Severe osteoporosis before and after lung transplantation

Elevated HDL cholesterol levels are associated with osteoporosis in lung transplant candidates with chronic obstructive pulmonary disease

BACKGROUND

Osteoporosis is common in advanced COPD and worsens rapidly after transplantation, potentially impairing quality of life. Increased high density lipoprotein cholesterol (HDLc) has been observed in COPD and linked with osteoporosis in the general population. This association has not been previously examined in COPD.

METHODS

We reviewed the records of 245 COPD patients referred for lung transplant evaluation. Osteoporosis was defined by either dual energy X-ray absorptiometry scan or use of osteoporosis medications. The presence or absence of osteoporosis could be ascertained in 152 subjects. Cholesterol values and other clinical variables were assessed for their association with osteoporosis.

RESULTS

Clinical factors associated with osteoporosis included lower BMI [OR 0.81, 95% CI 0.73-0.90], higher HDLc [OR 1.04, 95% CI 1.02 to 1.07], and worse lung function. HDLc was an independent predictor of OP and demonstrated an inverse linear correlation with T-scores (r = -0.21, p = 0.05), which was stronger amongst males (r = -0.45, p = 0.004).

CONCLUSION

In COPD patients referred for lung transplantation, osteoporosis is highly prevalent. Raised HDLc levels are common in this group and are independently associated with OP.

Updated recommendations for the diagnosis and management of osteoporosis: a local perspective

Postmenopausal osteoporosis and osteoporosis in elderly men are major health problems, with a significant medical and economic burden. Although osteopenia and osteoporosis are more common locally than in the West, fracture rates are generally less than in Western countries. Vitamin D deficiency is common in the region and contributes adversely to bone health. Vitamin D deficiency should be suspected and treated in all subjects with ostopenia or osteoporosis. The use of risk factors to determine fracture risk has been adopted by the World Health Organization and many international societies. Absolute fracture risk methodology improves the use of resources by targeting subjects at higher risk of fractures for screening and management. The King Faisal Specialist Hospital Osteoporosis Working Group recommends screening for women 65 years and older and for men 70 years and older. Younger subjects with clinical risk factors and persons with clinical evidence of osteoporosis or diseases leading to osteoporosis should also be screened. These guidelines provide recommendations for treatment for postmenopausal women and men older than 50 years presenting with osteoporotic fractures for persons having osteoporosis-after excluding secondary causes-or for persons having low bone mass and a high risk for fracture. The Working Group has suggested an algorithm to use at King Faisal Specialist Hospital that is based on the availability, cost, and level of evidence of various therapeutic modalities. Adequate calcium and vitamin D supplement are recommended for all. Weekly alendronate (in the absence of contraindications) is recommended as first-line therapy. Alternatives to alendronate are raloxifene or strontium ranelate. Second-line therapies are zoledronic acid intravenously once yearly, when oral therapy is not feasible or complicated by side effects, or teriparatide in established osteoporosis with fractures.

Osteoporosis following organ transplantation: pathogenesis, diagnosis and management

Organ transplantation has become popular for the management of various chronic illnesses. With the advent of modern immunosuppressive treatments, the longevity of transplant recipients has increased. Consequently, morbid complications such as osteoporosis and bone fractures are seen at an increasing frequency in this population. In most transplant recipients, bone mineral density (BMD) falls shortly after transplantation. However, bone fracture rate plateaus in all except for post-renal transplant patients. Although the underlying pathophysiologic mechanism for this difference is not fully understood, potential mechanisms for sustained bone loss in renal transplant recipients may be persistent phosphorus wasting and defective bone mineralization. Current treatment regimens are based on studies in a small numbers of subjects with BMD as the primary outcome. Although BMD is recognized as a gold standard in the assessment of bone fracture risk, to date, its association with bone fracture risk in the general post-transplant population is not robust. Therefore, randomized controlled trials with bone fracture as the primary end point are crucial. The development of noninvasive bone markers in distinguishing bone turnover and bone mineralization status is also pivotal since skeletal lesions are heterogeneous in various organ transplantations. The elucidation of these underlying skeletal lesions is necessary for the consideration of selective treatment in this population.

Osteoporosis is a prevalent finding in patients with solid organ failure awaiting transplantation - a population based study

Post-transplant bone disease is common in solid organ recipients; however, there is limited information on their pre-transplant bone status. We aimed to compare bone mineral density (BMD) in different categories of patients with end-stage organ failure awaiting transplantation (Tx) in Norway. Overall 291 adult patients were enrolled, including 60, 84, 81 and 66 patients with end-stage lung, liver, kidney and heart failure, respectively. Mean age was 51 ± 12 yr with no significant differences between the groups. We measured BMD in lumbar spine, femur, proximal one third and ultra-distal radius by dual energy X-ray absorptiometry. Differences in T- and Z-scores between the groups were compared by ANOVA. Low bone mass was found in all four groups of patients. Both T- and Z-scores differed (p < 0.05) at all measured sites between the groups. Patients with lung failure had the highest prevalence of osteoporosis (67%) and lowest Z-scores, followed by patients with liver (31%), kidney (24%), and heart (23%) failure. Osteoporosis is prevalent in all groups of organ transplant candidates, and poor bone health is remarkably pronounced in patients with chronic lung disease. General practitioners and specialists who care for these patients before they are referred for transplantation should consider measures to prevent osteoporosis at an earlier stage.

A roadmap to the brittle bones of cystic fibrosis

Cystic fibrosis (CF) is an autosomal recessive disorder which despite advances in medical care continues to be a life-limiting and often fatal disease. With increase in life expectancy of the CF population, bone disease has emerged as a common complication. Unlike the osteoporosis seen in postmenopausal population, bone disease in CF begins at a young age and is associated with significant morbidity due to fractures, kyphosis, increased pain, and decreased lung function. The maintenance of bone health is essential for the CF population during their lives to prevent pain and fractures but also as they approach lung transplantation since severe bone disease can lead to exclusion from lung transplantation. Early recognition, prevention, and treatment are key to maintaining optimal bone health in CF patients and often require a multidisciplinary approach. This article will review the pathophysiology, current clinical practice guidelines, and potential future therapies for treating CF-related bone disease.

Prevalence of bone loss in a population with cystic fibrosis

The adverse effect of an increased life expectancy for people with cystic fibrosis (CF) is the increased risk of complications, such as CF-related low bone mineral density (BMD). Diagnosis of CF-related low BMD is confirmed by a dual-energy X-ray absorptiometry (DXA) scan. This study reports the results of an audit of DXA scans in 108 adults with CF in our clinic. The most common risk factors for bone loss were vitamin D deficiency (89%), CF-related diabetes (53%), low body mass index (39%) and post-lung transplant (25%); half of those with bone loss were genotype homozygous DF508. Overall fracture incidence was 5.5%; low BMD was not associated with high fracture rates. Thus BMD may not be a good predictor of fracture risk. Treatment includes bisphosphonates, which are difficult to take and have uncertain long-term effects. It is unknown whether bisphosphonate therapy is justified in this already overburdened group.

Optimizing post-transplant outcomes in lung transplantation

Lung transplant recipients are at risk of numerous complications, which range from early events, such as primary graft dysfunction, to late events, including opportunistic infection or graft loss caused by chronic rejection. Although lung transplantation is often the only therapeutic option that can improve quality of life and prolong survival for many forms of end-stage lung disease, survival following lung transplantation is significantly worse than survival following transplantation of other solid organs. Carefully choosing potential recipients for listing, maximizing the likelihood that donor organs will function well following implantation, appropriate use of immunosuppressive agents to prevent allograft rejection, prophylactic or pre-emptive strategies to prevent allograft infection and appropriate surveillance to detect significant complications are key to maximizing the likelihood of prolonged graft and patient survival while avoiding significant complications following lung transplantation. Post-transplant outcomes will be optimized by a team approach to comprehensive management of the lung transplantation recipient combined with vigilant surveillance to detect complications in a timely fashion.

Osteoporosis in lung transplant candidates compared to matched healthy controls

PURPOSE

Advanced lung disease increases the risk for diminished bone mineral density (BMD). The prevalence and severity of osteoporosis in lung transplant candidates is unclear.

METHODS

We retrospectively evaluated BMD of subjects screened for lung transplant at our institution. Observed prevalence of osteoporosis and osteopenia within our cohort was compared to the expected prevalence of each from the Third National Health and Nutrition Examination Survey (NHANES III) data matched for age, gender, and race. Lateral chest radiographs were evaluated for vertebral fractures.

RESULTS

  High prevalence rates of osteoporosis (37%) and combined osteoporosis/osteopenia (86%) were observed. Subjects with pulmonary fibrosis had higher BMD and T-scores compared to all other subgroups. All subjects within the cohort had a higher observed combined rate of osteoporosis/osteopenia at all bone sites compared to expected rates from healthy, matched controls. Vertebral fractures were present in 23% of subjects but did not correlate with BMD or the diagnosis of osteoporosis.

CONCLUSIONS

Abnormal BMD was prevalent in most pre-lung transplant subjects, with striking differences noted in comparison with a healthy, matched cohort. Lateral chest radiographs in combination with BMD data give a more complete picture of bone abnormalities. Osteoporosis screening prior to lung transplantation should be performed to identify high-risk subjects for fracture and allow for intervention.

Vitamin D status in relation to nutritional depletion and muscle function in patients with advanced pulmonary disease

Muscle weakness is an important complication of advanced pulmonary disease and it is associated with reduced functional activity and lower survival. Vitamin D may be involved in muscle function. The aim of this study was to investigate determinants of calcidiol (25-hydroxycholecalciferol, the major circulating indicator of vitamin D) status and associations between vitamin D metabolites and muscle function in relation to nutritional depletion. Fifty-two percent of the underweight patients (n = 42) and 55% of the normal-weight ones (n = 29) had vitamin D deficiency (< 37.5 nmol/L). The resulting models of linear regression showed that, for the calcidiol model, 24.7% of the variation for calcidiol was explained by fat mass index, vitamin D intake, and FEV(1)/FVC. The results further suggested that vitamin D intake was a stronger predictor of calcidiol status in the underweight patients than in the normal-weight ones. In the resulting models for 6-minute walking distance, calcidiol was a significant predictor, which tended to be more marked in the underweight patients than in the normal-weight ones. Low serum calcidiol concentration was associated with fat mass, lung obstruction, and low intake of vitamin D, especially in the underweight patients, and calcidiol was a predictor of walking distance.

[Medical complications of lung transplantation]

In 2010, lung transplantation is a valuable therapeutic option for a number of patients suffering from of end-stage non-neoplastic pulmonary diseases. The patients frequently regain a very good quality of life, however, long-term survival is often hampered by the development of complications such as the bronchiolitis obliterans syndrome, metabolic and infectious complications. As the bronchiolitis obliterans syndrome is the first cause of death in the medium and long term, an intense immunosuppressive treatment is maintained for life in order to prevent or stabilize this complication. The immunosuppression on the other hand induces a number of potentially severe complications including metabolic complications, infections and malignancies. The most frequent metabolic complications are arterial hypertension, chronic renal insufficiency, diabetes, hyperlipidemia and osteoporosis. Bacterial, viral and fungal infections are the second cause of mortality. They are to be considered as medical emergencies and require urgent assessment and targeted therapy after microbiologic specimens have been obtained. They should not, under any circumstances, be treated empirically and it has also to be kept in mind that the lung transplant recipient may present several concomitant infections. The most frequent malignancies are skin cancers, the post-transplant lymphoproliferative disorders, Kaposi's sarcoma and some types of bronchogenic carcinomas, head/neck and digestive cancers. Lung transplantation is no longer an exceptional procedure; thus, the pulmonologist will be confronted with such patients and should be able to recognize the symptoms and signs of the principal non-surgical complications. The goal of this review is to give a general overview of the most frequently encountered complications. Their assessment and treatment, though, will most often require the input of other specialists and a multidisciplinary and transversal approach.

Vitamin d deficiency in cystic fibrosis

Cystic Fibrosis is the most common inherited genetic respiratory disorder in the Western World. Hypovitaminosis D is almost universal in CF patients, likely due to a combination of inadequate absorption, impaired metabolism, and lack of sun exposure. Inadequate levels are associated with the high prevalence of bone disease or osteoporosis in CF patients, which is associated with increased morbidity including fractures, kyphosis, and worsening pulmonary status. Treatment goals include regular monitoring 25 hydroxyvitamin D (25OHD) levels with aggressive treatment for those with levels <75 nmol/L (<30 ng/mL). More research is needed to determine optimal supplementation goals and strategies.

'Old' bones in young bodies: the tale of cystic fibrosis

PURPOSE OF REVIEW

Cystic fibrosis (CF) is the most common genetic disease within the white population and leads to premature respiratory failure. Approximately, 60 000 individuals are currently living with CF in North America and Europe, almost half of whom are adults.

RECENT FINDINGS

Dozens of studies across the globe indicate that CF adults have low bone density and increased rates of fractures. This genesis of the problem appears to be in late childhood to adolescence.

SUMMARY

Prevention and treatment of CF-related bone disease must address the myriad risk factors (decreased absorption of fat-soluble vitamins due to pancreatic insufficiency, altered sex hormone production, chronic lung infection with increased serum levels of proinflammatory, bone-active cytokines, malnutrition and low body weight, physical inactivity and glucocorticoid therapy) for poor bone health. This review will address the pathogenesis, diagnosis and treatment of bone disease in CF. It will also discuss best practice guidelines for optimizing bone health in patients with CF.

Vitamin D inhibition of pro-fibrotic effects of transforming growth factor beta1 in lung fibroblasts and epithelial cells

The mechanisms that control fibroproliferation and matrix deposition in lung fibrosis remain unclear. We speculate that vitamin D deficiency may contribute to pulmonary fibrosis since vitamin D deficiency has been implicated in several diseases. First, we confirmed the presence of vitamin D receptors (VDRs) in cultured NIH/3T3 and lung fibroblasts. Fibroblasts transfected with a vitamin D response element-reporter construct and exposed to the active vitamin D metabolite, 1,25(OH)(2)D(3), showed increased promoter activity indicating VDR functionality in these cells. Testing the effects of 1,25(OH)(2)D(3) on fibroblasts treated with transforming growth factor beta1 (TGFbeta1), considered a driver of many fibrotic disorders, we found that 1,25(OH)(2)D(3) inhibited TGFbeta1-induced fibroblast proliferation in a dose-dependent fashion. 1,25(OH)(2)D(3) also inhibited TGFbeta1 stimulation of alpha-smooth muscle actin expression and polymerization and prevented the upregulation of fibronectin and collagen in TGFbeta1-treated fibroblasts. Finally, we examined how 1,25(OH)(2)D(3) affects epithelial-mesenchymal transformation of lung epithelial cells upon exposure to TGFbeta1. We showed that the TGFbeta1-induced upregulation of mesenchymal cell markers and abnormal expression of epithelial cell markers were blunted by 1,25(OH)(2)D(3). These observations suggest that under TGFbeta1 stimulation, 1,25(OH)(2)D(3) inhibits the pro-fibrotic phenotype of lung fibroblasts and epithelial cells.

Bisphosphonates for osteoporosis in people with cystic fibrosis

BACKGROUND

Osteoporosis is a bone mineralisation disorder occurring in about one third of adults with cystic fibrosis (CF). Bisphosphonates can increase bone mineral density (BMD) and decrease the risk of new fractures in post-menopausal women and people receiving long-term oral corticosteroids.

OBJECTIVES

To assess the effects of bisphosphonates on the frequency of fractures, BMD, quality of life, adverse events, trial withdrawals, and survival in people with CF.

SEARCH STRATEGY

We searched the CF and Genetic Disorders Group Trials Register of references (identified from electronic database searches and handsearches of journals and abstract books) on 29 October 2008.Additional searches of Pubmed were performed on 01 November 2008.

SELECTION CRITERIA

Randomised controlled trials of at least six months duration studying bisphosphonates in people with CF.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials and extracted data. Trial investigators were contacted to obtain missing data.

MAIN RESULTS

Seven trials were identified and five (with a total of 145 adult participants) were included.Data were combined when available from four included studies in participants without a lung transplant. This showed that there was no significant reduction in fractures between groups. However, after six months, the percentage change in BMD increased in those on bisphosphonates at the lumbar spine, mean difference (MD) 4.61 (95% confidence interval (CI) 3.90 to 5.32) and at the hip, MD 3.35 (95% CI 1.63 to 5.07); but did not significantly change at the distal forearm, MD -0.49 (95% CI -2.42-1.45). There was clinical heterogeneity between studies and not all studies reported all outcomes. Bone pain was the most common adverse event with intravenous agents. Flu-like symptoms were also increased in those taking bisphosphonates.In participants with a lung transplant (one study), intravenous pamidronate did not change the number of new fractures. At axial sites, BMD increased with treatment compared to controls: percentage change in bone mineral density at lumbar spine, MD 6.20 (95% CI 4.28 to 8.12) and femur MD 7.90 (95% CI 5.78 to 10.02).

AUTHORS' CONCLUSIONS

Oral and intravenous bisphosphonates increase BMD in people with CF. Severe bone pain and flu-like symptoms may occur with intravenous agents. Additional trials are needed to determine if bone pain is more common or severe (or both) with the more potent zoledronate and if corticosteroids ameliorate or prevent these adverse events. Trials in larger populations are needed to determine effects on fracture rate and survival.

Update on cystic fibrosis-related bone disease: a special focus on children

A high prevalence of low bone mineralization is documented in adult patients with cystic fibrosis (CF). Osteopenia is present in up to 85% of adult patients and osteoporosis in 10% to 34%. In children, study results are discordant probably because of comparisons to different control populations and corrections for bone size in growing children. Malnutrition, inflammation, vitamin D and vitamin K deficiency, altered sex hormone production, glucocorticoid therapy, and physical inactivity are well known risk factors for poor bone health. Puberty is a critical period for bone mineralization and requires a careful follow-up to achieve optimal bone peak mass. Strategies for optimizing bone health, such as monitoring bone mineral density (BMD) and providing preventive care are necessary from childhood through adolescence to minimize CF-related bone disease in adult CF patients.

Bilateral pathological hip fractures in a patient with a bipulmonary transplant: a case report

The use of immunosuppressive agents to prevent tissue rejection may predispose patients to osteoporosis and fractures. We report a case of bilateral pathological hip fractures in a woman with osteoporosis who had undergone a bipulmonary transplant. To reduce the risk of pathological fractures, patients are given prophylaxes for osteoporosis prior to organ transplantation, but they remain at increased risk of fractures. They should be informed that this side-effect may occur after transplantation.

Intravenous zoledronate improves bone density in adults with cystic fibrosis (CF)

OBJECTIVE

Reduced bone mineral density (BMD) and increased rates of atraumatic fracture are observed in cystic fibrosis (CF) patients, causing increasing morbidity as this population ages. The study aimed to assess the safety, tolerability and effect on BMD of intravenous zoledronate in adults with CF and osteopaenia.

DESIGN

Randomized, double-blind, placebo-controlled clinical trial.

SETTING

Adult CF outpatient clinics at two hospitals.

PATIENTS

Twenty-two non-transplanted CF patients aged > or = 18 years with a bone densitometry T-score of < -1.5 at one of three sites (lumbar spine, femoral neck, distal forearm) were studied. Participants were randomized to receive either 2 mg zoledronate i.v. (n = 10) or normal saline (placebo, n = 12) every 3 months for 2 years (8 infusions). All participants received calcium and vitamin D supplements twice daily.

MEASUREMENTS

Percentage change in areal BMD from baseline.

RESULTS

Lumbar spine BMD increased from baseline more with zoledronate than placebo at 6 months (5.35 +/- 0.76 vs. 1.19 +/- 1.20%, P = 0.012), 12 months (6.6 +/- 1.5 vs. 0.35 +/- 1.55%, P = 0.011) and 24 months (6.14 +/- 1.86 vs. 0.44 +/- 0.10, P = 0.021). Femoral neck BMD increased more after zoledronate than placebo at 6 months (3.2 +/- 1.6 vs.-1.43 +/- 0.43%, P = 0.019), 12 months (4.12 +/- 1.8 vs.-1.59 +/- 1.4%, P = 0.024) and 24 months (4.23 +/- 1.3 vs.-2.5 +/- 1.41%, P = 0.0028). Forearm BMD did not change. Zoledronate was associated with flu-like and musculoskeletal side effects, particularly after the first infusion. There were no fractures in either group.

CONCLUSION

Intravenous zoledronate was significantly more effective than placebo for increasing BMD in adults with CF and osteopaenia, but side effects limited its tolerability.

Bone mineral density and secondary hyperparathyroidism in pulmonary hypertension

BACKGROUND

Low bone mineral density (BMD) is common in chronic lung diseases and associated with reduced quality of life. Little is known about BMD in pulmonary hypertension (PH).

METHODS

Steroid-naïve patients with PH (n=34; 19 idiopathic, 15 chronic thromboembolic) had BMD measured by DXA at the time of diagnostic right heart catheterization. Exercise capacity, quality of life and various parameters related to PH severity and bone metabolism were also assessed. 24 patients with left heart failure (LHF) were similarly assessed as controls.

RESULTS

The prevalence of osteopenia was high both in PH (80%) and in controls with LHF (75%). Low BMD was associated with lean body mass, age, lower BMI, impaired exercise capacity and in PH with higher pulmonary vascular resistance. Serum parathyroid hormone (PTH) was elevated and considerably higher in PH than in LHF (above normal, in 55 vs 29%). Secondary hyperparathyroidism was not related to impaired renal function but possibly to low vitamin D status.

CONCLUSIONS

Osteopenia is common in PH and in chronically ill patients with LHF. Osteopenia is associated with known risk factors but in PH also with disease severity. Preventive measures in an increasingly chronic ill PH population should be considered. Secondary hyperparathyroidism is highly prevalent in PH and might contribute to bone and possibly pulmonary vascular disease. Whether adequate vitamin D substitution could prevent low BMD in PH remains to be determined.

Post-transplantation lymphoproliferative disease: Epstein-Barr virus DNA levels, HLA-A3, and survival

RATIONALE

Elevation in Epstein-Barr virus (EBV) circulating DNA has been proposed as a marker for development of post-transplant lymphoproliferative disease (PTLD), but few published data exist in the study of lung-transplant recipients.

OBJECTIVES

To determine if elevated EBV DNA levels, in combination with other risk factors, were predictive of PTLD.

METHODS

We conducted a retrospective, single-center study examining all lung transplant recipients (n = 296) and EBV DNA levels (n = 612) using real-time TaqMan polymerase chain reaction. There were 13 cases of PTLD overall, of which 5 occurred in the era of EBV DNA monitoring.

MEASUREMENTS AND MAIN RESULTS

EBV DNA levels were distributed differently among seropositive and seronegative patients, with the latter having higher values (P < 0.0001). Among the cohort of pretransplantation seropositive patients, there was one diagnosed with PTLD. The EBV DNA level in this patient was elevated at the time of PTLD diagnosis (sensitivity = 100%, specificity = 100% for PTLD). Among the cohort of pretransplantation seronegative patients, there were four with a diagnosis of PTLD. In all four patients, the EBV DNA level was detectable (sensitivity = 100%, specificity = 24%), but in only two was it elevated (sensitivity = 50%, specificity = 22%). HLA-A3 expression in the recipient and/or donor conferred additional risk for PTLD among the seronegative patients (P = 0.026 to 0.003). No other PTLD risk factor was found.

CONCLUSIONS

EBV DNA levels are a useful but imperfect predictor of PTLD in patients with lung transplants. Pretransplant EBV status affected the results of the assay and should be considered when interpreting test results. HLA-A3 was strongly linked to PTLD and may be a novel marker of PTLD risk.

Post-transplantation osteoporosis

Osteoporosis is prevalent in transplant recipients and is related to pre- and post-transplantation factors. Low bone density and fractures may antedate transplantation, related to traditional risk factors for osteoporosis, effects of chronic illness, and end-stage organ failure and its therapy, on the skeleton. Bone loss after transplantation is related to adverse effects of immunosuppressive drugs (glucocorticoids and calcineurin inhibitors) on bone remodeling. Newer immunosuppressive medications may permit lower doses of glucocorticoids and may be associated with decreased bone loss and fractures. Bisphosphonates are currently the most effective agents for the prevention and treatment of post-transplantation osteoporosis.

Transplantation osteoporosis

In the past two decades, there has been a rapid increase in the number of organ transplanted worldwide, including Brazil, along with an improvement in survival and quality of life of the transplant recipients. Osteoporosis and a high incidence of fragility fractures have emerged as a complication of organ transplantation. Many factors contribute to the pathogenesis of osteoporosis following organ transplantation. In addition, most patients have some form of bone disease prior to transplantation, which is usually related to adverse effects of end-stage organ failure on the skeleton. This chapter reviews the mechanisms of bone loss that occur both in the early and late post-transplant periods, as well as the features specific to bone loss after kidney, lung, liver, cardiac and bone marrow transplantation. Prevention and treatment for osteoporosis should be instituted prior and in the early and late phase after transplantation, and will also be addressed in this article.

Nutritional management of cystic fibrosis patients

PURPOSE OF REVIEW

We critique recent advances in nutritional care of patients with cystic fibrosis focusing on our understanding of the role of fecal elastase as a pancreatic function test, enzyme replacement therapy and bone health.

RECENT FINDINGS

Fecal elastase measured by the monoclonal antibody method is a useful screening test for delineating cystic fibrosis patients with pancreatic insufficiency (needing enzyme replacement therapy) from those with pancreatic sufficiency. Cutoff levels, however, have not been clearly defined, particularly in infancy. Newer enzyme products that attempt to improve the intralumenal intestinal pH with bicarbonate or using a combination of unprotected and enteric coated products fail to completely correct nutrient maldigestion. Compromised bone health in cystic fibrosis patients may be due to multiple factors including calcium, vitamin D, and vitamin K deficiencies and lung inflammation. Current recommendations for treatment of bone health in cystic fibrosis are not evidence-based.

SUMMARY

Fecal elastase is a useful marker of pancreatic function but limitations for this test exist. The presence of an acidic intestinal milieu and hitherto poorly defined intestinal factors may contribute to the failure of current enzyme preparations to correct nutrient assimilation in cystic fibrosis. The many factors that contribute to bone health must be evaluated when developing treatment strategies.

Comparison of alendronate vs alendronate plus mechanical loading as prophylaxis for osteoporosis in lung transplant recipients: a pilot study

BACKGROUND

Osteoporosis is known to complicate outcomes after lung transplantation (Tx).

METHODS

To determine the efficacy of bisphosphonate therapy combined with the osteogenic stimulus of mechanical loading, 30 lung transplant recipients (LTRs) were randomly assigned either to alendronate (10 mg/day; n = 10), alendronate (10 mg/day) + resistance exercise (n = 10) or to a control group (n = 10). Alendronate was initiated at 7 days after Tx. Bone mineral density (BMD) of the lumbar spine was measured by dual-energy X-ray absorptiometry before and 2 and 8 months after Tx. Resistance training was initiated at 2 months after Tx and consisted of lumbar extension exercise performed 1 day/week for 6 months.

RESULTS

Lumbar BMD decreased significantly to below pre-transplant baseline at 2 months after Tx in controls (-12.5 +/- 2.1%), but not in the alendronate (1.5 +/- 1.2%) or alendronate + training (1.5 +/- 0.9%) groups. At 8 months after Tx, lumbar BMD in controls was 14.1 +/- 3.9% below baseline (p < or = 0.05), but was 1.4 +/- 1.1% above baseline in alendronate recipients (p > or = 0.05). The alendronate + training group showed a significantly increased lumbar BMD with values 10.8 +/- 2.3% greater than before Tx.

CONCLUSIONS

These results suggest that resistance exercise plus alendronate is more effective than alendronate alone in restoring BMD. Anti-osteoporosis therapy in LTRs should include both an anti-resorptive agent and an osteogenic stimulus, such as mechanical loading.

Cytokines, bone turnover markers and weight change in candidates for lung transplantation

Weight loss in chronic obstructive pulmonary disease (COPD) is associated with increased morbidity and may negatively affect bone mineral density. Increased serum levels of cytokines such as tumour necrosis factor (TNF)-alpha have been associated with weight loss and with bone resorption. We studied the association between systemic inflammation, markers for bone turnover and recent weight change in underweight (n=48) and normal-weight patients (n=23) candidates for lung transplantation where the majority (56%) had COPD. Osteoporosis or osteopenia was present in all the diagnostic groups. The resulting model of linear regression in COPD patients showed that for the 1-CTP (a marker of bone resorption) model, the total variation of 61% was explained by recent weight change, sTNF-alpha receptor(R)II, dose of prednisolon and age. The resulting model of linear regression in the whole group of patients showed that the total variation of 72% was explained by recent weight change, sTNF-alpha RI, diagnosis (COPD/other diagnosis), dose of prednisolon and C-reactive protein. In conclusion, our results showed that serum concentration of 1-CTP was positively associated with sTNF-alpha receptor II and negatively with recent weight change in patients with advanced COPD. Recent weight loss in both the underweight and normal-weight patients showed to be a more important contributor than recent weight loss only in underweight patients for explaining variations in 1-CTP.

Update on maintaining bone health in cystic fibrosis

PURPOSE OF REVIEW

The high prevalence of decreased bone density in adults with cystic fibrosis is now well recognized, and guidelines for screening and treatment of cystic fibrosis-related bone disease have recently been published. This review summarizes the current best practices for optimizing bone health in cystic fibrosis and highlight recent findings that provide insight into the etiology of cystic fibrosis-related bone disease.

RECENT FINDINGS

Recent research suggests that cystic fibrosis-related bone disease actually starts during childhood, when individuals with cystic fibrosis fail to demonstrate normal bone calcium accretion. The failure to reach peak bone mass is made worse by increased osteoclast activity and bone resorption. This combination results in decreased bone density and an increased risk of fracture. Recent clinical studies suggest that multiple contributing factors need to be addressed in cystic fibrosis to optimize bone health: malnutrition, vitamin and mineral malabsorption, recurrent infections, inadequate sex hormones, and lack of exercise. Oral bisphosphonates have been demonstrated to be effective in cystic fibrosis and should be used when osteoporosis or progressive osteopenia is present.

SUMMARY

Research suggests cystic fibrosis-related bone disease actually begins during childhood, and guidelines now exist to aid in identifying and treating those with decreased bone density.

Orthopedic Complications of Solid-Organ Transplantation

Organ transplantation has undeniably increased the longevity and quality of life of patients with end-stage organ failure. Its has, however, introduced the skeletal complications of (1) fragility fractures and decreased bone density due to pretransplant bone loss and immunosuppressive therapy, and (2) avascular necrosis leading to subchondral fracture and secondary osteoarthritis. This article reviews these two skeletal complications of solid-organ transplantation that lead to structural failure of bone and result in significant morbidity and reduced quality of life.

Methotrexate, azathioprine, cyclosporine, and risk of fracture

We studied the fracture risk associated with use of methotrexate, azathioprine, and cyclosporine. The study was designed as a case-control study. All patients with a fracture (n = 124,655) in the year 2000 in Denmark served as cases. Information on fractures and confounders was retrieved from the National Hospital Discharge Register and a number of other national registers. For each case, three age- and gender-matched controls were randomly drawn from the general population (n = 373,962). Exposure was use of the drugs and a number of covariates including other immunosuppressive drugs, corticosteroids, any cancer, Crohn's disease, ulcerative colitis, rheumatoid arthritis, psoriasis, liver and kidney disease, prior fracture, and alcoholism. Azathioprine was associated with an increase in overall fracture risk, but besides this, none of the drugs was significantly associated with overall fracture risk or risk of hip, spine, or forearm fracture. Liver [odds ratio (OR) = 1.55, 95% confidence interval (CI) 1.42-1.69] and kidney (OR = 1.26, 95% CI 1.16-1.37) diseases were significantly associated with increased risk of fractures. Azathioprine was associated with an increase in overall fracture risk but not in the risk of spine, hip, or forearm fractures. Methotrexate and cyclosporine were not associated with fracture risk. It thus seems that the underlying disease for which the treatment is administered may be responsible for much of the increase in fracture risk rather than the drugs used to treat the disorder in question.

Pretransplantation bone disease in patients with primary pulmonary hypertension

INTRODUCTION

Osteoporosis is a common condition in patients with end-stage lung disease, but little attention has been given to bone disease in patients with primary pulmonary hypertension (PPH). The purposes of this study were as follows: (1) to determine the prevalence of osteoporosis in patients with severe PPH before lung transplantation, (2) to investigate whether generally accepted risk factors for osteoporosis would play a role in this special group of patients, and (3) to determine whether there is an association between functional parameters and pretransplantion bone mass.

DESIGN

A retrospective analysis of 18 consecutive patients with PPH accepted for lung transplantation at the University Hospital of Zurich.

MEASUREMENTS AND RESULTS

Decreased bone mineral density (BMD) [T score <- 1.0] was found in 11 of 18 patients (61%) at the femoral neck (FN) and 13 of 18 patients (72%) at the lumbar spine (LS). We did not find a significant difference of BMD in a gender- or age-specific manner. Body mass index (BMI) correlated significantly with BMD and T score at the FN and WT. Pulmonary vascular resistance (PVR) was notably linked with BMD at the FN. We found a positive association between walking distance in the 12-min walking test and BMD at the FN and WT.

CONCLUSIONS

Low bone density is a very frequent condition in patients with severe PPH. In contrast to the general population, in our study group neither age nor female gender were significantly associated with lower bone mass. Body weight and BMI were highly coupled with BMD. Among the functional parameters, walking distance and PVR were correlated to BMD at the FN. Considering that patients with PPH may have an improved life expectancy in the future, the early diagnosis, prevention, and treatment of osteoporosis should receive high priority.

Osteoporosis in diffuse parenchymal lung disease

STUDY OBJECTIVES

There are no studies focused on skeletal status in patients with diffuse parenchymal lung disease (DPLD). We hypothesized that patients with DPLD referred for lung transplantation would have a high prevalence of osteoporosis related to corticosteroid use or reduced pulmonary function and exercise capacity.

DESIGN

Retrospective cohort study.

SETTING

Tertiary care center.

PATIENTS

Eighty-six patients with DPLD referred to our center for lung transplantation evaluation between March 1999 and April 2004.

MEASUREMENTS AND RESULTS

Dual-energy X-ray absorptiometry was used to measure bone mineral density (BMD) at the lumbar spine, femoral neck, total hip, and radius at the time of referral. Criteria developed by the World Health Organization were used to define osteopenia and osteoporosis. Fifty-five patients (64%) had usual interstitial pneumonia-pattern lung disease, 14 patients (16%) had nonspecific interstitial pneumonia-pattern lung disease, and 17 patients (20%) had other forms of DPLD. Sixty-four patients (74%) were receiving corticosteroids, and 43 patients (50%) were receiving preventive therapy for osteoporosis. Eleven patients (13%; 95% confidence interval [CI], 7 to 22%) met criteria for osteoporosis at any site, and 49 patients (57%; 95% CI, 46 to 68%) had osteopenia. Lower body mass index (BMI) [adjusted odds ratio (OR), 1.3; 95% CI, 1.1 to 1.6; p = 0.007] and Hispanic ethnicity (adjusted OR, 9.7; 95% CI, 1.8 to 52; p = 0.008) were independently associated with an increased risk of osteoporosis. Linear regression analysis confirmed that BMD at the femoral neck and hip was directly associated with BMI (p < 0.002). These findings were not affected by adjustment for the use of corticosteroids or osteoporosis prophylaxis, pulmonary function, or exercise performance.

CONCLUSIONS

Reduced BMD was common in patients with DPLD who were referred for lung transplantation. Lower BMD was associated with lower BMI, whereas there was no association with other clinical factors in our cohort. Hispanic patients with DPLD had a higher risk of osteoporosis than non-Hispanic patients, independent of other variables. Given their increased risk of bone loss, patients with DPLD should undergo screening for osteoporosis and receive prophylaxis and treatment according to published guidelines.

Mild to moderate cystic fibrosis is not associated with increased fracture risk in children and adolescents

OBJECTIVES

To determine whether children and adolescents with cystic fibrosis (CF), pancreatic insufficiency (PI), and mild-to-moderate lung disease have an increased risk of fracture compared with concurrent healthy control subjects.

STUDY DESIGN

A lifetime fracture history questionnaire was administered to 186 subjects (ages 6 to 25 years) with CF, PI and mild-to-moderate lung disease and 427 healthy white control subjects (ages 4 to 25 years).

RESULTS

A fracture was reported by 24% of subjects with CF and 23% of healthy control subjects. Average age of first fracture was similar between the groups (8.3 years for subjects and 8.8 years for controls). The radius/ulna was the most common fracture site in both groups. Risk of fracture, adjusted for sex and age, was not greater in the CF group compared with the control group (hazard ratio: 0.96, 95% CI: 0.68, 1.30, P = .82).

CONCLUSION

Children and adolescents with CF, PI, and mild-to-moderate lung disease were not at an increased risk of fracture.

Osteoporose após transplante de órgãos sólidos

A osteoporose é uma complicação comum após os transplantes de rim, coração, fígado e pulmão. Os esquemas imunossupressores para evitar a rejeição do órgão enxertado após o transplante freqüentemente incluem glicocorticóides, ciclosporina A e tacrolimus, os quais possuem efeitos danosos sobre a homeostase mineral óssea, impostos a um esqueleto já comprometido. Outros fatores que provavelmente contribuem para a patogênese da osteoporose pós-transplante são deficiência de vitamina D, hiperparatireoidismo secundário e hipogonadismo. Medidas para avaliação da saúde óssea antes do transplante deveriam ser realizadas: densitometria mineral óssea, radiografia da coluna, avaliação do nível de vitamina D e dos hormônios gonadais. Todos os pacientes transplantados deveriam ser submetidos à profilaxia da perda óssea. Estudos clínicos sugerem que os bisfosfonatos são os agentes mais promissores para a prevenção e o tratamento da osteoporose pós-transplante.

Increased Vitamin A and E Levels in Adult Cystic Fibrosis Patients after Lung Transplantation

Most patients with cystic fibrosis (CF) and pancreatic insufficiency require supplementation with fat-soluble vitamins to maintain normal serum levels. Even with supplementation, toxicity is rare. We evaluated serum vitamin A and E levels in 23 adult patients with CF who underwent double lung transplantation. Twenty-one of the subjects were pancreatic insufficient. Fifteen subjects had serum vitamin levels before and after transplant. The median time posttransplantation for these subjects was 9 months. Mean serum vitamin A and E levels were significantly higher posttransplantation (P<0.0001, P<0.001, respectively). Eight subjects who only had posttransplant vitamin levels also had abnormally high vitamin A levels. Although the etiology of this novel finding is unclear, possibilities include altered absorption, drug interactions, impaired retinol metabolism, or increased hepatic synthesis of retinol binding protein.

Treatment of bone disease in cystic fibrosis

PURPOSE OF REVIEW

As individuals with cystic fibrosis (CF) have experienced marked improvements in longevity over the last three decades, bone disease has emerged as a new problem. Bone disease in CF has not been previously reviewed in this journal. Therefore, this review will give a brief overview of bone disease in CF and then concentrate on treatment options.

RECENT FINDINGS

In some series, as many as three fourths of adults with CF have low bone density. Decreased absorption of fat-soluble vitamins due to pancreatic insufficiency, altered sex hormone production, chronic inflammation, physical inactivity, and glucocorticoid treatment are some of the factors that contribute to this problem. Vitamin D depletion most likely contributes to bone disease, but identifying the safest and most efficacious vitamin D supplementation has yet to be resolved. Calcium and vitamin K supplementations are important if the diet contains less than the recommended amounts. Treatment of delayed puberty and adult hypogonadism with hormone replacement is recommended to achieve peak bone mass and maintain bone density. Bisphosphonates, including pamidronate and alendronate, are beneficial in improving bone mineral density before and after transplantation in CF adults. Bisphosphonates have not been studied in CF children.

SUMMARY

Although much progress has been made in our understanding of the pathogenesis, natural history, and clinical manifestations of bone disease in CF, treatment options are still evolving. More attention to nutrition, in terms of the maintenance of lean body mass and vitamin D and calcium supplementation, is likely to decrease bone complications. Bisphosphonates can be of value in CF adults with low bone density. Several clinical trials are under way to help optimize the treatment of CF bone disease.

Prevalence and correlates of vertebral fractures in adults with cystic fibrosis

INTRODUCTION

Osteoporosis associated with cystic fibrosis (CF) is becoming increasingly important as the life expectancy of patients continues to increase.

MATERIALS AND METHODS

We studied 191 adults with CF (18-50 years old; 100 men, 91 women). Total body, lumbar spine, and total proximal femur bone mineral density (BMD) were measured by dual-energy X-ray absorptiometry, and lateral spinal radiographs were taken for assessment of vertebral fractures. A range of anthropometric, clinical and biochemical variables were evaluated as potential correlates.

RESULTS

BMD T score values at the lumbar spine lower than -2.5 SD were observed in 27.3% and 11.2% of male and female patients, respectively. These proportions fell to 14% and 9.9% for total hip and 10.4% and 12.1% for total body, in men and women, respectively. Vertebral deformities were identified in 26.7% of the patients with a slightly higher prevalence in males (32%) than in females (21%, P = 0.058). Multiple vertebral deformities were observed in 12% and 7.7% of men and women, respectively. BMD values were significantly related to body weight, FEV1, age of puberty and occasionally to cumulative steroid dose in both genders. BMD values were also significantly related with serum albumin, IgG and cholinesterase. Serum estradiol levels were found below the normal range in 23% of the women and 27% of the men, and was significantly related to femur BMD values in both women and men. Significantly lower serum estradiol and free testosterone levels were observed in men with vertebral fractures. Serum osteocalcin was below the normal range in 36% and urinary deoxypyridinoline above the normal range in 51% of the patients.

CONCLUSIONS

This study indicates that osteoporosis is a common complication of CF, being related to disease progression and apparently due to both excess bone resorption and inadequate bone formation. Estradiol deficiency may have a significant role in the pathogenesis in both genders. Vertebral fracture prevalence is high and greater than expected from prevalent BMD values.

Severe osteopenia in CFTR-null mice

Osteoporosis is a common complication in cystic fibrosis (CF) patients. In this study, we performed a histomorphometric analysis of the bones of a mouse genetic model of human CF in which both copies of the cystic fibrosis transmembrane conductance regulator (CFTR) gene are inactivated. We find that, even in the absence of obvious nutritional and therapeutic differences, the CFTR mutation is associated with severe osteopenia. Bone mineral density (BMD) of total body and of individual bones is significantly diminished. CFTR mutants display a striking significant (50%) reduction of cortical bone width and thinner trabeculae. Analysis of dynamic parameters indicates a significant reduction of bone formation and a concomitant strong increase in bone resorption. Active osteoclasts where found mostly associated with cortical bone. Our data support the concept that CF-associated osteoporosis is part of the syndromic symptoms associated with the CFTR mutation.

Effect of oral bisphosphonates on bone mineral density and body composition in adult patients with cystic fibrosis: a pilot study

BACKGROUND

Approximately two thirds of adult patients with cystic fibrosis have reduced bone mineral density and up to one quarter have osteoporosis at one or more sites. Any bone mineral deficits are likely to be exacerbated in patients following lung transplantation by their immunosuppressive regimen. Vertebral collapse and rib fractures will impair the ability to cough and the efficacy of physiotherapy treatments.

METHODS

Patients attending the Leeds Regional Adult Cystic Fibrosis Unit with either osteopenia or osteoporosis on dual energy x ray absorptiometry (DXA) scanning were offered treatment with oral bisphosphonates after exclusion of abnormal vitamin D, calcium, or phosphate levels, abnormal thyroid function, or hypogonadism. Those declining treatment or patients with a normal initial DXA scan formed the control group. A second DXA scan was performed after a mean of 2.4 years in the treatment group and 2.9 years in the non-treatment group. Patients in the active group were asked to complete a short questionnaire detailing their adherence to treatment.

RESULTS

The medians of the differences in annual changes in bone parameters between treatment and control groups showed significant differences in bone mineralisation in favour of the treatment group at the lumbar spine (L2-L4), the femoral neck, and for total body measurements. There were no significant differences in weight, height, or body composition in either patient group. Most treated patients stated that they adhered to treatment most of the time.

CONCLUSION

Treatment with oral bisphosphonates may improve bone mineralisation in adult patients with cystic fibrosis. The results of this pilot study need to be further explored in a randomised controlled trial.

Normal annual increase of bone mineral density during two years in patients with cystic fibrosis

OBJECTIVES

To determine prospectively for 2 years the change in bone mineral density (BMD) in patients with cystic fibrosis (CF) and to correlate clinical data and routine biochemical parameters of bone metabolism and infection with BMD.

METHODS

Fifty-four patients with CF, aged 6 to 33 years, were included. BMD was measured using dual-energy x-ray absorptiometry in lumbar spine (LS) and femoral neck (FN). Anthropometric data and biochemical markers of bone metabolism and infection were measured. The number of intravenous antibiotic courses per year (ivAC) and pulmonary function were assessed.

RESULTS

The patients had normal anthropometric data and normal growth, but 36% and 33% of the patients had BMD z score <-1 standard deviation in LS and in FN, respectively. Nevertheless, BMD increased at a normal rate during the 2 years and was correlated to weight and lung function. Intact parathyroid hormone was positively correlated with the increase of BMD in both LS and FN during childhood. Blood sedimentation rate, serum concentration of immunoglobulin G, and ivAC were negatively correlated with BMD in FN. Patients with 2 more severe CF transmembrane conductance regulator mutations had significantly lower BMD in FN than other genetic combinations.

CONCLUSION

The study suggests that low BMD in CF is multifactorial and depends on infection and nutritional parameters. Differences in BMD of LS and FN suggested higher susceptibility to infection in FN at all ages. Longitudinal studies starting early before bacterial colonization would be valuable to determine the relative role of infection in the development of BMD in CF.

Recognizing and treating glucocorticoid-induced osteoporosis in patients with pulmonary diseases

Glucocorticoids are frequently used to treat patients with pulmonary diseases, but continuous long-term use of glucocorticoids may lead to significant bone loss and an increased risk of fragility fractures. Patients with certain lung diseases, regardless of pharmacotherapy-particularly COPD and cystic fibrosis-and patients waiting for lung transplantation are also at increased risk of osteoporosis. Fragility fractures, especially of the hip, will have substantial effects on the health and well-being of older patients. Vertebral collapse and kyphosis secondary to glucocorticoid-induced osteoporosis (GIO) may affect lung function. Identification of patients with osteopenia, osteoporosis, or fragility fractures related to osteoporosis is strongly recommended and should lead to appropriate treatment. Prevention of GIO in patients receiving continuous oral glucocorticoids is also recommended. In patients receiving either high-dose inhaled glucocorticoids or low- to medium-dose inhaled glucocorticoids with frequent courses of oral glucocorticoids, bone mineral density measurements should be performed to screen for osteopenia and osteoporosis. A bisphosphonate (risedronate or alendronate), calcium and vitamin D supplementation, and lifestyle modifications are recommended for the prevention and treatment of GIO.

Vitamin D deficiency, bone mineral density and weight in patients with advanced pulmonary disease

OBJECTIVE

To study the influence of underweight, body composition and vitamin D deficiency on bone mineral density in patients with advanced pulmonary disease.

DESIGN

Cross-sectional study with time span for inclusion set at 5 years.

SETTING

The clinical work and biochemical analyses were carried out at Rikshospitalet University Hospital, Norway. Analyses for vitamin D metabolites and bone markers were carried out at Aker University Hospital, and bone measurements at Clinic of Osteoporosis.

SUBJECTS

Seventy-one candidates for lung transplantation (63% chronic obstructive pulmonary disease, 42 underweight and 29 normal weight) were included.

MAIN OUTCOME MEASURES

Body composition, bone mineral density at lumbar spine and femur neck, serum concentration of calcidiol and vitamin D intake.

RESULTS

Subnormal calcidiol levels were present in 52% of the underweight patients and 69% of the normal-weight patients. The resulting models of linear regression showed that for the lumbar spine T scores model, the total variation of 16.7% was explained by group (underweight/normal weight), sex and age. For the femur neck T scores model, the total variation of 20.4% was explained by the interaction of underweight and vitamin D deficiency (with borderline significance) and by arm muscle circumference percentage of standard. In patients with normal calcidiol levels, the median intake of vitamin D was 17 microg in the underweight patients and 11 microg in the normal-weight patients.

CONCLUSIONS

Vitamin D deficiency was common in both underweight and normal-weight patients, but only in the underweight patients, an association between vitamin D deficiency and reduced femur neck T scores was indicated.

Estudio de la densidad mineral ósea en pacientes adultos con fibrosis quística

BACKGROUND AND OBJECTIVE

Due to recent medical advances, patients with cystic fibrosis (CF) can expect longer survival rates and, as a result, face previously unreported complications such as osteoporosis. Our goal was to determine the mineral bone density in young adult patients with CF attended in the adult CF Unit, and correlate these findings with other clinical variables of interest in this patient population.

PATIENTS AND METHOD

We carried out a transversal study from 1999 to 2002 of 34 patients with CF (19 males and 15 females. Mean age 23 years). Upon enrollment in the study, patient gender and age were recorded along with Schwachman and Brasfield scores, pulmonary function test results (spirometry) and sputum analysis, phosphorus and calcium balance, vitamin D intake, and dual energy X-ray absorptiometry (DEXA) findings of the spinal column (L2-L4) and femur.

RESULTS

54.5% of all study patients were found to have an abnormal mineral bone density. Fifteen patients met criteria for osteopenia and 3 for osteoporosis. Age, treatment with inhaled corticosteroids, and pulmonary function test results correlated with bone density.

CONCLUSIONS

DEXA scans should be performed in young adults with CF at least once during the course of their illness on the basis of the high prevalence of mineral bone density abnormalities in this population.

A Survey of Clinical Practice of Lung Transplantation in North America

OBJECTIVES

The clinical practice of lung transplantation (LT) varies widely among transplant centers. The objective of this study was to determine the practice patterns of North American lung transplant programs in specific areas that are considered controversial by most lung transplant practitioners.

METHODS

The Transplant/Immunology Network of the American College of Chest Physicians (ACCP) designed a survey and distributed it through the ACCP using a Web-based survey tool. The survey was divided into the following two sections: (1) patient selection issues; and (2) posttransplant management. Additional questions were asked about graft preservation, retransplantation, and living donor operations. A single 64-question survey was sent to each lung transplant program in the United Sates registered in the United Network of Organ Sharing database as of September 2001 and to each of the five active Canadian programs.

RESULTS

The survey was conducted in September and October 2002. Fifty of 65 active centers completed the survey, for a response rate of 77%. The data are presented in graphic format as a percentage of respondents.

CONCLUSION

This survey provides a large, time-sensitive database summarizing the clinical practice of LT in North America. In general, the survey responses demonstrated a remarkable degree of consistency around patient selection criteria, but much greater variance in posttransplant management of lung transplant recipients. These findings may reflect the fact that a published selection criteria guideline exists, but no similar documents have been designed for postoperative management. Hopefully, postoperative areas with widely divergent approaches to management will foster future collaborative studies aimed at identifying the most appropriate practices.

Musculoskeletal manifestations in cystic fibrosis

Although bone and joint manifestations are common in children with cystic fibrosis (CF), they have received little attention in adults. As compared to healthy individuals, bone mineral density is low, even with calcium intakes greater than 1500 mg/d. Nevertheless, calcium and phosphate levels in blood and urine are often normal, and vitamin D levels vary. Short stature with a low body mass index and central hypogonadism are the rule in these patients. Fractures and kyphosis are often reported. CF arthropathy occurs in 2-8.5% of patients. Arthritis develops, and there may be skin eruptions. Non-steroidal antiinflammatory drug therapy is effective. Hypertrophic osteoarthropathy associated with respiratory failure is present in 2-7% of patients. Rheumatoid arthritis, spondyloarthropathies, sarcoidosis, and amyloidosis have been reported in association with CF. Knee pain due to patellofemoral syndrome, quinolone-induced arthropathy, and mechanical back pain have been described. Rheumatoid factor titers are higher than in healthy controls, particularly in patients with episodic arthritis. No data are available on antiperinuclear factor or antikeratin antibody titers. Tests for antinuclear antibody are usually negative. Circulating immune complex levels and antibodies to heat shock proteins may be elevated. Antineutrophil cytoplasmic antibody of the bactericidal/permeability-increasing protein (BPI) or azurocidin (AZ) type has been reported, often in high titers (up to 40%).