MS), are presented. Blood donors from Asturias (Spain) were selected as the reference population (n=59). Blood samples were collected, after donation, taking the necessary precautions to avoid contamination. All subjects analyzed had normal renal function and nutritional status, as shown from their creatinine and albumin levels. A total number of 14 elements (Al, Ca, Cr, Mn, Fe, Co, Cu, Zn, Rb, Sr, Mo, Cd, Pb, and U) were monitored almost simultaneously. Serum samples were diluted 1+4 with ultrapure water and matrix interferences were corrected using Sc, Ga, Y, and Tl as internal standards. Fe, Cu, and Zn were also determined by isotope dilution analysis (IDA). Reference trace element concentrations intervals observed containing 95% of the reference distribution after excluding outliers are presented. Fourteen serum samples from hemodialysis patients were also analyzed for comparison. High levels of Al, Cr, Sr, Mo, Mn, Pb, U, Co, and Cu and low levels of Fe, Zn, and Rb were found in the serum samples from hemodialysis patients compared to the corresponding reference values observed in this work.

[Regulation of the calcium-sensing receptor. Influence of secondary hyperparathyroidism]. / Regulación del receptor sensor de calcio. Influencia del hiperparatiroidismo secundario.

The parathyroid glands have a great sensitivity to small changes in the extracellular ionic calcium. The calcium-sensing receptor (CaR) is a G protein-coupled receptor that responds to extracellular ionic calcium changes activating several intracellular signalling systems (phospholipases C, A2 and D) finally inhibiting the PTH secretion. In addition to calcium, there are some other agonists and modulators such as the Mg2+, spermine, amyloid beta-peptides, a variety of aminoacids, especially aromatic aminoacids and ionic strength. In the uraemia, the sensitivity of the parathyroid glands to calcium is altered and higher values of calcium are necessary to suppress the PTH. In the secondary hyperparathyroidism the CaR expression is reduced. It has been found a negative correlation between cellular proliferation and the expression of the CaR in hyperplasic glands. Despite it is a calcium receptor, the expression of the CaR does not seem to be regulated by calcium and there is some controversy about the role of calcitriol regulating its expression. On the other hand, the phosphorous induces hyperplasia of the parathyroid gland increasing the cellular proliferation and a decrease of the CaR expression.

[Effect of desferrioxamine and deferiprone on osteocalcin secretion in osteoblast-type cells]. / Efecto de la desferrioxamina y de la deferiprona sobre la secreción de osteocalcina en células tipo osteoblasto.

Desferrioxamine and deferiprone are both metal-chelating drugs often used in aluminum-overloaded dialysis patients. In these patients, desferrioxamine produces an improvement on bone mineralisation without a relevant decrease in bone aluminum. Thus, desferrioxamine might have a direct effect on bone cells. The aim of this study was to assess the effect of desferrioxamine and deferiprone on 1,25(OH)2D3-stimulated osteocalcin secretion in osteoblast--like cells. The study was carried out in MG-63 cell cultures. Cells were seeded at a density of 15,000 cel/cm2 and grown to confluence for 72 hours in DMEM supplemented with 10% FCS. The medium was then replaced by another medium containing 1% BSA, 10(-9) M 1,25(OH)2D3 and desferrioxamine 5, 10, 20, 40, 60, 80 microM or deferiprone 15, 30, 60, 120, 180, 240 microM. Tris-HCl at pH 7.4 was used as control. After 48 hours, supernatants were collected for the measurement of secreted osteocalcin. Desferrioxamine and deferiprone, at high doses (desferrioxamine: 60 microM, 80 microM; deferiprone: 180 microM, 240 microM), inhibited the 1,25(OH)2D3-induced osteocalcin secretion. On the contrary, at lower doses (desferrioxamine 5 microM; deferiprone 15 microM) stimulated the secretion. In summary, these results suggest that desferrioxamine and deferiprone exert a direct effect on bone cell metabolism that might be independent from their metal-chelating properties.

[Calcitriol dose optimization in the treatment of secondary hyperparathyroidism during dialysis. Results at 6 months]. / Optimización de la dosis de calcitriol en el tratamiento del hiperparatiroidismo secundario en diálisis. Resultados a seis meses.

One recent report have recommended to start calcitriol therapy with a dose according to PTH levels, rather than starting with a fixed dose increasing it according to PTH response. As there are no clinical studies supporting this strategy we tested his hypothesis. Haemodialysis patients from 28 centres (N = 141) were included, the aim was to achieve a PTH between 100 and 285 pg/mL (goal) in 6 months. The main inclusion criteria were: serum PTH > 250 pg/mL, Ca < 10.5 mg/dL, P < 6.5 mg/dL and Ca x P < 60. Patients were divided according PTH into 4 groups and calcitriol was dosed accordingly. A (PTH 250-350; 0.5 microgram), B (PTH 351-550; 1-1.5 micrograms), C (PTH 551-750; 1.5-2 micrograms) and D (PTH < 750 pg/mL; 2-3 micrograms). PTH was measured monthly in groups A, B, C and fortnightly in D. Ca, P and Ca x P were measured fortnightly (groups A, B, C) and weekly in D. According to PTH results calcitriol was modified, reducing 50% if PTH was suppressed > 60%, and increasing 50% if PTH suppression was < 15% (fig. 1). Patients were stopped treatment and excluded from study when Ca, P and Ca x P product trespass the established inclusion criteria. The study was completed by 100 patients, 34 with strict compliance of the protocol (compliant), and 66 with one o more protocol violations, the most frequent was lack of strict adherence to the dosing regime (non compliant). Among the compliant, 82.4% reached the goal in contrast with 13.8% of the non compliant (p < 0.001) (table II). In addition, the compliant showed (all patients in all groups) a greater and significant decrease in PTH (from 616 +/- 288 to 202 +/- 82), by contrast, 21.5% of the non-compliant did not decrease--but increased--their PTH levels. The compliant showed also fewer side effects than the non-compliant (25% vs 55.6%, p < 0.006). These results demonstrate several advantages when starting calcitriol therapy with a dose proportional to the severity of HPTH.