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Duggal S, Sharma S, Rai N, Chauhan D, Upadhyay V, Srivastava S, Porwal K, Kulkarni C, Trivedi AK, Gayen JR, Mishra PR, Chattopadhyay N, Pal S. Anti-Microbial Drug Metronidazole Promotes Fracture Healing: Enhancement in the Bone Regenerative Efficacy of the Drug by a Biodegradable Sustained-Release In Situ Gel Formulation. Biomedicines 2024; 12:1603. [PMID: 39062176 PMCID: PMC11274654 DOI: 10.3390/biomedicines12071603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 07/09/2024] [Accepted: 07/10/2024] [Indexed: 07/28/2024] Open
Abstract
Nitroimidazoles comprise a class of broad-spectrum anti-microbial drugs with efficacy against parasites, mycobacteria, and anaerobic Gram-positive and Gram-negative bacteria. Among these drugs, metronidazole (MTZ) is commonly used with other antibiotics to prevent infection in open fractures. However, the effect of MTZ on bone remains understudied. In this paper, we evaluated six nitroimidazole drugs for their impact on osteoblast differentiation and identified MTZ as having the highest osteogenic effect. MTZ enhanced bone regeneration at the femur osteotomy site in osteopenic ovariectomized (OVX) rats at the human equivalent dose. Moreover, in OVX rats, MTZ significantly improved bone mass and strength and improved microarchitecture compared to the vehicle-treated rats, which was likely achieved by an osteogenic mechanism attributed to the stimulation of the Wnt pathway in osteoblasts. To mitigate the reported neurological and genotoxic effects of MTZ, we designed an injectable sustained-release in situ gel formulation of the drug that improved fracture healing efficacy by 3.5-fold compared to oral administration. This enhanced potency was achieved through a significant increase in the circulating half-life and bioavailability of MTZ. We conclude that MTZ exhibits osteogenic effects, further accentuated by our sustained-release delivery system, which holds promise for enhancing bone regeneration in open fractures.
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Affiliation(s)
- Shivali Duggal
- Division of Endocrinology, CSIR-Central Drug Research Institute, Council of Scientific and Industrial Research, Lucknow 226031, India
| | - Shivani Sharma
- Division of Endocrinology, CSIR-Central Drug Research Institute, Council of Scientific and Industrial Research, Lucknow 226031, India
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India
| | - Nikhil Rai
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India
- Division of Pharmaceutics and Pharmacokinetics, CSIR-Central Drug Research Institute, Council of Scientific and Industrial Research, Lucknow 226031, India
| | - Divya Chauhan
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India
- Division of Pharmaceutics and Pharmacokinetics, CSIR-Central Drug Research Institute, Council of Scientific and Industrial Research, Lucknow 226031, India
| | - Vishal Upadhyay
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India
- Division of Cancer Biology, CSIR-Central Drug Research Institute, Council of Scientific and Industrial Research, Lucknow 226031, India
| | - Swati Srivastava
- Division of Cancer Biology, CSIR-Central Drug Research Institute, Council of Scientific and Industrial Research, Lucknow 226031, India
| | - Konica Porwal
- Division of Endocrinology, CSIR-Central Drug Research Institute, Council of Scientific and Industrial Research, Lucknow 226031, India
| | - Chirag Kulkarni
- Division of Endocrinology, CSIR-Central Drug Research Institute, Council of Scientific and Industrial Research, Lucknow 226031, India
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India
| | - Arun K. Trivedi
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India
- Division of Cancer Biology, CSIR-Central Drug Research Institute, Council of Scientific and Industrial Research, Lucknow 226031, India
| | - Jiaur R. Gayen
- Division of Pharmaceutics and Pharmacokinetics, CSIR-Central Drug Research Institute, Council of Scientific and Industrial Research, Lucknow 226031, India
| | - Prabhat R. Mishra
- Division of Pharmaceutics and Pharmacokinetics, CSIR-Central Drug Research Institute, Council of Scientific and Industrial Research, Lucknow 226031, India
| | - Naibedya Chattopadhyay
- Division of Endocrinology, CSIR-Central Drug Research Institute, Council of Scientific and Industrial Research, Lucknow 226031, India
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India
| | - Subhashis Pal
- Division of Endocrinology, CSIR-Central Drug Research Institute, Council of Scientific and Industrial Research, Lucknow 226031, India
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University, Atlanta, GA 30322, USA
- Division of Medical Research, SRM Medical College Hospital and Research Centre, SRM Institute of Science and Technology (SRM IST), Kattankulathur 603203, India
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Jaikaransingh V. Bone health and fracture prevention after kidney transplantation. J Clin Transl Endocrinol 2024; 36:100345. [PMID: 38737624 PMCID: PMC11081796 DOI: 10.1016/j.jcte.2024.100345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 04/21/2024] [Accepted: 04/24/2024] [Indexed: 05/14/2024] Open
Abstract
Changes in bone health and strength are common after kidney transplantation and can lead to an increased risk of fracture. This has implications for morbidity, mortality and renal allograft survival. This review will focus on the changes that occur in bone health and fracture risk after kidney transplantation and examine the evidence available to guide diagnostic and therapeutic decisions with the aim of fracture prevention.
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Affiliation(s)
- Vishal Jaikaransingh
- University of Florida College of Medicine – Jacksonville, Department of Medicine, Division of Nephrology, United States
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Tsai HL, Lin TC, Lin NC, Yang HH, Chang JW. Risk Factors for Fractures in Renal Transplantation: A Population-Based Cohort Study. Am J Nephrol 2023; 54:498-507. [PMID: 37783206 DOI: 10.1159/000533125] [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: 05/13/2023] [Accepted: 07/17/2023] [Indexed: 10/04/2023]
Abstract
INTRODUCTION Kidney transplant recipients are at an increased risk of fractures, and targeted preventive strategies are needed. Therefore, in this retrospective cohort study, we investigated a large population-based cohort to identify the transplant recipient-specific risk factors for fractures in Taiwanese kidney transplant recipients. METHODS We conducted a retrospective cohort study using the National Health Insurance Research Database. Patients who underwent renal transplantation between 2003 and 2015 were identified and followed until December 31, 2015, to observe the development of fractures. Variables associated with the development of post-transplant fractures were identified by calculating hazard ratios in a Cox regression model. RESULTS 5,309 renal transplant recipients were identified, of whom 553 (10.4%) were diagnosed with post-transplant fractures. Independent predictors of post-transplant fractures included an age at transplant ≥65 years (p < 0.001), female sex (p < 0.001), fractures within 3 years prior to transplantation (p < 0.001), and diabetes mellitus (p < 0.001). In addition, daily prednisolone doses >2.9–5.3 mg/day (p < 0.001), >5.3–8.7 mg/day (p < 0.001), and >8.7 mg/day (p < 0.001) were also independent predictors of post-transplant fractures. Conversely, the use of peritoneal dialysis before renal transplantation (p = 0.021), hypertension (p = 0.005), and the use of tacrolimus (p < 0.001), azathioprine (p = 0.006), mycophenolate mofetil/mycophenolic acid (p = 0.002), mTOR inhibitors (p = 0.004), and calcium supplements (p = 0.009) were inversely correlated with post-transplant fractures. CONCLUSION We recommend minimizing daily glucocorticoids as early and as far as possible in conjunction with immunosuppressive regimens such as tacrolimus, azathioprine, mycophenolate mofetil/mycophenolic acid, mTOR inhibitors, and calcium supplements, especially in older female recipients and in recipients with diabetes and a history of prior fractures.
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Affiliation(s)
- Hsin-Lin Tsai
- Division of Pediatric Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tzu-Ching Lin
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Niang-Cheng Lin
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Transplantation Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hui-Hsin Yang
- Division of Pediatric Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jei-Wen Chang
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Hasparyk UG, Vigil FMB, Bartolomei VS, Nunes VM, Simões e Silva AC. Chronic Kidney Disease-Mineral Bone Disease biomarkers in kidney transplant patients. Curr Med Chem 2022; 29:5230-5253. [DOI: 10.2174/0929867329666220318105856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 01/16/2022] [Accepted: 01/20/2022] [Indexed: 11/22/2022]
Abstract
Background:
Chronic Kidney Disease associated with Mineral Bone Disease (CKD-MBD) is frequent in kidney transplant patients. Post-transplantation bone disease is complex, especially in patients with pre-existing metabolic bone disorders that are further affected by immunosuppressive medications and changes in renal allograft function. Main biochemical abnormalities of mineral metabolism in kidney transplantation (KTx) include hypophosphatemia, hyperparathyroidism (HPTH), insufficiency or deficiency of vitamin D, and hypercalcemia.
Objective:
This review aimed to summarize the pathophysiology and main biomarkers of CKD-MBD in KTx.
Methods:
A comprehensive and non-systematic search in PubMed was independently made with an emphasis on biomarkers in mineral bone disease in KTx.
Results:
CKD-MBD can be associated with numerous factors including secondary HPTH, metabolic dysregulations before KTx, and glucocorticoids therapy in post-transplant subjects. Fibroblast growth factor 23 (FGF23) reaches normal levels after KTx with good allograft function, while calcium, vitamin D and phosphorus, ultimately, result in hypercalcemia, persistent vitamin D insufficiency, and hypophosphatemia respectively. As for PTH levels, there is an initial tendency of a significant decrease, followed by a raise due to secondary or tertiary HPTH. In regard to sclerostin levels, there is no consensus in the literature.
Conclusion:
KTx patients should be continuously evaluated for mineral homeostasis and bone status, both cases with successful kidney transplantation and those with reduced functionality. Additional research on CKD-MBD pathophysiology, diagnosis, and management is essential to guarantee long-term graft function, better prognosis, good quality of life, and reduced mortality for KTx patients.
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Affiliation(s)
- Ursula Gramiscelli Hasparyk
- Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - Flávia Maria Borges Vigil
- Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - Victória Soares Bartolomei
- Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - Vitor Moreira Nunes
- Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - Ana Cristina Simões e Silva
- Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
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Lin TL, Wu CY, Yen JJY, Juan CK, Chang YL, Ho HJ, Chen YJ. Fracture risks in patients with atopic dermatitis: A nationwide matched cohort study. Ann Allergy Asthma Immunol 2021; 127:667-673.e2. [PMID: 34537357 DOI: 10.1016/j.anai.2021.09.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 08/20/2021] [Accepted: 09/08/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND The risk of osteoporosis has been explored in atopic dermatitis (AD). The long-term risk of fractures in patients with AD and the effects of various AD treatments on bone health remain to be elucidated. OBJECTIVE To evaluate the long-term risk of fractures in patients with AD. METHODS This nationwide matched cohort study was conducted using the National Health Insurance Research Database of Taiwan for the period 1997 to 2013. A total of 36,855 patients with AD and 147,420 reference subjects without AD were identified. Demographic characteristics and comorbidities were compared, and cumulative incidence of fractures was evaluated. Adjusted hazard ratios for fracture risks of AD and various AD treatments were calculated using the Cox proportional hazards model. RESULTS A total of 1518 patients (4.12%) in the AD cohort and 5579 patients (3.78%) in the reference cohort had fractures (P = .003). The mean ages were 22.6 years in both groups. The 16-year cumulative incidence of fractures in the AD cohort (8.043%) was significantly higher than that in the reference cohort (7.366%) (P = .002). Severe AD (adjusted hazard ratio [aHR], 1.31; 95% confidence interval [CI], 1.08-1.59) was independently associated with fractures. Other independent risk factors included exposure to topical (aHR, 1.21; 95% CI, 1.05-1.39) or systemic (≥10 mg/d; aHR, 1.62; 95% CI, 1.38-1.91) corticosteroids. Use of disease-modifying antirheumatic drugs (aHR, 0.71; 95% CI, 0.53-0.90) and phototherapy (aHR, 0.73; 95% CI, 0.56-0.95) was associated with a lower risk of fractures. The results were consistent across sensitivity analyses. CONCLUSION Patients with AD have a higher incidence of fractures. Severe AD is independently associated with fractures.
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Affiliation(s)
- Teng-Li Lin
- Department of Dermatology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chun-Ying Wu
- Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Institute of Biomedical Informatics, Institute of Public Health, National Yang Ming Chiao Tung University, Taipei, Taiwan; Division of Translational Research and Center of Excellence for Cancer Research, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Public Health, China Medical University, Taichung, Taiwan; National Institute of Cancer Research, National Health Research Institutes, Miaoli, Taiwan
| | - Jeffrey J-Y Yen
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan; Taiwan Mouse Clinic, Academia Sinica, Taipei, Taiwan
| | - Chao-Kuei Juan
- Department of Dermatology, Taichung Veterans General Hospital, Taichung, Taiwan; Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Ling Chang
- Department of Dermatology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Hsiu J Ho
- Institute of Biomedical Informatics, Institute of Public Health, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Ju Chen
- Department of Dermatology, Taichung Veterans General Hospital, Taichung, Taiwan; Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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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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7
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Affiliation(s)
- S. Bandini
- U. O. Nefrologia, Dialisi e Trapianto, Azienda Ospedaliera Careggi, Firenze
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8
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Gregorini M, Sileno G, Pattonieri EF, Corradetti V, Abelli M, Ticozzelli E, Scudeller L, Grignano MA, Esposito P, Bogliolo L, Giacomoni A, Rampino T. Understanding Bone Damage After Kidney Transplantation: A Retrospective Monocentric Cross Sectional Analysis. Transplant Proc 2017; 49:650-657. [PMID: 28457365 DOI: 10.1016/j.transproceed.2017.02.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Kidney transplantation (KT) immunosuppression may induce bone tissue damage with bone mineral density (BMD) loss increasing bone fractures risk. Steroid therapy is considered the major player, but others factors are still under review. PATIENTS AND METHODS We designed an observational retrospective cohort study to evaluate bone damage after KT. The prevalence of osteopenia, osteoporosis, bone fractures, and the associated risk factors were investigated. The following parameters were recorded before transplantation and at the last follow-up: demographic indexes, cumulative steroid dose (CSD), dialytic and transplantologic age, previous nephropathy, femoral and lumbar BMD, fractures, immunosuppressors, calcemia, phosphoremia, rejection episodes, estimated glomerular filtration rate, and parathyroid hormone and vitamin D levels. Stata software (Stata Corporation, College Station, Texas, United States) was used for the statistical analysis, to perform the Fisher's exact test, Kruskal-Wallis test, Student t test, as well as univariate and multivariate analyses. RESULTS The analyzed cohort was composed of 297 patients (65.3% males and 34.7% females). Sixty percent of KT patients had normal BMD, 24% had osteopenia, and 15% had osteoporosis. Twelve percent were victims of bone fractures (8.4% minor, 2% femoral, and 1.7% vertebral). A significant correlation (P <.05) was observed for both osteopenia and osteoporosis with menopause, transplantologic age, CSD, previous glomerulonephritis, and mammalian target of rapamycin (mTOR) inhibitors treatment (imTOR). CONCLUSION This study confirms the correlation between CSD (both before and after transplantation) and post-transplantation bone damage. It also shows that a large fraction of these patients had normal BMD related with a low steroid dose in our protocols. This correlation between imTOR assumption and osteoporosis deserves attention and warrants further in vitro analyses to be performed.
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Affiliation(s)
- M Gregorini
- Unit of Nephrology, Dialysis and Transplantation, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - G Sileno
- Unit of Nephrology, Dialysis and Transplantation, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - E F Pattonieri
- Unit of Nephrology, Dialysis and Transplantation, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Clinic and Surgical Science, University of Pavia, Pavia, Italy.
| | - V Corradetti
- Unit of Nephrology, Dialysis and Transplantation, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Clinic and Surgical Science, University of Pavia, Pavia, Italy
| | - M Abelli
- Unit of General Surgery 2, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - E Ticozzelli
- Unit of General Surgery 2, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - L Scudeller
- Clinical Epidemiology Unit, Fondazione IRCCS Policlinico San Matteo of Pavia, Pavia, Italy
| | - M A Grignano
- Unit of Nephrology, Dialysis and Transplantation, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - P Esposito
- Unit of Nephrology, Dialysis and Transplantation, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - L Bogliolo
- Unit of Reumatology, Fondazione IRCCS Policlinico San Matteo of Pavia, Pavia, Italy
| | - A Giacomoni
- Department of Surgery, Niguarda Transplant Center, Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - T Rampino
- Unit of Nephrology, Dialysis and Transplantation, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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9
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Wong J, Tan MZW, Chandran M. Fifty shades of gray: Bone disease in renal transplantation. PROCEEDINGS OF SINGAPORE HEALTHCARE 2015. [DOI: 10.1177/2010105815611808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Kidney transplantation is the renal replacement therapy of choice for patients with end stage renal disease. Advances in technology, surgical techniques and pharmacotherapy have improved renal allograft survival. Increasingly, we are seeing long term side effects related to renal transplantation, bone disease being a major one amongst them. Renal transplant patients have a higher risk of fragility fractures even when compared to those who remain on dialysis. This is likely to be related to pre-existing underlying bone disease and the emergence of new metabolic bone problems post-transplant. Conditions such as persistent hyperparathyroidism and the use of certain immunosuppressive agents have a deleterious effect on the post renal transplant bone. Remarkable advances in the field of metabolic bone research have been made in the last decade and newer imaging techniques, biomarkers and therapeutic options are now available for osteoporosis in the general population. Interest is being focused on attempting to extrapolate these new discoveries to the management of bone disease post renal transplant. This review will briefly describe the metabolic bone changes that occur after transplantation and will provide an update on the currently available investigative options and therapeutic strategies for the management of post renal transplant bone disease.
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Affiliation(s)
- Jiunn Wong
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | | | - Manju Chandran
- Department of Endocrinology, Singapore General Hospital, Singapore
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10
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Current Status of Research on Osteoporosis after Solid Organ Transplantation: Pathogenesis and Management. BIOMED RESEARCH INTERNATIONAL 2015; 2015:413169. [PMID: 26649301 PMCID: PMC4662986 DOI: 10.1155/2015/413169] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 10/29/2015] [Accepted: 10/29/2015] [Indexed: 12/23/2022]
Abstract
Improved survival following organ transplantation has brought to the forefront some long-term complications, among which osteoporosis and associated fractures are the major ones that adversely affect the quality of life in recipients. The pathogenesis of osteoporosis in transplant recipients is complex and multifactorial which may be related to increased bone resorption, decreased bone formation, or both. Studies have shown that the preexisting underlying metabolic bone disorders and the use of immunosuppressive agents are the major risk factors for osteoporosis and fractures after organ transplantation. And rapid bone loss usually occurs in the first 6–12 months with a significant increase in fracture risk. This paper will provide an updated review on the possible pathogenesis of posttransplant osteoporosis and fractures, the natural history, and the current prevention and treatment strategies concerning different types of organ transplantation.
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The consequences of pediatric renal transplantation on bone metabolism and growth. Curr Opin Organ Transplant 2015; 18:555-62. [PMID: 23995376 DOI: 10.1097/mot.0b013e3283651b21] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW During childhood, growth retardation, decreased final height and renal osteodystrophy are common complications of chronic kidney disease (CKD). These problems remain present in patients undergoing renal transplantation, even though steroid-sparing strategies are more widely used. In this context, achieving normal height and growth in children after transplantation is a crucial issue for both quality of life and self-esteem. The aim of this review is to provide an overview of pathophysiology of CKD-mineral bone disorder (MBD) in children undergoing renal transplantation and to propose keypoints for its daily management. RECENT FINDINGS In adults, calcimimetics are effective for posttransplant hyperparathyroidism, but data are missing in the pediatric population. Fibroblast growth factor 23 levels are associated with increased risk of rejection, but the underlying mechanisms remain unclear. A recent meta-analysis also demonstrated the effectiveness of rhGH therapy in short transplanted children. SUMMARY In 2013, the daily clinical management of CKD-MBD in transplanted children should still focus on simple objectives: to optimize renal function, to develop and promote steroid-sparing strategies, to provide optimal nutritional support to maximize final height and avoid bone deformations, to equilibrate calcium/phosphate metabolism so as to provide acceptable bone quality and cardiovascular status, to correct all metabolic and clinical abnormalities that can worsen both bone and growth (mainly metabolic acidosis, anemia and malnutrition), promote good lifestyle habits (adequate calcium intake, regular physical activity, no sodas consumption, no tobacco exposure) and eventually to correct native vitamin D deficiency (target of 25-vitamin D >75 nmol/l).
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12
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Dounousi E, Leivaditis K, Eleftheriadis T, Liakopoulos V. Osteoporosis after renal transplantation. Int Urol Nephrol 2014; 47:503-11. [PMID: 25384432 DOI: 10.1007/s11255-014-0862-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 10/19/2014] [Indexed: 02/07/2023]
Abstract
Bone loss and fracture are serious sequelae of kidney transplantation, associated with morbidity, mortality and high economic costs. The pathogenesis of post-transplantation bone loss is multifactorial and complex. Pre-existing bone mineral disease is responsible for a significant part, but it is aggravated by risk factors emerging after renal transplantation with immunosuppressive agents being one of the key contributors. The decrease in bone mass is particularly prominent during the first 6-12 months after transplantation, continuing at a lower rate thereafter. Bone mineral density measurements do not predict bone histology and bone biopsy findings reveal heterogeneous lesions, which vary according to time after transplantation. Currently, vitamin D and bisphosphonates are the most extensively tested therapeutic agents against this accelerated bone loss in renal transplant recipients. Both of these agents have proven effective, but there is no evidence that they decrease fracture risk. More studies are needed to examine the complex pathophysiologic mechanisms implicated in this population, as well as the effects of different therapeutic interventions on bone disorders after kidney transplantation.
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Affiliation(s)
- Evangelia Dounousi
- Division of Nephrology, Department of Internal Medicine, School of Health Sciences, University Hospital of Ioannina, University of Ioannina, Ioannina, Greece
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13
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Kulak CAM, Borba VZC, Kulak Júnior J, Custódio MR. Bone disease after transplantation: osteoporosis and fractures risk. ACTA ACUST UNITED AC 2014; 58:484-92. [DOI: 10.1590/0004-2730000003343] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2014] [Accepted: 05/28/2014] [Indexed: 01/16/2023]
Abstract
Organ transplantation is the gold standard therapy for several end-stage diseases. Bone loss is a common complication that occurs in transplant recipients. Osteoporosis and fragility fractures are serious complication, mainly in the first year post transplantation. Many factors contribute to the pathogenesis of bone disease following organ transplantation. This review address the mechanisms of bone loss including the contribution of the immunosuppressive agents as well as the specific features to bone loss after kidney, lung, liver, cardiac and bone marrow transplantation. Prevention and management of bone loss in the transplant recipient should be included in their post transplant follow-up in order to prevent fractures.
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14
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Systemic and nonrenal adverse effects occurring in renal transplant patients treated with mTOR inhibitors. Clin Dev Immunol 2013; 2013:403280. [PMID: 24151517 PMCID: PMC3789319 DOI: 10.1155/2013/403280] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 07/08/2013] [Accepted: 08/04/2013] [Indexed: 02/07/2023]
Abstract
The mammalian target of rapamycin inhibitors (mTOR-I), sirolimus and everolimus, are immunosuppressive drugs largely used in renal transplantation. The main mechanism of action of these drugs is the inhibition of the mammalian target of rapamycin (mTOR), a regulatory protein kinase involved in lymphocyte proliferation. Additionally, the inhibition of the crosstalk among mTORC1, mTORC2, and PI3K confers the antineoplastic activities of these drugs. Because of their specific pharmacological characteristics and their relative lack of nephrotoxicity, these inhibitors are valid option to calcineurine inhibitors (CNIs) for maintenance immunosuppression in renal transplant recipients with chronic allograft nephropathy. However, as other immunosuppressive drugs, mTOR-I may induce the development of several adverse effects that need to be early recognized and treated to avoid severe illness in renal transplant patients. In particular, mTOR-I may induce systemic nonnephrological side effects including pulmonary toxicity, hematological disorders, dysmetabolism, lymphedema, stomatitis, cutaneous adverse effects, and fertility/gonadic toxicity. Although most of the adverse effects are dose related, it is extremely important for clinicians to early recognize them in order to reduce dosage or discontinue mTOR-I treatment avoiding the onset and development of severe clinical complications.
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Abstract
PURPOSE OF REVIEW Mineral and bone disorders (MBDs), inherent complications of moderate and advanced chronic kidney disease, occur frequently in kidney transplant recipients. However, much confusion exists about the clinical application of diagnostic tools and preventive or treatment strategies to correct bone loss or mineral disarrays in transplanted patients. We have reviewed the recent evidence about prevalence and consequences of MBD in kidney transplant recipients and examined diagnostic, preventive and therapeutic options to this end. RECENT FINDINGS Low turnover bone disease occurs more frequently after kidney transplantation according to bone biopsy studies. The risk of fracture is high, especially in the first several months after kidney transplantation. Alterations in minerals (calcium, phosphorus and magnesium) and biomarkers of bone metabolism (parathyroid hormone, alkaline phosphatase, vitamin D and FGF-23) are observed with varying impact on posttransplant outcomes. Calcineurin inhibitors are linked to osteoporosis, whereas steroid therapy may lead to both osteoporosis and varying degrees of osteonecrosis. Sirolimus and everolimus might have a bearing on osteoblast proliferation and differentiation or decreasing osteoclast-mediated bone resorption. Selected pharmacologic interventions for the treatment of MBD in transplant patients include steroid withdrawal, and the use of bisphosphonates, vitamin D derivatives, calcimimetics, teriparatide, calcitonin and denosumab. SUMMARY MBD following kidney transplantation is common and characterized by loss of bone volume and mineralization abnormalities, often leading to low turnover bone disease. Although there are no well established therapeutic approaches for management of MBD in renal transplant recipients, clinicians should continue individualizing therapy as needed.
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Santos RLD, Lacerda MCM, Gonçalves RT, Martins MA, Souza MMGD. Immunosuppressants: implications in Orthodontics. Dental Press J Orthod 2012. [DOI: 10.1590/s2176-94512012000200012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Becerik S, Gürkan A, Afacan B, Özgen Öztürk V, Atmaca H, Töz H, Atilla G, Emingil G. Gingival Crevicular Fluid Osteocalcin, N-Terminal Telopeptides, and Calprotectin Levels in Cyclosporin A–Induced Gingival Overgrowth. J Periodontol 2011; 82:1490-7. [DOI: 10.1902/jop.2011.100600] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Wesseling-Perry K, Bacchetta J. CKD-MBD after kidney transplantation. Pediatr Nephrol 2011; 26:2143-51. [PMID: 21394466 PMCID: PMC3203246 DOI: 10.1007/s00467-011-1829-6] [Citation(s) in RCA: 19] [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: 09/13/2010] [Revised: 02/11/2011] [Accepted: 02/12/2011] [Indexed: 01/01/2023]
Abstract
Successful kidney transplantation corrects many of the metabolic abnormalities associated with chronic kidney disease (CKD); however, skeletal and cardiovascular morbidity remain prevalent in pediatric kidney transplant recipients and current recommendations from the Kidney Disease Improving Global Outcomes (KDIGO) working group suggest that bone disease-including turnover, mineralization, volume, linear growth, and strength-as well as cardiovascular disease be evaluated in all patients with CKD. Although few studies have examined bone histology after renal transplantation, current data suggest that bone turnover and mineralization are altered in the majority of patients and that biochemical parameters are poor predictors of bone histology in this population. Dual energy X-ray absorptiometry (DXA) scanning, although widely performed, has significant limitations in the pediatric transplant population and values have not been shown to correlate with fracture risk; thus, DXA is not recommended as a tool for the assessment of bone density. Newer imaging techniques, including computed tomography (quantitative CT (QCT), peripheral QCT (pQCT), high resolution pQCT (HR-pQCT) and magnetic resonance imaging (MRI)), which provide volumetric assessments of bone density and are able to discriminate bone microarchitecture, show promise in the assessment of bone strength; however, future studies are needed to define the value of these techniques in the diagnosis and treatment of renal osteodystrophy in pediatric renal transplant recipients.
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Affiliation(s)
- Katherine Wesseling-Perry
- Department of Pediatrics, David Geffen School of Medicine at UCLA, A2-383 MDCC, 650 Charles Young Drive, Los Angeles, CA 90095, USA.
| | - Justine Bacchetta
- Department of Pediatrics, David Geffen School of Medicine at UCLA, A2-383 MDCC, 650 Charles Young Drive, Los Angeles, CA 90095 USA
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Abstract
In light of greatly improved long-term patient and graft survival after renal transplantation, improving other clinical outcomes such as risk of fracture and cardiovascular disease is of paramount importance. After renal transplantation, a large percentage of patients lose bone. This loss of bone results from a combination of factors that include pre-existing renal osteodystrophy, immunosuppressive therapy, and the effects of chronically reduced renal function after transplantation. In addition to low bone volume, histological abnormalities include decreased bone turnover and defective mineralization. Low bone volume and low bone turnover were recently shown to be associated with cardiovascular calcifications, highlighting specific challenges for medical therapy and the need to prevent low bone turnover in the pretransplant patient. This Review discusses changes in bone histology and mineral metabolism that are associated with renal transplantation and the effects of these changes on clinical outcomes such as fractures and cardiovascular calcifications. Therapeutic modalities are evaluated based on our understanding of bone histology.
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Vestergaard P. Adverse Effects of Drugs on Bone and Calcium Metabolism/Physiology. Clin Rev Bone Miner Metab 2008. [DOI: 10.1007/s12018-007-9002-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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21
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Valta H, Jalanko H, Holmberg C, Helenius I, Mäkitie O. Impaired bone health in adolescents after liver transplantation. Am J Transplant 2008; 8:150-7. [PMID: 17973968 DOI: 10.1111/j.1600-6143.2007.02015.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Long-term complications related to immunosuppressive medication are an important problem after liver transplantation (OLT). This study was carried out to evaluate the bone health and risk factors for osteoporosis and fractures in 40 pediatric liver transplant recipients. The results of 208 longitudinal bone mineral density (BMD) measurements were analyzed retrospectively. In addition, a dual-energy X-ray absorptiometry was performed to assess the bone mineral content more precisely and to detect subclinical vertebral fractures (VF). The median age of the patients was 14 years and mean postoperative follow-up 7.0 years. The results showed that over half (58%) had lumbar spine (LS) Z-score </=-1.0 and one-fifth (18%) had asymptomatic VF. LS Z-score tended to increase from the first year after OLT, but during puberty the bone mass gain was suboptimal and Z-scores decreased in some subjects. Patients with VF were older at the time of OLT (p = 0.002) and their LS Z-score was lower (p = 0.001). Children transplanted before 10 years of age had less VF (p = 0.004) and higher LS Z-score (p = 0.005) than older patients. In conclusion, adolescent liver recipients are prone to osteoporosis and prevention should be targeted especially to this age group.
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Affiliation(s)
- H Valta
- Department of Pediatric Nephrology and Transplantation, Hospital for Children and Adolescents, University of Helsinki, Finland
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Kerschan-Schindl K, Ruzicka M, Mahr S, Paireder M, Krestan C, Gleiss A, Bieglmayer C, Fialka-Moser V, Pacher R, Grimm M, Pietschmann P. Unexpected low incidence of vertebral fractures in heart transplant recipients: analysis of bone turnover. Transpl Int 2007; 21:255-62. [PMID: 18039318 DOI: 10.1111/j.1432-2277.2007.00598.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Heart transplantation (HTX) is associated with a reduction in bone mineral density (BMD). Different markers of bone metabolism have been used, and the applied immunosuppressive regimens have also changed over time. This study was performed to re-investigate bone metabolism in HTX recipients. Twenty-five HTX recipients were compared with 25 HTX candidates in respect of biochemical parameters of bone metabolism, BMD, and the frequency of fractures for 1 year. Osteopenia or osteoporosis was observed in approximately two-thirds of the HTX recipients. Nevertheless, only three (12%) HTX recipients developed a vertebral fracture within 1 year after transplantation; no peripheral fractures occurred. Compared with HTX candidates, HTX recipients had lower serum levels of osteocalcin, and higher serum levels of cross-linked-N-telopeptide of type I collagen (NTX). In HTX recipients, osteocalcin initially reached a nadir, increased during the first 3 months, and decreased thereafter. Bone-specific alkaline phosphatase initially increased and then decreased. Serum levels of NTX and parathyroid hormone remained high throughout the year. Despite a high bone turnover, an unexpectedly low rate of vertebral fractures was registered. Nevertheless, each fragility fracture is a serious complication and we need to take steps to prevent this complication.
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Abstract
Glucocorticoids have been the main agents for preventing organ rejection,but unfortunately they possess serious side effects. Newer immunosuppressive agents have therefore been introduced to overcome these effects and have had a dramatic impact on reducing the incidence of organ rejection, enhancing donor organ acceptance, and hence patient survival posttransplantation. However, calcineurin inhibitors (CIs), such as cyclosporine and tacrolimus, also have serious effects causing rapid and severe bone loss in animal models and humans. The mechanism accounting for this action is unclear at present, but the role of T lymphocyte action via RANKL seems to be of essence in triggering bone loss. The mechanism is complex and in vitro studies often produce results that are opposite to those seen in vivo. In addition to acute, rapid, and severe bone loss (ARSBL), the clinical picture shows an extremely high incidence of fractures at all sites, and depends upon the organ transplanted, preexisting bone disease, interval before transplantation, and the dose and duration of multiple immunosuppressive drugs. Other immune-modifying drugs, such as azathioprine, mycophenolate mofetil, and sirolimus, which are used in conjunction with glucocorticoids and CIs have not been shown to promote bone loss experimentally or clinically. With the exception of glucocorticoids, all of the agents discussed here demand further investigation with regard to their effects on bone health in the clinical setting.
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Affiliation(s)
- Ronald Tamler
- Mount Sinai School of Medicine, New York, NY 10029, USA
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25
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Abstract
A broad range of different factors aggravates renal osteodystrophy, which is present in virtually all patients with chronic kidney disease and after successful kidney transplantation. Altered hormonal status, including sex hormones and parathyroid hormone (PTH), a deficit of 1,25(OH)(2) vitamin D(3) (calcitriol), immunosuppressive therapy and post-operative immobilization contribute to a progressive loss of bone density and structure. The decrease of bone mass is particularly prominent during the first 6 months after kidney transplantation and is associated with an increased number of fractures, both compared with the normal population as well as with dialysis patients. At particular risk are patients with a history of diabetes, long duration of haemodialysis and post-menopausal women. To prevent post-transplant bone loss prescription of steroids should be minimized and withdrawn as early as possible. Additional intake of alpha-calcidol [25(OH) vitamin D(3)] or calcitriol, despite normal serum levels, reduces persistent hyperparathyroidism after kidney transplantation, improves intestinal calcium absorption and activates osteoblasts. Inhibition of osteoclasts by biphosphonate therapy seems to effectively reverse bone loss during the early and late course of kidney transplantation. However, as the majority of transplant recipients have a low-turnover bone disease, inhibition of osteoclasts, through which bone turnover is impaired, might further reduce osteoblast activity and promote osteoid synthesis. Most investigations were small-scale studies with 10-100 participants and a follow up of only 12 months. This makes conclusions on the effect of any intervention on the fracture rate impossible. Larger, randomized multicentre studies investigating bone-sparing therapy on hard end points are therefore advocated.
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Affiliation(s)
- K Kodras
- Medical University of Vienna, Vienna, Austria
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Campistol JM, Holt DW, Epstein S, Gioud-Paquet M, Rutault K, Burke JT. Bone metabolism in renal transplant patients treated with cyclosporine or sirolimus. Transpl Int 2005; 18:1028-35. [PMID: 16101723 DOI: 10.1111/j.1432-2277.2005.00163.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Sirolimus is a new immunosuppressive agent used as treatment to prevent acute renal allograft rejection. One of the complications of renal transplantation and subsequent long-term immunosuppression is bone loss associated with osteoporosis and consequent fracture. Two open-label, randomized, phase 2 studies comparing sirolimus versus cyclosporine (CsA) included indices of bone metabolism as secondary end-points. Markers of bone turnover, serum osteocalcin and urinary N-telopeptides, were measured over a 1-year period in 115 patients receiving either CsA or sirolimus as a primary therapy in combination with azathioprine and glucocorticoids (study A) or mycophenolate mofetil (MMF) and glucocorticoids (study B). Urinary excretion of N-telopeptides and the concentrations of serum osteocalcin were consistently higher in the CsA-treated patients and significantly different at week 24 for N-telopeptides and at weeks 12, 24, and 52 for osteocalcin. In conclusion, future trials are warranted to test whether a sirolimus-based regimen conserves bone mineral density compared with a CsA-based regimen.
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Affiliation(s)
- Josep M Campistol
- Unidad de Transplante Renal, Hospital Clinic I Provincial, Barcelona, Spain.
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27
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Abstract
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.
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Affiliation(s)
- Rogério Cipriani
- Serviço de Endocrinologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, RJ.
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Abstract
We describe a constellation of bone diseases characterized by the common feature of acute, rapid, and severe bone loss accompanied by dramatic fracture rates. These disorders are poorly recognized, resulting mainly from systemic diseases, frailty, immobilization, and immunosuppressive drugs, such as glucocorticoids and the calcineurin inhibitors. The opportunity to prevent or treat fractures is commonly missed because they are often not detected. Ideally, patients need to be identified early and preventative therapy initiated promptly to avoid the rapid bone loss and fractures. The most effective therapy at present seems to be the bisphosphonates, particularly when bone resorption is predominant. However, more severe forms of bone loss that result from an osteoblastic defect and reduced bone formation may benefit potentially more from newer anabolic agents, such as recombinant human parathyroid hormone (rhPTH).
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Affiliation(s)
- Solomon Epstein
- Mount Sinai Bone Program, Department of Medicine, Mount Sinai School of Medicine, New York, New York 10029, USA.
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Mikuls TR, Julian BA, Bartolucci A, Saag KG. Bone mineral density changes within six months of renal transplantation. Transplantation 2003; 75:49-54. [PMID: 12544870 DOI: 10.1097/00007890-200301150-00009] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The effective use of new steroid-sparing immunosuppressive regimens may lower cumulative glucocorticoid use among renal transplant recipients. However, it is unknown what effect this therapeutic trend has had on bone disease. METHODS Unselected newly transplanted inpatients (n=45) were identified and comprehensively evaluated for metabolic bone disease at a median of 16 days (range 9-33) posttransplant. A follow-up evaluation was conducted a median of 5.7 months (range 4.8-9.3) later. Follow-up values for bone mineral density (BMD) and select laboratories were compared with baseline values using nonparametric statistics. Odds ratios (ORs) and 95% confidence intervals (CIs) were used to describe the associations of baseline characteristics, select laboratory values, and cumulative prednisone and cyclosporine use with spinal BMD loss and were calculated using logistic regression. RESULTS A significant decrease in intact parathyroid hormone (P<0.001) and a significant increase in calcitriol (P=0.02) were noted postengraftment. At follow-up, subjects had lost a mean of 2.4% BMD at the lumbar spine (P=0.003) but did not experience significant declines at the femoral neck. The highest tertiles of cumulative prednisone (OR=28.4; 95% CI 2.5-329 and OR=15.8; 95% CI 1.4-179, respectively) and past alcohol use (OR=9.3; 95% CI 1.46-58.5) were significantly associated with spinal BMD loss. CONCLUSIONS Significant loss in lumbar BMD occurred within 6 months of transplantation in more than one third of a prospective cohort of renal transplant recipients. Lumbar bone loss seemed to be mediated primarily by glucocorticoid dose and a history of alcohol use.
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Affiliation(s)
- Ted R Mikuls
- Section of Rheumatology and Immunology, Department of Medicine, University of Nebraska Medical Center, USA
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Abdelhadi M, Ericzon BG, Hultenby K, Sjoden G, Reinholt FP, Nordenstrom J. Structural skeletal impairment induced by immunosuppressive therapy in rats: cyclosporine A vs tacrolimus. Transpl Int 2002. [DOI: 10.1111/j.1432-2277.2002.tb00149.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Stempfle HU, Werner C, Siebert U, Assum T, Wehr U, Rambeck WA, Meiser B, Theisen K, Gärtner R. The role of tacrolimus (FK506)-based immunosuppression on bone mineral density and bone turnover after cardiac transplantation: a prospective, longitudinal, randomized, double-blind trial with calcitriol. Transplantation 2002; 73:547-52. [PMID: 11889427 DOI: 10.1097/00007890-200202270-00010] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Tacrolimus (FK506) is a new immunosuppressive drug in organ transplantation that has demonstrated experimentally to be more deleterious on bone mineral metabolism than cyclosporine. The purpose of this clinical study was to evaluate the effects of a tacrolimus-based immunosuppression on the skeleton and to investigate in a prospective, longitudinal, randomized, double-blind, study the effect of 0.25 microg calcitriol (1,25-dihydroxyvitamin D3) versus placebo in the prevention of bone loss and fracture rate after heart transplantion (HTx). METHODS A total of 53 patients (5 female, 48 male, mean age: 53+/-11 years) were randomized to the study medication. Basic therapy included calcium and sex hormone replacement in hypogonadism. Bone mineral density of the lumbar spine (LS) and femoral neck (FN) were performed at baseline, after 12 and 24 months. Biochemical indexes of mineral metabolism were measured every 3 months. RESULTS Overall bone mineral density (BMD) was significantly decreased after HTx (T-score-LS: 89+/-13%; FN: 88+/-14%). LS-BMD (% change in g/cm2) increased significantly within the study period in the calcitriol group (12 months: 7.1+/-8.1%, P<0.01; 24 months: 14.0+/-10.1%, P<0.01) and showed a positive trend in the placebo group (12 months: 4.5+/-9.3%, NS; 24 months: 6.2+/-8.0%, NS). FN-BMD in the calcitriol group was stable (12 months: -2.1+/-4.2%; NS; 24 months: -0.9+/-3.2%, NS). FN-BMD in the placebo group decreased significantly within the first 12 month follow-up period (-7.3+/-5.4; P<0.05) and stabilized within 2 years (-8.0+/-4.1%; P < 0.05). Fracture incidence was low during the study interval (first year: 5.0%, second year: 0%). Bone resorption markers decreased significantly during calcitriol therapy. CONCLUSIONS High dose tacrolimus-based immunosuppressive regimen is associated with a rapid bone loss early after cardiac transplantation. Beyond the first 6 months after HTx, calcium, vitamin D, and hormone supplementation in hypogonadism lead sufficiently to bone mineral recovery. Besides immunosuppression, both concomitant hypogonadism and secondary hyperparathyroidism play a major role for the bone loss and should be therefore monitored and treated adequately. Low dose calcitriol should be substituted for at least 2 years as additional antiresorptive therapy.
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Affiliation(s)
- Hans-Ulrich Stempfle
- Medizinische Klinik, Klinikum Innenstadt, Department of Cardiology, Ludwig-Maximilians University, 80336 Munich, Germany
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Abstract
With improvements in techniques for measuring bone mass, interest and concern have increased about the effects of asthma therapies, particularly corticosteroids, on bone mineral density. Whether asthma itself causes bone loss remains unclear. Studies evaluating the effect of asthma therapies on bone mineral density are often difficult to interpret because of methodologic problems. These studies show that oral corticosteroids are associated with a reduction in bone mineral density and an increased risk of fracture. Studies evaluating the effects of inhaled corticosteroids on bone mineral density provide conflicting data, but there is increasing evidence that inhaled corticosteroids may have an adverse effect on bone. However, the benefits of inhaled corticosteroids in the treatment of asthma remain far greater than the risks. The data for the effects of other asthma therapies on bone mineral density are limited.
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Affiliation(s)
- Conroy A Wong
- Department of Medicine, Middlemore Hospital, Auckland, New Zealand.
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35
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Koller H, Mayer G. [Immunosuppressive therapy and bone metabolism after kidney transplantation]. ACTA MEDICA AUSTRIACA 2001; 28:81-5. [PMID: 11475107 DOI: 10.1046/j.1563-2571.2001.01019.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The success of transplant medicine due to improvements of immunosuppressive therapy has led to a significant increase of patient and organ survival. With the increasing number of transplantations, however, long term complications, often affecting the skeletal system, are becoming more frequent. Bone alterations often exist prior to transplantation in patients with chronic renal failure. There are two types of renal osteopathy, including "low-turnover bone disease", consisting of osteomalacia, and adynamic bone disease, and "high-turnover bone disease" due to the development of secondary hyperparathyroidism. Many patients show evidence of both disorders (mixed bone disease). During the first months after transplantation patients lose bone mass rapidly. One of the major factors responsible for the development of osteoporosis is thought to be the intensive immunosuppressive therapy during that period, steroids in particular seem to play an important role. To what extent other medications influence bone metabolism has not been established. Currently there are no studies about a standardized therapy and treatment relies mainly on experience with other forms of osteoporosis.
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Affiliation(s)
- H Koller
- Klinische Abteilung für Nephrologie, Universitätsklinik für Innere Medizin, Leopold-Franzens-Universität, Anichstrasse 35, A-6020 Innsbruck.
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37
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Abstract
During the past 50 years, many immunosuppressive drugs have been described. Often their mechanisms of action were established long after their discovery. Eventually these mechanisms were found to fall into five groups: (i) regulators of gene expression; (ii) alkylating agents; (iii) inhibitors of de novo purine synthesis; (iv) inhibitors of de novo pyrimidine synthesis; and (v) inhibitors of kinases and phosphatases. Glucocorticoids exert immunosuppressive and anti-inflammatory activity mainly by inhibiting the expression of genes for interleukin-2 and other mediators. Cyclophosphamide metabolites alkylate DNA bases and preferentially suppress immune responses mediated by B-lymphocytes. Methotrexate and its polyglutamate derivatives suppress inflammatory responses through release of adenosine; they suppress immune responses by inducing the apoptosis of activated T-lymphocytes and inhibiting the synthesis of both purines and pyrimidines. Azathioprine metabolites inhibit several enzymes of purine synthesis. Mycophenolic acid and mizoribine inhibit inosine monophosphate dehydrogenase, thereby depleting guanosine nucleotides. Mycophenolic acid induces apoptosis of activated T-lymphocytes. A leflunomide metabolite and Brequinar inhibit dihydroorotate dehydrogenase, thereby suppressing pyrimidine nucleotide synthesis. Cyclosporine and FK-506 (Tacrolimus) inhibit the phosphatase activity of calcineurin, thereby suppressing the production of IL-2 and other cytokines. In addition, these compounds have recently been found to block the JNK and p38 signaling pathways triggered by antigen recognition in T-cells. In contrast, rapamycin inhibits kinases required for cell cycling and responses to IL-2. Rapamycin also induces apoptosis of activated T-lymphocytes. Immunosuppressive and anti-inflammatory compounds in development include inhibitors of p38 kinase and of the type IV isoform of cyclic AMP phosphodiesterase which is expressed in lymphocytes and monocytes.A promising future application of immunosuppressive drugs is their use in a regime to induce tolerance to allografts. The role of leukocytes in grafts, and the induction of apoptosis of clones of responding T-lymphocytes, is discussed.
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Affiliation(s)
- A C Allison
- SurroMed Corporation, 1060 E. Meadow Circle, Palo Alto, CA 94303, USA
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39
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Abstract
Many therapeutic regimens in cancer treatment carry the risk of causing or favoring the development of osteoporosis. Therapies in which hypogonadism may occur are most relevant in this respect. Prompt hormone replacement therapy is indicated in these patients. In patients in whom this is undesirable because of a hormone-dependent tumor, the risk of osteoporosis should be assessed by means of osteodensitometry, and prophylactic or therapeutic measures should be instituted if necessary. Early intervention improves outcome because osteoporosis therapy is most effective in preventing deterioration of bone mass. There remains much uncertainty in assessing the risk of combination chemotherapy with regard to the development of osteoporosis. Negative effects on the skeleton have, however, been demonstrated for individual drugs, such as methotrexate and ifosfamide. Negative effects of the tumor itself on bone metabolism may aggravate the degree of osteoporosis. Detailed data and long-term experience to assess the risk are urgently needed in this area and constitute an important research topic for the coming years and decades. This review discusses the most prevalent mechanisms of osteoporosis caused by cancer treatment and outlines therapeutic strategies for the prevention and treatment of therapy-induced bone loss.
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Affiliation(s)
- J Pfeilschifter
- Berufsgenossenschaftliche Kliniken Bergmannsheil, Department of Internal Medicine, University of Bochum, Germany
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40
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Abstract
Post-renal-transplantation bone disease is a well known entity. Immunosuppressive agents and persistence of hyperparathyroidism have primarily been implicated in its etiology. Renal transplantation patients are unique in that the bone changes occur on a background of pre-existing renal osteodystrophy. This review focuses on post-renal-transplantation bone disease. Unfortunately, the existing data in the review period, besides being scanty, provide conflicting information. This is due to the diversity of immunosuppressive regimens employed, the patient populations studied, diagnostic tools and criteria used by different centers, and the lack of formal trials.
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Affiliation(s)
- I R Dissanayake
- Department of Medicine, Albert Einstein Medical Center, Medical College of Pennsylvania, Philadelphia, USA
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Florén CH, Ahrén B, Bengtsson M, Bartosik J, Obrant K. Bone mineral density in patients with Crohn's disease during long-term treatment with azathioprine. J Intern Med 1998; 243:123-6. [PMID: 9566640 DOI: 10.1046/j.1365-2796.1998.00246.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To ascertain whether patients with Crohn's disease treated with azathioprine maintained bone mineral mass better than patients treated with steroids alone. DESIGN Retrospective study. SETTING University Hospital of Malmö, Sweden. SUBJECTS A total of 59 patients with ileocolonic, ileocaecal or colonic Crohn's disease. METHODS Bone mass was assessed by dual photon X-ray absorptiometry at the level of L2-L4. RESULTS Patients treated with a high lifetime dose of steroids (> 5 g prednisolone) had significantly (P = 0.011) lower Z-score of L2-L4 (-0.87 +/- 1.11; 11 SD) than steroid-treated patients, who had received a low dose of prednisolone (< 5 g) (0.08 +/- 1.16 SD). Azathioprine did not negatively influence the steroid effect on bone mineral density. CONCLUSIONS Azathioprine does not seem to affect bone mineral density by itself. However, by being steroid-saving, it seems to conserve bone mineral mass in patients with Crohn's disease.
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Affiliation(s)
- C H Florén
- Department of Internal Medicine, Malmö University Hospital, Lund University, Sweden
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Dissanayake IR, Goodman GR, Bowman AR, Ma Y, Pun S, Jee WS, Epstein S. Mycophenolate mofetil: a promising new immunosuppressant that does not cause bone loss in the rat. Transplantation 1998; 65:275-8. [PMID: 9458030 DOI: 10.1097/00007890-199801270-00025] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Posttransplantation bone disease is a well-described phenomenon; among its etiology is immunosuppressant-induced bone disease. Mycophenolate mofetil (MMF) has emerged as a promising new immunosuppressant. Our study was designed to investigate the effect of MMF on in vivo bone mineral metabolism. METHODS Twenty-four 6-month-old male Sprague-Dawley rats were randomized into two groups to receive either MMF vehicle daily for 28 days or 30 mg/kg MMF daily for 28 days. The serum was assayed for osteocalcin and 1,25-dihydroxy vitamin D3. Subsequent to double-labeling, the right tibiae were removed on day 28 for histomorphometry. RESULTS MMF suppressed bone gla protein (osteocalcin) levels on days 14 and 28 (P < 0.05). Except for percentage osteoid perimeter, there was no difference in bone histomorphometry between the two groups. CONCLUSION In this relatively short-term study, MMF did not cause osteopenia in the rat model, but the suppressed bone gla protein merits further study.
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Affiliation(s)
- I R Dissanayake
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, Pennsylvania 19141, USA
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Mechanisms of Immunosupressant-Induced Bone Disease. ACTA ACUST UNITED AC 1998. [DOI: 10.1016/s1569-2590(08)60150-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Aroldi A, Tarantino A, Montagnino G, Cesana B, Cocucci C, Ponticelli C. Effects of three immunosuppressive regimens on vertebral bone density in renal transplant recipients: a prospective study. Transplantation 1997; 63:380-6. [PMID: 9039927 DOI: 10.1097/00007890-199702150-00009] [Citation(s) in RCA: 97] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The influence of three different immunosuppressive regimens with cyclosporine (CsA) on the development of osteopenia in renal transplant patients was assessed. Fifty-three adults with first kidney transplants participated in a randomized trial to analyze the efficacy of three different immunosuppressive regimens: CsA alone (group 1), CsA plus steroids (group 2), and CsA plus steroids plus azathioprine (group 3). Lumbar spine bone mineral density was assessed by dual energy x-ray absorptiometry every 6 months for 18 months. The values for trabecular mass were expressed as bone mineral density and as a fraction of the standard deviation of the mean of the normal value for patient's sex and decade of age (Z-score). Statistical analysis was performed on Z-score and "Z-score change" (value after 6 months minus the basal value at transplantation). At the 18th month, the Z-score increased significantly in treatment group 1 without steroids (P=0.006) and decreased significantly in steroid-treated groups 2 (P<0.001) and 3 (P<0.001). Comparing the two genders, Z-score decreased less in premenopausal women than in men (P=0.018). "Z-score change" did not correlate with steroid dosage, was high in patients with high basal bone mineral density, and was directly associated with the duration of dialysis (P=0.008). In conclusion, premenopausal transplant recipients showed a lower decrease of lumbar bone mineral density than men. In transplant recipients given CsA with steroids, lumbar bone mineral density decreased significantly, while it increased significantly in patients given CsA alone.
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Affiliation(s)
- A Aroldi
- Divisione di Nefrologia e Dialisi and Direzione Scientifica, IRCCS, Ospedale Maggiore di Milano, Italy
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Affiliation(s)
- S Epstein
- Albert Einstein Medical Center, Philadelphia, Pennsyivania, USA
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