Role of bone in regulation of systemic acid-base balance

The association between bone density of lumbar spines and different daily protein intake in different renal function

BACKGROUND

Low protein intake (LPI) has been suggested as a treatment for chronic kidney disease (CKD). However, protein intake is essential for bone health.

METHODS

We studied the database of the National Health and Nutrition Examination Survey, 2005-2010. Basic variables, metabolic diseases, and bone density of different femoral areas were stratified into four subgroups according to different protein intake (DPI) (that is, <0.8, 0.8-1.0, 1.0-1.2, and >1.2 g/kg/day).

RESULTS

Significant differences were found among all lumbar area bone mineral density (BMD) and T-scores (p < 0.0001). There was an apparent trend between a decreasing BMD in the CKD groups with increasing DPI in all single lumbar spines (L1, L2, L3, and L4) and all L spines (L1-L4). Compared with DPI (0.8-1.0 g/day/kg), higher risks of osteoporosis were noticed in the subgroup of >1.2 g/day/kg over L2 (relative risk (RR)=1.326, 95% confidence interval (CI)=1.062-1.656), subgroup >1.2 g/day/kg over L3 (RR = 1.31, 95%CI = 1.057-1.622), subgroup <0.8 g/day/kg over L4 (RR = 1.276, 95%CI = 1.015-1.605), subgroup <0.8 g/day/kg over all L spines (RR = 11.275, 95%CI = 1.051-1.548), and subgroup >1.2 g/day/kg over all L spines (RR = 0.333, 95%CI = 1.098-1.618). However, a higher risk of osteoporosis was observed only in the non-CKD group. There was an apparent trend of higher DPI coexisting with lower BMD and T scores in patients with CKD. For osteoporosis (reference:0.8-1.0 g/day/kg), lower (<0.8 g/day/kg) or higher DPI (>1.2 g/day/kg) was associated with higher risks in the non-CKD group, but not in the CKD group.

CONCLUSIONS

In the CKD group, LPI for renal protection was safe without threatening L spine bone density and without causing a higher risk of osteoporosis.

The effect of changing dialysate bicarbonate concentration on serum bicarbonate, body weight and normalized nitrogen appearance rate

INTRODUCTION

Most hemodialysis machines deliver a fixed bicarbonate concentration. Higher concentrations may improve acidosis, but risk post-hemodialysis alkalosis, whereas lower concentrations potentially increase acidosis but reduce alkalosis. We reviewed the effects of lowering dialysate bicarbonate.

METHODS

We reviewed peri-dialysis chemistries in patients switching to a lower bicarbonate dialysate at 4 time points over 19 months.

RESULTS

We studied 126 patients, mean age 63.7 ± 16.3 years, 57.9% males. Post-hemodialysis alkalosis fell from 1.6 to 0.3% sessions, but pre-hemodialysis acidosis increased from 11.9 to 23.8% sessions (p = 0.005) reducing dialysate bicarbonate from 32 to 28 mmol/L. After 3 months, pre-hemodialysis serum bicarbonate fell (21.1 ± 2.3 to 19.8 ± 2.2 mmol/L), and post-hemodialysis (24.9 ± 2.1 to 22.5 ± 2.0 mmol/L, p < 0.001) with a fall in pre-hemodialysis weight from 74.6 ± 20.7 to 71.7 ± 18.2 kg, normalized protein nitrogen accumulation rate 0.8 ± 0.28 to 0.77 ± 0.2 g/kg/day, p < 0.05, and serum albumin 39.7 ± 4.2 to 37.7 ± 4.9 g/L, p < 0.001. Thereafter, apart from pre- and post-hemodialysis serum bicarbonate, weight and normalized protein nitrogen accumulation stabilized, although albumin remained lower (37.6 ± 4.0 g/L, p < 0.001). On multivariate logistic analysis, serum bicarbonate increased more with lower pre-hemodialysis bicarbonate standardized coefficient β 0.5 (95% confidence interval -0.6 to -0.42), increased normalized protein nitrogen accumulation β 0.2 (0.96 to 2.38), p < 0.001, and session time β 0.09, (0.47 to 5.98), p < 0.022, and less with lower dialysate bicarbonate 0.0-0.23 (-1.54 to -0.74), p < 0.001.

CONCLUSION

Increases in SE-Bic with hemodialysis, depend on the bicarbonate gradient, session time and nPNA. Lower D-Bic reduces post-hemodialysis alkalosis but increases pre-hemodialysis acidosis and may initially have adverse effects on weight and normalized protein nitrogen accumulation.

Chemical Diversity of Teeth and Bone Fragments from a Newly Discovered Upper Muschelkalk Bone Bed from Silesia, Poland

The new exposure of the Upper Muschelkalk clays and dolomites located south of Kalety (Tarnogórski District, Silesia, Poland) provided numerous remains of vertebrates represented by teeth, scales, long bones, and coprolites. Despite the influence of hydrothermal processes leading to dolomitization and Zn-Pb deposit formation, the preservation of fossil remains is good. The taxonomic diversity and accumulation of vertebrate debris in the dolomite are similar to other “bone beds” from the Muschelkalk and the Lower Keuper units. The SEM-EDS, EMP-WDS, and XRD analyses confirm that the examined remains consist of hydroxylapatite containing carbonate ions. Most vertebrate teeth as well as some bone fragments show zoning in the BSE imaging. In tooth cross-sections, three or two zones are preserved: (I) the outermost zone, associated with diagenetic mineralization of enameloid apatite, (II) a intermediate zone (orthodentine), and (III) the most porous internal zone (osteodentine). Decreasing P, Ca, Sr in the composition of the apatite which forms successive zones, is visible from the most external to the central part. Selective diagenetic substitution and adsorption of some elements by apatite crystals can allow recognition of the genetic origin of highly damaged or transported fragments scattered in the sedimentary layers. The chemical behavior of bioapatite, from deposition to digenesis, shows its useful role for identification of the formation process and potential, younger changes (e.g., hydrothermal overprint). The X-ray diffraction data, particularly cell parameters “a” and “c”, can determine the degree of crystallinity and/or diagenesis. Moreover, correlation between some elements/ions (e.g., Sr, Ba, Ca, Mg, F, OH) can be helpful for the identification of the fossil type, especially if the bones are small and incomplete.

Distal renal tubular acidosis: a systematic approach from diagnosis to treatment

Renal tubular acidosis (RTA) comprises a group of disorders in which excretion of hydrogen ions or reabsorption of filtered HCO₃ is impaired, leading to chronic metabolic acidosis with normal anion gap. In the current review, the focus is placed on the most common type of RTA, Type 1 RTA or Distal RTA (dRTA), which is a rare chronic genetic disorder characterized by an inability of the distal nephron to secrete hydrogen ions in the presence of metabolic acidosis. Over the years, knowledge of the molecular mechanisms behind acid secretion has improved, thereby greatly helping the diagnosis of dRTA. The primary or inherited form of dRTA is mostly diagnosed in infancy, childhood, or young adulthood, while the acquired secondary form, as a consequence of other disorders or medications, can happen at any age, although it is more commonly seen in adults. dRTA is not as “benign” as previously assumed, and can have several, highly variable long-term consequences. The present review indeed reports and summarizes both clinical symptoms and diagnosis, long-term outcomes, genetic inheritance, epidemiology and current treatment options, with the aim of shedding more light onto this rare disorder. Being a chronic condition, dRTA also deserves attention in the transition between pediatric and adult nephrology care, and as a rare disease it has a place in the European and Italian rare nephrological diseases network.

Bicarbonate: The Alternative Buffer for Peritoneal Dialysis

For a long time bicarbonate, the physiological buffer of the body, was suggested to be the best buffer for peritoneal dialysis. However, since the production of bicarbonate containing solutions is associated with technical problems, lactate was favored. To avoid the well-known disadvantages of lactate solution concerning biocompatibility and possible metabolic side effects, different attempts have been made to use bicarbonate as a buffer in peritoneal dialysis. One of the major approaches was the total replacement of lactate by bicarbonate combined with storage of the fluid in a specially designed double-chamber bag. Further solutions of the above-mentioned problem were the on-line preparation of bicarbonate fluids for intermittent peritoneal dialysis, the addition of bicarbonate just before use, the combination of bicarbonate with organic acids, or its combination with the dipeptide glycylglycine as a stabilizing agent.

By now, the beneficial effect of the neutral bicarbonate fluid, for example, on cell viability and cell functions, has been demonstrated in many different in vitro and animal studies. However, only few reports on clinical experience have been published. These investigations demonstrated independently that bicarbonate fluids diminish inflow pain, are well tolerated by the patients, and may correct metabolic acidosis of uremic patients. A controlled randomized multicenter trial using 34 mmol/L bicarbonate for at least three months confirmed that bicarbonate is as efficacious as lactate in equimolar concentrations. Concomitant investigations on energy metabolism and redox state of red blood cells and phospholipid secretion of mesothelial cells additionally demonstrated the improvement of cell function with bicarbonate solutions. For some patients with severe metabolic acidosis the bicarbonate concentration used in the multicenter trial seemed to be too low. Thus, a fluid containing a higher bicarbonate concentration was tested in a pilot study resulting in the expected significant increase of arterial bicarbonate levels.

In summary, bicarbonate-containing peritoneal dialysis solutions are a promising alternative to lactate, especially if bicarbonate concentrations are adjusted individually to the patient's need.

A Study on Effect of Bicarbonate Supplementation on the Progression of Chronic Kidney Disease

Introduction:

Chronic kidney disease (CKD) is a major health problem in India. Prevalence of CKD will continue to rise, reflecting the growing elderly population and increasing number of patients with diabetes and hypertension.

Methods:

A total of 67 patients with CKD participated in the study. Patients were randomized into two groups. Group 1 received oral bicarbonate and Group 2 was the control group. Their baseline, 6 and 9 months estimated glomerular filtration rate (eGFR), bicarbonate, muscle mass and serum albumin were estimated. We analysed the effect of bicarbonate supplementation on the progression of CKD.

Results:

Bicarbonate supplementation decreased the metabolic acidosis in CKD patients. After bicarbonate supplementation, the serum bicarbonate level increased time-dependently from 16.62 to 18.02 and 19.77 mEq/L after 6 and 9 months, respectively. It also restored the eGFR to its baseline value. The eGFR values of Group 1 at baseline, after 6 months and 9 months were 22.39, 22.66, and 22.65 mL/min/1.73 m2, respectively. In contrast, the eGFR value in Group 2 reduced significantly. Patients who received bicarbonate supplementation displayed increased serum albumin levels compared with the controls. The albumin level was significantly increased from 4.05 to 4.24 and 4.34 g/dL, respectively, after 6 and 9 months (P = 0.0001). Also, bicarbonate supplementation showed significant improvement in muscle mass.

Conclusion:

Study confirms the role of bicarbonate in relieving the metabolic acidosis and thereby its possible role in the management of CKD progression.

The negative effect of unloading exceeds the bone-sparing effect of alkaline supplementation: a bed rest study

Potassium bicarbonate was administrated to an already alkaline diet in seven male subjects during a 21-day bed rest study and was able to decrease bed rest induced increased calcium excretion but failed to prevent bed rest-induced bone resorption.

INTRODUCTION

Supplementation with alkali salts appears to positively influence calcium and bone metabolism and, thus, could be a countermeasure for population groups with an increased risk for bone loss. However, the extent to which alkalization counteracts acid-induced bone resorption or whether it merely has a calcium and bone maintenance effect is still not completely understood. In the present study, we hypothesized that additional alkalization to an already alkaline diet can further counteract bed rest-induced bone loss.

METHODS

Seven healthy male subjects completed two parts of a crossover designed 21-day bed rest study: bed rest only (control) and bed rest supplemented with 90 mmol potassium bicarbonate (KHCO₃) daily.

RESULTS

KHCO₃supplementation during bed rest resulted in a more alkaline status compared to the control intervention, demonstrated by the increase in pH and buffer capacity level (pH p = 0.023, HCO₃p = 0.02, ABE p = 0.03). Urinary calcium excretion was decreased during KHCO₃ supplementation (control 6.05 ± 2.74 mmol/24 h; KHCO₃ 4.87 ± 2.21 mmol/24 h, p = 0.03); whereas, bone formation was not affected by additional alkalization (bAP p = 0.58; PINP p = 0.60). Bone resorption marker UCTX tended to be lower during alkaline supplementation (UCTX p = 0.16).

CONCLUSIONS

The more alkaline acid-base status, achieved by KHCO₃ supplementation, reduced renal calcium excretion during bed rest, but was not able to prevent immobilization-induced bone resorption. However, advantages of alkaline salts on bone metabolism may occur under acidic metabolic conditions or with respect to the positive effect of reduced calcium excretion within a longer time frame.

TRIAL REGISTRATION

Trial number: NCT01509456.

Calcium fluxes at the bone/plasma interface: Acute effects of parathyroid hormone (PTH) and targeted deletion of PTH/PTH-related peptide (PTHrP) receptor in the osteocytes

Calcium ion concentration ([Ca2+]) in the systemic extracellular fluid, ECF-[Ca2+], is maintained around a genetically predetermined set-point, which combines the operational level of the kidney and bone/ECF interfaces. The ECF-[Ca2+] is maintained within a narrow oscillation range by the regulatory action of Parathyroid Hormone (PTH), Calcitonin, FGF-23, and 1,25(OH)2D3. This model implies two correction mechanisms, i.e. tubular Ca2+ reabsorption and osteoclast Ca2+ resorption. Although their alterations have an effect on the ECF-[Ca2+] maintenance, they cannot fully account for rapid correction of the continuing perturbations of plasma [Ca2+], which occur daily in life. The existence of Ca2+ fluxes at quiescent bone surfaces fulfills the role of a short-term error correction mechanism in Ca2+ homeostasis. To explore the hypothesis that PTH regulates the cell system responsible for the fast Ca2+ fluxes at the bone/ECF interface, we have performed direct real-time measurements of Ca2+ fluxes at the surface of ex-vivo metatarsal bones maintained in physiological conditions mimicking ECF, and exposed to PTH. To further characterize whether the PTH receptor on osteocytes is a critical component of the minute-to-minute ECF-[Ca2+] regulation, metatarsal bones from mice lacking the PTH receptor in these cells were tested ex vivo for rapid Ca2+ exchange. We performed direct real-time measurements of Ca2+ fluxes and concentration gradients by a scanning ion-selective electrode technique (SIET). To validate ex vivo measurements, we also evaluated acute calcemic response to PTH in vivo in mice lacking PTH receptors in osteocytes vs littermate controls. Our data demonstrated that Ca2+ fluxes at the bone-ECF interface in excised bones as well as acute calcemic response in the short-term were unaffected by PTH exposure and its signaling through its receptor in osteocytes. Rapid minute-to-minute regulation of the ECF-[Ca2+] was found to be independent of PTH actions on osteocytes. Similarly, mice lacking PTH receptor in osteocytes, responded to PTH challenge with similar calcemic increases.

Canagliflozin triggers the FGF23/1,25-dihydroxyvitamin D/PTH axis in healthy volunteers in a randomized crossover study

BACKGROUND

Sodium glucose cotransporter-2 (SGLT2) inhibitors are the most recently approved class of drugs for type 2 diabetes and provide both glycemic efficacy and cardiovascular risk reduction. A number of safety issues have been identified, including treatment-emergent bone fractures. To understand the overall clinical profile, these safety issues must be balanced against an attractive efficacy profile. Our study was designed to investigate pathophysiological mechanisms mediating treatment-emergent adverse effects on bone health.

METHODS

We conducted a single-blind randomized crossover study in hospitalized healthy adults (n = 25) receiving either canagliflozin (300 mg/d) or placebo for 5 days. The primary end-point was the drug-induced change in AUC for plasma intact fibroblast growth factor 23 (FGF23) immunoactivity between 24 and 72 hours.

RESULTS

Canagliflozin administration increased placebo-subtracted mean levels of serum phosphorus (+16%), plasma FGF23 (+20%), and plasma parathyroid hormone (PTH) (+25%), while decreasing the level of 1,25-dihydroxyvitamin D (-10%). There was substantial interindividual variation in the magnitude of each of these pharmacodynamic responses. The increase in plasma FGF23 was correlated with the increase in serum phosphorus, and the decrease in plasma 1,25-dihydroxyvitamin D was correlated with the increase in plasma FGF23.

CONCLUSIONS

Canagliflozin induced a prompt increase in serum phosphorus, which triggers downstream changes in FGF23, 1,25-dihydroxyvitamin D, and PTH, with potential to exert adverse effects on bone health. These pharmacodynamic data provide a foundation for future research to elucidate pathophysiological mechanisms of adverse effects on bone health, with the objective of devising therapeutic strategies to mitigate the drug-associated fracture risk.

TRIAL REGISTRATION

ClinicalTrial.gov (NCT02404870).

FUNDING

Supported by the Intramural Program of NIDDK.

Prediction of Renal Acid Load in Adult Patients on Parenteral Nutrition

Metabolic acidosis and metabolic bone disease are frequent complications in patients on parenteral nutrition (PN). A common contributor to these complications could be a daily high renal acid load. This study aims to find a method for predicting the potential total acid load (PTAL) and the pH of the compounded parenteral nutrition mixtures. The pH and titratable acidity (TA) of fifty compounded mixtures were measured. The potential metabolic acid load (PMAL) was calculated by considering the amount of nutrients that are acid producers and consumers. The PTAL of the TPN mixtures was calculated by adding TA to PMAL. Multiple linear regression analyses were used to develop a predictive model for the TA and pH of the compounded mixtures. The predicted TA and pH values of the analyzed mixtures agreed with those measured (Passing-Bablok analysis). The PTAL was >50 mmol/day for 82% of the mixtures, >75 mmol/day for 40% of the mixtures, and >100 mmol/day for 22% of the mixtures. The prediction of the renal acid load in patients on long-term PN could allow more appropriate acid-base balancing. Moreover, predicting the pH of such mixtures could be useful to pharmacists to assess the stability and compatibility of the components in the compounded mixtures.

Characteristics and diagnostic workup of the patient at risk to sustain fragility fracture

The human body undergoes several physiological adaptations as a result of the aging process. Amongst other organs, the skeleton is also affected and when bone fragility is present, an increase in both morbidity and mortality has been reported. Identification of risk factors to calculate the probability for a given patient to develop a fragility fracture it is therefore of paramount importance. Moreover, the existence of an in house protocol for diagnostic work up using biochemical tests and imaging investigations is essential. In the herein study we discuss a diagnostic protocol that has been developed in our clinic based on knowledge from the literature and our clinical experience.

Urine Ammonium, Metabolic Acidosis and Progression of Chronic Kidney Disease

The metabolism of a typical Western diet generates 50-100 mEq of acid (H+) per day, which must be excreted in the urine for the systemic acid-base to remain in balance. The 2 major mechanisms that are responsible for the renal elimination of daily acid under normal conditions are ammonium (NH4+) excretion and titratable acidity. In the presence of systemic acidosis, ammonium excretion is intensified and becomes the crucial mechanism for the elimination of acid. The impairment in NH4+ excretion is therefore associated with reduced acid excretion, which causes excess accumulation of acid in the body and consequently results in metabolic acidosis. Chronic kidney disease (CKD) is associated with the impairment in acid excretion and precipitation of metabolic acidosis, which has an adverse effect on the progression of CKD. Recent studies suggest that the progressive decline in renal ammonium excretion in CKD is an important determinant of the ensuing systemic metabolic acidosis and is an independent factor for predicting the worsening of kidney function. While these studies have been primarily performed in hypertensive individuals with CKD, a closer look at renal NH4+ excretion in non-hypertensive individuals with CKD is warranted to ascertain its role in the progression of kidney disease.

Acidogenic mineral additions increased Ca mobilization in prepartum sows

Increased sow milk production is associated with an increase in unexplained sow mortality during prepartum and early postpartum periods. This association has led to purported claims of hypocalcemic disorders. Assuming similar responses as dairy cows, feeding anionic mineral salts in late gestation and early lactation may reduce potential hypocalcemia related disorders in sows. Two experiments using CAD-MATE (Granco Minerals, Petersburg, VA), an acidogenic mineral supplement (AMS), were designed to determine the amount required to increase urinary Ca excretion and to identify renal compensatory responses to acid loads in sows. In Exp. 1, 30 multiparous gestating sows (Landrace × Large White) were fed 1 of 6 diets with either 0, 0.5, 1.0, 1.5, 2.0, or 2.5% AMS additions for 14 d. Diets provided a range (33 to -216 mEq/kg) of cation-anion balance, calculated as Na + K - Cl - S. Two 24-h urine samples were collected via bladder catheters for mineral analysis. One venous blood sample was drawn from 2 sows per diet on d 14. In Exp. 2, twelve sows were fed 1 of 3 diets to provide either 0, 1.5, or 2.5% AMS. Three 24-h composites of urine and fecal excreta were collected and analyses were used to calculate apparent mineral retention. Venous blood pH (range 7.41 to 7.33) and base excess (range 5.4 to 0.5 mmol/L) decreased (linear, < 0.10), but blood ionized Ca (range 1.28 to 1.37 mmol/L) increased (linear, < 0.05) proportionally to dietary AMS additions. Blood anion gap was not affected by diet. Urine pH decreased (linear, < 0.10) with additions of AMS (range 7.47 to 5.52). In Exp. 2, urinary SO (range 134 to 396 mEq/d) and NH (range 84 to 323 mEq/d) excretion increased ( < 0.05) with AMS additions. Urinary Mg, Na, and K excretion did not differ among treatments. Fecal excretion of Ca, Mg, and P increased ( < 0.05) in sows fed diets with 2.5% AMS. Fecal K, Na, and Cl excretion did not differ among treatments. Apparent Ca retention decreased ( < 0.05) with AMS additions, but apparent Mg and Cl retention increased ( < 0.05). In conclusion, AMS induced a renal compensated acid load as exhibited by urinary ion excretion patterns and maintenance of blood gas values within physiological ranges. Feeding diets with 1.5 or 2.5% AMS increased urinary and fecal Ca excretion and decreased apparent Ca retention implying an increase in mobilization of body Ca pools in prepartum sows.

Efficacy and safety of osteoporosis medications in a rat model of late-stage chronic kidney disease accompanied by secondary hyperparathyroidism and hyperphosphatemia

This study showed that bisphosphonate was safe and effective for the treatment of bone disorders in stage 4 chronic kidney disease (CKD) rats. Intermittent teriparatide therapy showed an anabolic action on bone even under secondary hyperparathyroidism conditions without having an adverse effect on mineral metabolism in late-stage CKD.

INTRODUCTION

Patients with late-stage CKD are at high risk for fragility fractures. However, there are no consensus on the efficacy and safety of osteoporosis medications for patients with late-stage CKD. In the present study, we aimed to examine the efficacy and safety of alendronate (ALN) and teriparatide (TPD) for treating bone disorder in late-stage CKD with pre-existing secondary hyperparathyroidism using a rat model of CKD.

METHODS

Male 10-week-old Sprague-Dawley rats were subjected to a 5/6 nephrectomy or sham surgery and randomized into the following four groups: sham, vehicle (saline subcutaneous (sc) daily), ALN (50 μg/kg sc daily), and TPD (40 μg/kg sc daily). Medications commenced at 24 weeks of age and continued for 4 weeks. Micro-computed tomography, histological analysis, infrared spectroscopic imaging, and serum assays were performed.

RESULTS

Nephrectomized rats developed hyperphosphatemia, secondary hyperparathyroidism (SHPT), and high creatinine, equivalent to CKD stage 4 in humans. ALN suppressed the bone turnover and increased the degree of mineralization in cortical bone, resulting in an improvement in the mechanical properties. TPD further increased the bone turnover and significantly increased the degree of mineralization, micro-geometry, and bone volume, resulting in a significant improvement in the mechanical properties. Both ALN and TPD had no adverse effect on renal function and mineral metabolism.

CONCLUSIONS

BP is safe and effective for the treatment of bone disorders in stage 4 CKD rats. Intermittent TPD therapy showed an anabolic action on bone even under SHPT conditions without having an adverse effect on mineral metabolism in late-stage CKD.

Response of cattle with clinical osteochondrosis to mineral supplementation

Since 1982, farmers in the North West province and other parts of South Africa have noticed an increase in the incidence of lameness in cattle. Macro- and microscopical lesions of joints resembled osteochondrosis. Pre-trial data indicated that cattle with osteochondrotic lesions recovered almost completely when fed a supplement containing bio-available micro- and macrominerals of high quality. In the present trial, 43 clinically affected cattle of varying ages (1-5 years) and sexes were randomly divided into three groups. Each group was fed the same commercial supplement base with differing micro- and macromineral concentrations to determine the effect of mineral concentrations on the recovery from osteochondrosis. Both supplements 1 and 2 contained 25% of the recommended National Research Council (NRC) mineral values. Additional phosphate was added to supplement 2. Supplement 3, containing 80% of the NRC mineral values, was used as the control. Results from all three groups indicated no recovery from osteochondrosis. Urine pH of a small sample of the test cattle showed aciduria (pH &lt; 6). Supplement analysis revealed addition of ammonium sulphate that contributed sulphate and nitrogen to the supplement. Supplementary dietary cation anion difference (DCAD) values were negative at -411 mEq/kg, -466 mEq/kg and -467 mEq/kg for supplements 1, 2 and 3, respectively, whereas the pre-trial supplement was calculated at +19.87 mEq/kg. It was hypothesised that feeding a low (negative) DCAD diet will predispose growing cattle to the development of osteochondrosis or exacerbate subclinical or clinical osteochondrosis in cattle.

Akermanite used as an alkaline biodegradable implants for the treatment of osteoporotic bone defect

In osteoporosis scenario, tissue response to implants is greatly impaired by the deteriorated bone regeneration microenvironment. In the present study, a Mg-containing akermanite (Ak) ceramic was employed for the treatment of osteoporotic bone defect, based on the hypothesis that both beneficial ions (e.g. Mg2+ect.) released by the implants and the weak alkaline microenvironment pH (μe-pH) it created may play distinct roles in recovering the abnormal bone regeneration by stimulating osteoblastic anabolic effects. The performance of Ak, β-tricalcium phosphate (β-TCP) and Hardystone (Har) in healing a 3 mm bone defect on the ovariectomized (OVX) osteoporotic rat model was evaluated. Our results indicated that, there's more new bone formed in Ak group than in β-TCP or Har group at week 9. The initial μe-pHs of Ak were significantly higher than that of the β-TCP and Blank group, and this weak alkaline condition was maintained till at least 9 weeks post-surgery. Increased osteoblastic activity which was indicated by higher osteoid secretion was observed in Ak group at week 4 to week 9. An intermediate layer which was rich in phosphorus minerals and bound directly to the new forming bone was developed on the surface of Ak. In a summary, our study demonstrates that Ak exhibits a superior bone regenerative performance under osteoporosis condition, and might be a promising candidate for the treatment of osteoporotic bone defect and fracture.

Preliminary report on osteochondrosis in cattle in the north-western parts of South Africa

The north-western part of South Africa, in particular, is well known for mineral imbalances. Aphosphorosis, resulting in rickets and osteomalacia, received a lot of attention at the turn of the nineteenth century (1882–1912). This was followed in 1997 by research on Vryburg hepatosis, another area-specific mineral imbalance–related disease in young calves reared on manganese-rich soil derived from the weathering of dolomitic (carbonate) rock formations. In 1982, a totally new syndrome (osteochondrosis) manifested in, amongst others, areas in South Africa where aphosphorosis was rife. Osteochondrosis was also identified in the south-western parts of Namibia as well as southern Botswana and other areas in South Africa. Osteochondrosis has a multifactorial aetiology and this study focused on the role of minerals, particularly phosphorus, in the development of the disease. A significant improvement in the clinical signs in experimental animals and a reduction of osteochondrosis occurred on farms where animals received bioavailable trace minerals and phosphorus as part of a balanced lick. An increase in the occurrence of the disease on farms during severe drought conditions in 2012–2013 prompted researchers to investigate the possible role of chronic metabolic acidosis in the pathogenesis of the disease.

Central and Peripheral Fatigue During Resistance Exercise - A Critical Review

Resistance exercise is a popular form of conditioning for numerous sport disciplines, and recently different modes of strength training are being evaluated for health benefits. Resistance exercise differs significantly in nature, and several variables determine the direction and range of adaptive changes that occur in the muscular and skeletal system of the body. Some modes of resistance training can also be effective in stimulating the cardiovascular system. These variables include exercise selection (general, specific, single or multi joint, dynamic, explosive), type of resistance (free weights, variable resistance, isokinetics), order of exercise (upper and lower body or push and pull exercises), and most of all the training load which includes intensity expressed as % of 1RM, number of repetitions, number of sets and the rest interval between sets. Manipulating these variables allows for specific adaptive changes which may include gains in muscle mass, muscle strength or muscle endurance. It has been well established that during resistance exercise fatigue occurs, regardless of the volume and intensity of work applied. The peripheral mechanisms of fatigue have been studied and explained in more detail than those related to the CNS. This review is an attempt to bring together the latest knowledge regarding fatigue, both peripheral and central, during resistance exercise. The authors of this review concentrated on physiological and biochemical mechanisms underlying fatigue in exercises performed with maximal intensity, as well as those performed to exhaustion with numerous repetitions and submaximal load.

Management of endocrine disease: Secondary osteoporosis: pathophysiology and management

Osteoporosis is a skeletal disorder characterized by decreased mass and compromised bone strength predisposing to an increased risk of fractures. Although idiopathic osteoporosis is the most common form of osteoporosis, secondary factors may contribute to the bone loss and increased fracture risk in patients presenting with fragility fractures or osteoporosis. Several medical conditions and medications significantly increase the risk for bone loss and skeletal fragility. This review focuses on some of the common causes of osteoporosis, addressing the underlying mechanisms, diagnostic approach and treatment of low bone mass in the presence of these conditions.

Extracellular fluid flow and chloride content modulate H(+) transport by osteoclasts

Background

Bone resorption takes place within the basic multicellular units (BMU), and the surface to be resorbed is isolated from adjacent bone surfaces by a sealing zone between osteoclast membrane and bone matrix, which defines the limits of the resorption lacuna. Considering that the extracellular fluid (ECF) in both BMU and the resorption lacuna can be isolated from its surroundings, I hypothesize that flow and ion composition of the bone ECF in these sites might contribute to the regulation of osteoclast H⁺ secretion. To investigate this hypothesis, I evaluated the H⁺ secretion properties of individual osteoclasts and osteoclast-like cells (OCL-cells) and investigated whether changes in flow or chloride content of the extracellular solution modify the H⁺ secretion properties in vitro.

Results

The results show that 1) osteoclasts are unable to secrete H⁺ and regulate intracellular pH (pH_i) under continuous flow conditions and exhibit progressive intracellular acidification; 2) the cessation of flow coincides with the onset of H⁺ secretion and subsequent progressive intracellular alkalinization of osteoclasts and OCL-cells; 3) osteoclasts exhibit spontaneous rhythmic oscillations of pH_i in non-flowing ECF, 4) pH_i oscillations are not abolished by concanamycin, NPPB, or removal of extracellular Na⁺ or Cl⁻; 5) extracellular Cl⁻ removal modifies the pattern of oscillations, by diminishing H⁺ secretion; 6) pH_i oscillations are abolished by continuous flowing of ECF over osteoclasts and OCL-cells.

Conclusions

The data suggest, for the first time, that ECF flow and Cl⁻ content have direct effects on osteoclast H⁺ secretion and could be part of a mechanism determining the onset of osteoclast H⁺ secretion required for bone resorption.

Electronic supplementary material

The online version of this article (doi:10.1186/s12860-015-0066-4) contains supplementary material, which is available to authorized users.

Optimizing haemodialysate composition

Survival and quality of life of dialysis patients are strictly dependent on the quality of the haemodialysis (HD) treatment. In this respect, dialysate composition, including water purity, plays a crucial role. A major aim of HD is to normalize predialysis plasma electrolyte and mineral concentrations, while minimizing wide swings in the patient's intradialytic plasma concentrations. Adequate sodium (Na) and water removal is critical for preventing intra- and interdialytic hypotension and pulmonary edema. Avoiding both hyper- and hypokalaemia prevents life-threatening cardiac arrhythmias. Optimal calcium (Ca) and magnesium (Mg) dialysate concentrations may protect the cardiovascular system and the bones, preventing extraskeletal calcifications, severe secondary hyperparathyroidism and adynamic bone disease. Adequate bicarbonate concentration [HCO₃⁻] maintains a stable pH in the body fluids for appropriate protein and membrane functioning and also protects the bones. An adequate dialysate glucose concentration prevents severe hyperglycaemia and life-threating hypoglycaemia, which can lead to severe cardiovascular complications and a worsening of diabetic comorbidities.

Arterialized venous bicarbonate is associated with lower bone mineral density and an increased rate of bone loss in older men and women

CONTEXT

Higher dietary net acid loads have been associated with increased bone resorption, reduced bone mineral density (BMD), and increased fracture risk.

OBJECTIVE

The objective was to compare bicarbonate (HCO3) measured in arterialized venous blood samples to skeletal outcomes.

DESIGN

Arterialized venous samples collected from participants in the Health, Aging and Body Composition (Health ABC) Study were compared to BMD and rate of bone loss.

SETTING

The setting was a community-based observational cohort.

PARTICIPANTS

A total of 2287 men and women age 74 ± 3 years participated.

INTERVENTION

Arterialized venous blood was obtained at the year 3 study visit and analyzed for pH and pCO2. HCO3 was determined using the Henderson-Hasselbalch equation.

MAIN OUTCOME MEASURE

BMD was measured at the hip by dual-energy x-ray absorptiometry at the year 1 (baseline) and year 3 study visits.

RESULTS

Plasma HCO3 was positively associated with BMD at both year 1 (P = .001) and year 3 (P = .001) in models adjusted for age, race, sex, clinic site, smoking, weight, and estimated glomerular filtration rate. Plasma HCO3 was inversely associated with rate of bone loss at the total hip over the 2.1 ± 0.3 (mean ± SD) years between the two bone density measurements (P < .001). Across quartiles of plasma HCO3, the rate of change in BMD over the 2.1 years ranged from a loss of 0.72%/y in the lowest quartile to a gain of 0.15%/y in the highest quartile of HCO3.

CONCLUSIONS

Arterialized plasma HCO3 was associated positively with cross-sectional BMD and inversely with the rate of bone loss, implying that systemic acid-base status is an important determinant of skeletal health during aging. Ongoing bone loss was linearly related to arterialized HCO3, even after adjustment for age and renal function. Further research in this area may have major public health implications because reducing dietary net acid load is possible through dietary intervention or through supplementation with alkaline potassium compounds.

Impaired bone metabolism in glycogen storage disease type 1 is associated with poor metabolic control in type 1a and with granulocyte colony-stimulating factor therapy in type 1b

BACKGROUND

Glycogen storage disease type 1 (GSD1) is a rare and genetically heterogeneous metabolic defect of gluconeogenesis due to mutations of either the G6PC gene (GSD1a) or the SLC37A4 gene (GSD1b). Osteopenia is a known complication of GSD1.

OBJECTIVES

The aim of this study was to investigate the effects of poor metabolic control and/or use of GSD1-specific treatments on bone mineral density (BMD) and metabolism in GSD1 patients.

METHODS

In a multicenter, cross-sectional case-control study, we studied 38 GSD1 (29 GSD1a and 9 GSD1b) patients. Clinical, biochemical and instrumental parameters indicative of bone metabolism were analyzed; BMD was evaluated by dual-emission X-ray absorptiometry and quantitative ultrasound.

RESULTS

Both GSD1a and GSD1b patients showed reduced BMD compared with age-matched controls. In GSD1a patients, these abnormalities correlated with compliance to diet and biochemical indicators of metabolic control. In GSD1b patients, BMD correlated with the age at first administration and the duration of granulocyte colony-stimulating factor (G-CSF) therapy.

CONCLUSIONS

Our data indicate that good metabolic control and compliance with diet are highly recommended to improve bone metabolism in GSD1a patients. GSD1b patients on G-CSF treatment should be carefully monitored for the risk of osteopenia/osteoporosis.

Protein and Essential Amino Acids to Protect Musculoskeletal Health during Spaceflight: Evidence of a Paradox?

Long-duration spaceflight results in muscle atrophy and a loss of bone mineral density. In skeletal muscle tissue, acute exercise and protein (e.g., essential amino acids) stimulate anabolic pathways (e.g., muscle protein synthesis) both independently and synergistically to maintain neutral or positive net muscle protein balance. Protein intake in space is recommended to be 12%-15% of total energy intake (≤1.4 g∙kg-1∙day-1) and spaceflight is associated with reduced energy intake (~20%), which enhances muscle catabolism. Increasing protein intake to 1.5-2.0 g∙kg-1∙day-1 may be beneficial for skeletal muscle tissue and could be accomplished with essential amino acid supplementation. However, increased consumption of sulfur-containing amino acids is associated with increased bone resorption, which creates a dilemma for musculoskeletal countermeasures, whereby optimizing skeletal muscle parameters via essential amino acid supplementation may worsen bone outcomes. To protect both muscle and bone health, future unloading studies should evaluate increased protein intake via non-sulfur containing essential amino acids or leucine in combination with exercise countermeasures and the concomitant influence of reduced energy intake.

The role of acidemia in maternal binge alcohol-induced alterations in fetal bone functional properties

BACKGROUND

Heavy alcohol consumption during pregnancy negatively impacts the physical growth of the fetus. Although the deleterious effects of alcohol exposure during late gestation on fetal brain development are well documented, little is known about the effect on fetal bone mechanical properties or the underlying mechanisms. The purpose of this study was to investigate the effects of late gestational chronic binge alcohol consumption and alcohol-induced acidemia, a critical regulator of bone health, on functional properties of the fetal skeletal system.

METHODS

Suffolk ewes were mated and received intravenous infusions of saline or alcohol (1.75 g/kg) over 1 hour on 3 consecutive days per week followed by 4 days without treatment beginning on gestational day (GD) 109 and concluding on GD 132 (term = 147 days). The acidemia group was exposed to increased inspired fractional concentrations of CO2 to closely mimic the alcohol-induced decreases in maternal arterial pH seen in the alcohol group.

RESULTS

Fetal femurs and tibias from the alcohol and acidemia groups were ~3 to 7% shorter in length compared with the control groups (p < 0.05). Three-point bending procedure demonstrated that fetal femoral ultimate strength (MPa) for the alcohol group was decreased (p < 0.05) by ~24 and 29%, while the acidemia group exhibited a similar decrease (p < 0.05) of ~32 and 37% compared with the normal control and saline control groups, respectively. Bone extrinsic and intrinsic mechanical properties including maximum breaking force (N) and normalized breaking force (N/kg) of fetal bones from the alcohol and acidemia groups were significantly decreased (p < 0.05) compared with both control groups.

CONCLUSIONS

We conclude that late gestational chronic binge alcohol exposure reduces growth and impairs functional properties of the fetal skeletal system and that the repeated episodes of alcohol-induced maternal acidemia may be at least partially responsible for these effects.

Impact of nutrition on muscle mass, strength, and performance in older adults

Muscle strength plays an important role in determining risk for falls, which result in fractures and other injuries. While bone loss has long been recognized as an inevitable consequence of aging, sarcopenia-the gradual loss of skeletal muscle mass and strength that occurs with advancing age-has recently received increased attention. A review of the literature was undertaken to identify nutritional factors that contribute to loss of muscle mass. The role of protein, acid-base balance, vitamin D/calcium, and other minor nutrients like B vitamins was reviewed. Muscle wasting is a multifactorial process involving intrinsic and extrinsic alterations. A loss of fast twitch fibers, glycation of proteins, and insulin resistance may play an important role in the loss of muscle strength and development of sarcopenia. Protein intake plays an integral part in muscle health and an intake of 1.0-1.2 g/kg of body weight per day is probably optimal for older adults. There is a moderate [corrected] relationship between vitamin D status and muscle strength. Chronic ingestion of acid-producing diets appears to have a negative impact on muscle performance, and decreases in vitamin B12 and folic acid intake may also impair muscle function through their action on homocysteine. An adequate nutritional intake and an optimal dietary acid-base balance are important elements of any strategy to preserve muscle mass and strength during aging.

Examining the relationship between diet-induced acidosis and cancer

Increased cancer risk is associated with select dietary factors. Dietary lifestyles can alter systemic acid-base balance over time. Acidogenic diets, which are typically high in animal protein and salt and low in fruits and vegetables, can lead to a sub-clinical or low-grade state of metabolic acidosis. The relationship between diet and cancer risk prompts questions about the role of acidosis in the initiation and progression of cancer. Cancer is triggered by genetic and epigenetic perturbations in the normal cell, but it has become clear that microenvironmental and systemic factors exert modifying effects on cancer cell development. While there are no studies showing a direct link between diet-induced acidosis and cancer, acid-base disequilibrium has been shown to modulate molecular activity including adrenal glucocorticoid, insulin growth factor (IGF-1), and adipocyte cytokine signaling, dysregulated cellular metabolism, and osteoclast activation, which may serve as intermediary or downstream effectors of carcinogenesis or tumor promotion. In short, diet-induced acidosis may influence molecular activities at the cellular level that promote carcinogenesis or tumor progression. This review defines the relationship between dietary lifestyle and acid-base balance and discusses the potential consequences of diet-induced acidosis and cancer occurrence or progression.

Impact of the diet on net endogenous acid production and acid-base balance

Net acid production, which is composed of volatile acids (15,000 mEq/day) and metabolic acids (70-100 mEq/day) is relatively small compared to whole-body H⁺ turnover (150,000 mEq/day). Metabolic acids are ingested from the diet or produced as intermediary or end products of endogenous metabolism. The three commonly reported sources of net acid production are the metabolism of sulphur amino acids, the metabolism or ingestion of organic acids, and the metabolism of phosphate esters or dietary phosphoproteins. Net base production occurs mainly as a result of absorption of organic anions from the diet. To maintain acid-base balance, ingested and endogenously produced acids are neutralized within the body by buffer systems or eliminated from the body through the respiratory (excretion of volatile acid in the form of CO₂) and urinary (excretion of fixed acids and remaining H⁺) pathways. Because of the many reactions involved in the acid-base balance, the direct determination of acid production is complex and is usually estimated through direct or indirect measurements of acid excretion. However, indirect approaches, which assess the acid-forming potential of the ingested diet based on its composition, do not take all the acid-producing reactions into account. Direct measurements therefore seem more reliable. Nevertheless, acid excretion does not truly provide information on the way acidity is dealt with in the plasma and this measurement should be interpreted with caution when assessing acid-base imbalance.

Protein intake, calcium balance and health consequences

High-protein (HP) diets exert a hypercalciuric effect at constant levels of calcium intake, even though the effect may depend on the nature of the dietary protein. Lower urinary pH is also consistently observed for subjects consuming HP diets. The combination of these two effects was suspected to be associated with a dietary environment favorable for demineralization of the skeleton. However, increased calcium excretion due to HP diet does not seem to be linked to impaired calcium balance. In contrast, some data indicate that HP intakes induce an increase of intestinal calcium absorption. Moreover, no clinical data support the hypothesis of a detrimental effect of HP diet on bone health, except in a context of inadequate calcium supply. In addition, HP intake promotes bone growth and retards bone loss and low-protein diet is associated with higher risk of hip fractures. The increase of acid and calcium excretion due to HP diet is also accused of constituting a favorable environment for kidney stones and renal diseases. However, in healthy subjects, no damaging effect of HP diets on kidney has been found in either observational or interventional studies and it seems that HP diets might be deleterious only in patients with preexisting metabolic renal dysfunction. Thus, HP diet does not seem to lead to calcium bone loss, and the role of protein seems to be complex and probably dependent on other dietary factors and the presence of other nutrients in the diet.

Distal renal tubular acidosis, hypokalemic paralysis, nephrocalcinosis, primary hypothyroidism, growth retardation, osteomalacia and osteoporosis leading to pathological fracture: a case report

Renal tubular acidosis (RTA) is a constellation of syndromes arising from different derangements of tubular acid transport. Recent advances in the biology of urinary acidification have allowed us to discern various molecular mechanisms responsible for these syndromes. RTA often presents as renal stone disease with nephrocalcinosis, ricket/osteomalacia and growth retardation in children with ultimate short stature in adulthood. The case reported here has features of distal renal tubular acidosis (dRTA), hypokalemic paralysis, primary hypothyroidism, growth retardation, osteomalacia and osteopenia leading to stress fracture. All these features presenting in a single case (as in our case) is a rare occurrence, so far other cases of distal renal tubular acidosis (dRTA) have been reported.

Body fluid dynamics: back to the future

Pioneering investigations conducted over a half century ago on tonicity, transcapillary fluid exchange, and the distribution of water and solute serve as a foundation for understanding the physiology of body fluid spaces. With passage of time, however, some of these concepts have lost their connectivity to more contemporary information. Here we examine the physical forces determining the compartmentalization of body fluid and its movement across capillary and cell membrane barriers, drawing particular attention to the interstitium operating as a dynamic interface for water and solute distribution rather than as a static reservoir. Newer work now supports an evolving model of body fluid dynamics that integrates exchangeable Na(+) stores and transcapillary dynamics with advances in interstitial matrix biology.

Low-carbohydrate diets: a matter of love or hate

Low-carbohydrate diets (LChD) have become very popular among the general population. These diets have been used to lose body weight and to ameliorate various abnormalities like diabetes, nonalcoholic fatty liver disease, polycystic ovary syndrome, narcolepsy, epilepsy, and others. Reports suggest that body weight reduction and glycemic control could be attained while following LChD. However, these advantages are more notably found in short periods of time consuming an LChD. Indeed, the safety and efficacy of the latter diets in the long term have not been sufficiently explored. In contrast to what has been proposed, other mentioned pathologies are not improved or are even worsened by carbohydrate restriction. Therefore, the aim of this review is to define the concept of LChD and to explain their clinical effects in the short and long term, their influence on metabolism, and the opinion of nutrition or health authorities. Finally, evincing the research gaps of LChD that are here exposed will later allow us to reach a consensus with regard to their utilization.

A physiological skeletal model for radionuclide and stable element biokinetics in children and adults

A physiological skeletal model (PSM) is described that represents the skeletal uptake, retention, and clearance of both bone-surface-seeking and bone-volume-seeking radionuclides and stable elements. A key objective of the PSM is to model the higher skeletal growth and bone turnover in infants and children (compared to adults) in order to account for their greater uptake and cancer risk from bone-seeking contaminants such as lead and plutonium. The PSM is a compartmental model that allows for the incorporation of organic and inorganic material in the bone volume via quiescent bone surfaces, forming bone surfaces and the lacuno-canaliculi system. The model uniquely incorporates a tertiary phase of mineralization via bone fluids. The PSM's structural concepts and biokinetic parameters--such as realistic mass transfers, organ and tissue masses, and bone remodeling half-times--are selected mainly on the basis of physiological and anatomical criteria. For brevity, model parameter values are evaluated for adults only. The PSM is an improvement on existing skeletal models that are based more on compartment structures and pathways that rendered good fits to biokinetic data rather than on being anatomically and physiologically accurate.

Acidosis, hypoxia and bone

Bone homeostasis is profoundly affected by local pH and oxygen tension. It has long been recognised that the skeleton contains a large reserve of alkaline mineral (hydroxyapatite), which is ultimately available to neutralise metabolic H(+) if acid-base balance is not maintained within narrow limits. Bone cells are extremely sensitive to the direct effects of pH: acidosis inhibits mineral deposition by osteoblasts but it activates osteoclasts to resorb bone and other mineralised tissues. These reciprocal responses act to maximise the availability of OH(-) ions from hydroxyapatite in solution, where they can buffer excess H(+). The mechanisms by which bone cells sense small pH changes are likely to be complex, involving ion channels and receptors in the cell membrane, as well as direct intracellular effects. The importance of oxygen tension in the skeleton has also long been known. Recent work shows that hypoxia blocks the growth and differentiation of osteoblasts (and thus bone formation), whilst strongly stimulating osteoclast formation (and thus bone resorption). Surprisingly, the resorptive function of osteoclasts is unimpaired in hypoxia. In vivo, tissue hypoxia is usually accompanied by acidosis due to reduced vascular perfusion and increased glycolytic metabolism. Thus, disruption of the blood supply can engender a multiple negative impact on bone via the direct actions of reduced pO(2) and pH on bone cells. These observations may contribute to our understanding of the bone disturbances that occur in numerous settings, including ageing, inflammation, fractures, tumours, anaemias, kidney disease, diabetes, respiratory disease and smoking.

Impact of supplementation with bicarbonate on lower-extremity muscle performance in older men and women

This study describes the impact of bicarbonate treatment for 3 months on net acid excretion (NAE), nitrogen excretion, and muscle performance in older men and women. Bicarbonate reduced NAE, and the decrement was associated with a decrease in nitrogen excretion. Treatment also improved muscle power and endurance in the women.

INTRODUCTION

Bicarbonate enhances muscle performance during strenuous exercise, but its effect on performance during normal activity in older subjects is unknown.

METHODS

In this trial, healthy subjects age 50 and older were randomized to 67.5 mmol of bicarbonate or to no bicarbonate daily for 3 months. Changes in lower-extremity muscle power, endurance, urinary nitrogen, and NAE were compared across treatment groups in the 162 participants included in the analyses.

RESULTS

In the men and the women, bicarbonate was well tolerated, and as expected, it significantly decreased NAE. The change in NAE correlated with change in nitrogen excretion in women (r = 0.32, P = 0.002) with a similar trend in men (r = 0.23, P = 0.052). In the women, bicarbonate increased double leg press power at 70% one repetition maximum by 13% (P = 0.003) compared with no bicarbonate and improved other performance measures. Treatment with bicarbonate had no significant effect on muscle performance in the men.

CONCLUSIONS

Ingestion of bicarbonate decreased nitrogen excretion and improved muscle performance in healthy postmenopausal women. The bicarbonate-induced decline in NAE was associated with reduced nitrogen excretion in both men and women. These findings suggest that bicarbonate merits further evaluation as a safe, low-cost intervention that may attenuate age-related loss of muscle performance and mass in the elderly.

Claudin expression in the bone-lining cells of female rats exposed to long-standing acidemia

Besides enhancing osteoclast-mediated bone resorption, chronic metabolic acidosis (CMA) induces mineral efflux across the epithelial-like bone membrane formed by bone-lining cells (inactive osteoblasts), possibly via the paracellular pathway. However, there was a compensatory mechanism that restricted bone loss in the late phase of CMA, and changes in the expression of claudins, which are tight junction proteins known to regulate epithelial barrier function, were therefore anticipated in bone-lining cells. Herein, primary rat osteoblasts were found to express several transcripts of claudins, i.e., claudin-5, -11, -14, -15 and -16. Their protein expressions in bone-lining cells were demonstrated by immunohistochemistry in decalcified tibial sections. After exposure to CMA induced by oral administration of 1.5% NH(4)Cl for 21 days, expression of claudin-14, which normally seals the paracellular space and restricts ion movement, was increased, whereas that of claudin-15 and -16 which form pores for ion transport were decreased. Expressions of claudin-5 and -11 were not changed by CMA. In conclusion, the bone-lining cells of rats exposed to CMA for 21 days upregulated an ion-restrictive claudin (i.e., claudin-14), while downregulating ion-permeable claudins (i.e., claudin-15 and -16). These cellular responses might be parts of a compensatory mechanism accounting for deceleration of bone loss in late CMA.

Postgraduate Symposium: Positive influence of nutritional alkalinity on bone health

There is growing evidence that consumption of a Western diet is a risk factor for osteoporosis through excess acid supply, while fruits and vegetables balance the excess acidity, mostly by providing K-rich bicarbonate-rich foods. Western diets consumed by adults generate approximately 50-100 mEq acid/d; therefore, healthy adults consuming such a diet are at risk of chronic low-grade metabolic acidosis, which worsens with age as a result of declining kidney function. Bone buffers the excess acid by delivering cations and it is considered that with time an overstimulation of this process will lead to the dissolution of the bone mineral content and hence to reduced bone mass. Intakes of K, Mg and fruit and vegetables have been associated with a higher alkaline status and a subsequent beneficial effect on bone health. In healthy male volunteers an acid-forming diet increases urinary Ca excretion by 74% and urinary C-terminal telopeptide of type I collagen (C-telopeptide) excretion by 19% when compared with an alkali (base-forming) diet. Cross-sectional studies have shown that there is a correlation between the nutritional acid load and bone health measured by bone ultrasound or dual-energy X-ray absorptiometry. Few studies have been undertaken in very elderly women (>75 years), whose osteoporosis risk is very pertinent. The EVAluation of Nutrients Intakes and Bone Ultra Sound Study has developed and validated (n 51) an FFQ for use in a very elderly Swiss population (mean age 80.4 (sd 2.99) years), which has shown intakes of key nutrients (energy, fat, carbohydrate, Ca, Mg, vitamin C, D and E) to be low in 401 subjects. A subsequent study to assess net endogenous acid production (NEAP) and bone ultrasound results in 256 women aged > or = 75 years has shown that lower NEAP (P=0.023) and higher K intake (P=0.033) are correlated with higher bone ultrasound results. High acid load may be an important additional risk factor that may be particularly relevant in very elderly patients with an already-high fracture risk. The latter study adds to knowledge by confirming a positive link between dietary alkalinity and bone health indices in the very elderly. In a further study to complement these findings it has also been shown in a group of thirty young women that in Ca sufficiency an acid Ca-rich water has no effect on bone resorption, while an alkaline bicarbonate-rich water leads to a decrease in both serum parathyroid hormone and serum C-telopeptide. Further investigations need to be undertaken to study whether these positive effects on bone loss are maintained over long-term treatment. Mineral-water consumption could be an easy and inexpensive way of helping to prevent osteoporosis and could be of major interest for long-term prevention of bone loss.

Bone disease in medullary sponge kidney and effect of potassium citrate treatment

BACKGROUND AND OBJECTIVES

In medullary sponge kidney (MSK)-a common malformative renal condition in patients with calcium nephrolithiasis-hypercalciuria, incomplete distal renal tubular acidosis, and hypocitraturia are common. Clinical conditions with concomitant hypercalciuria and/or incomplete distal renal tubular acidosis are almost invariably associated with bone disease, making osteopathy highly likely in MSK, too. Patients with MSK have never been investigated for osteopathy; neither has the potential effect of potassium citrate administration (CA) on their urinary metabolic risk factors and on bone mineralization.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

These issues were retrospectively analyzed in 75 patients with MSK and primary stone risk factor (PSRF; hypercalciuria, hypocitraturia, hyperuricosuria, and/or hyperoxaluria) on an outpatient basis; 65 received CA (2.9 +/- 0.8 g/d), whereas 10 received only general "stone clinic" suggestions. The 24-h urinary excretion of calcium, phosphate, oxalate, uric acid, and citrate; morning urine pH; serum biochemistry; and bone mineral density were investigated at baseline and at the end of follow-up (78 +/- 13 and 72 +/- 15 mo in groups A and B, respectively).

RESULTS

CA led to a significant rise in urinary pH and citrate and decreased urinary calcium and phosphate (all P < 0.001). Patients with MSK and PSRF had reduced bone density. Bone density improved significantly in the group that was treated with oral CA.

CONCLUSIONS

Bone disease is very frequent in patients with MSK and concomitant PSRF. Long-term CA improves bone density. The concurrent effects of treatment on PSRF suggest that the subtle acidosis plays a pivotal role in bone disease and hypercalciuria in patients with MSK.

Bicarbonate therapy improves growth in children with incomplete distal renal tubular acidosis

Incomplete distal renal tubular acidosis (idRTA) has recently been associated with osteoporosis and growth retardation, attributed to the mild persistent metabolic acidosis. We hypothesized a therapeutic benefit from bicarbonate therapy on growth parameters in children with idRTA. In a study group of 40 surgically treated patients with posterior urethral valve (PUV) and normal estimated glomerular filtration rate, we evaluated the change in height standard deviation scores (SDSs) while they were on bicarbonate therapy in the presence of idRTA and complete distal renal tubular acidosis (dRTA). Age- and gender-matched healthy subjects constituted the control group (n = 55). Incomplete dRTA was evaluated by ammonium chloride acidification. The baseline height SDS of -1.94 +/- 0.41 and -5.31 +/- 1.95 in the groups with idRTA and complete dRTA, respectively, were significantly lower than that of the controls. After a follow-up period of 24.7 +/- 8.3 months on sodium bicarbonate therapy, the idRTA patients had a 66% increase in height SDS compared with 26% and 3% increases in the patients with PUV with complete dRTA and without dRTA, respectively. At the end of follow-up, mean height SDS in the group with idRTA no longer remained significantly lower than that of the controls (P = 0.42). We concluded that bicarbonate therapy improves height SDS in idRTA. This issue needs further validation in larger studies.

Low estimates of dietary acid load are positively associated with bone ultrasound in women older than 75 years of age with a lifetime fracture

Dietary acid load from Western diets may be a risk factor for osteoporosis. It can be estimated by net endogenous acid production (NEAP). No data currently exists for NEAP estimates and bone indices in the very elderly (i.e. > or = 75 y). The aim of this study was to determine the association between NEAP estimates by using the potential renal acid load (PRAL) equation and quantitative bone ultrasound (QUS) measurements at the heel [broadband ultrasound attenuation (BUA)] in Caucasian women. We assessed NEAP and QUS in 401 very elderly Swiss ambulatory women. We evaluated dietary intake and NEAP estimates with a validated FFQ. QUS was measured using Achilles (Lunar). We identified 2 subgroups: 256 women (80.6 y +/- 3; BUA, 96.8 dB/MHz) with a fracture history and the remaining 145 (79.9 y SD 2.9; BUA, 101.7 dB/MHz) without. Women who reported having suffered a fracture had lower BUA (P < 0.001) than nonfractured women but did not differ in nutrient intakes and NEAP. Lower NEAP (P = 0.023) and higher potassium intake (P = 0.033) were correlated with higher BUA, which remained significant even after adjustment for age, BMI, and osteoporosis treatment. BUA was positively correlated with calcium (P = 0.016) and BMI (P < 0.001). Women who reported no fractures had no significant correlations between nutrient intake, NEAP, and BUA. Low nutritional acid load was correlated with higher BUA in very elderly women with a fracture history. Although relatively weak compared with age and BMI, this association was significant and may be an important additional risk factor that might be particularly relevant in frail patients with an already high fracture risk.

Nutrition and bone health projects funded by the UK Food Standards Agency: have they helped to inform public health policy?

The UK Food Standards Agency convened an international group of expert scientists to review the Agency-funded projects on diet and bone health in the context of developments in the field as a whole. The potential benefits of fruit and vegetables, vitamin K, early-life nutrition and vitamin D on bone health were presented and reviewed. The workshop reached two conclusions which have public health implications. First, that promoting a diet rich in fruit and vegetable intakes might be beneficial to bone health and would be very unlikely to produce adverse consequences on bone health. The mechanism(s) for any effect of fruit and vegetables remains unknown, but the results from these projects did not support the postulated acid-base balance hypothesis. Secondly, increased dietary consumption of vitamin K may contribute to bone health, possibly through its ability to increase the gamma-carboxylation status of bone proteins such as osteocalcin. A supplementation trial comparing vitamin K supplementation with Ca and vitamin D showed an additional effect of vitamin K against baseline levels of bone mineral density, but the benefit was only seen at one bone site. The major research gap identified was the need to investigate vitamin D status to define deficiency, insufficiency and depletion across age and ethnic groups in relation to bone health.

Organic anions and potassium salts in nutrition and metabolism

The present review examines the importance of dietary organic anions in preventive nutrition. Organic anions are chiefly supplied by plant foods, as partially neutralised K salts such as potassium citrate, potassium malate and, to a lesser extent, oxalate or tartrate salts. Animal products may also supply K anions, essentially as phosphate, but also as lactate as a result of fermentative or maturation processes, but these K salts have little alkalinising significance. Citrate and malate anions are absorbed in the upper digestive tract, while a substantial proportion is probably metabolised in the splanchnic area. Whatever their site of metabolism, these anions finally yield KHCO3which is used by the kidneys to neutralise fixed acidity. This acidity essentially reflects the oxidation of excess S amino acids to sulfate ions, which is mainly related to the dietary protein level. Failure to neutralise acidity leads to low-grade metabolic acidosis, with possible long-term deleterious effects on bone Ca status and on protein status. Furthermore, low-grade acidosis is liable to affect other metabolic processes, such as peroxidation of biological structures. These metabolic disturbances could be connected with the relatively high incidence of osteoporosis and muscle-protein wasting problems observed in ageing individuals in Europe and Northern America. Providing a sufficient supply of K organic anions through fruit and vegetable intake should be recommended, fostering the actual motivational campaigns ('five (or ten) per d') already launched to promote the intake of plant foods rich in complex carbohydrates and various micronutrients.

Intake of fruit and vegetables: implications for bone health

These famous words by Mencken in the early 20th century about the meaning of life and death, may also apply to the struggle of the healthy skeleton against the deleterious effects of retained acid!’ ( Kraut & Coburn, 1994). The health-related benefit of a high consumption of fruit and vegetables and the influence of this food group on a variety of diseases has been gaining increasing prominence in the literature over a number of years. Of considerable interest to the osteoporosis field is the role that bone plays in acid–base balance. Natural, pathological and experimental states of acid loading and acidosis have been associated with hypercalciuria and negative Ca balance, and more recently the detrimental effects of ‘acid’ from the diet on bone mineral have been demonstrated. Suprisingly, consideration of the skeleton as a source of ‘buffer’ contributing to both the preservation of the body's pH and defence of the system against acid–base disorders has been ongoing for over three decades. However, it is only more recently that the possibility of a positive link between a high consumption of fruit and vegetables and indices of bone health has been more fully explored. A number of population-based studies published in the last decade have demonstrated a beneficial effect of fruit and vegetable and K intake on axial and peripheral bone mass and bone metabolism in men and women across the age-ranges. Further support for a positive link between fruit and vegetable intake and bone health can be found in the results of the Dietary Approaches to Stopping Hypertension (DASH) and DASH-Sodium intervention trials. There is now an urgent requirement for the implementation of: (1) fruit and vegetable and alkali administration–bone health intervention trials, including fracture risk as an end point; (2) reanalysis of existing dietary–bone mass and metabolism datasets to look specifically at the impact of dietary ‘acidity’ on the skeleton.

Regulation of bone cell function by acid–base balance

Bone growth and turnover results from the coordinated activities of two key cell types. Bone matrix is deposited and mineralised by osteoblasts and it is resorbed by osteoclasts, multinucleate cells that excavate pits on bone surfaces. It has been known since the early 20th century that systemic acidosis causes depletion of the skeleton, an effect assumed to result from physico-chemical dissolution of bone mineral. However, our own work has shown that resorption pit formation by cultured osteoclasts was absolutely dependent on extracellular acidification; these cells are inactive at pH levels above about 7·3 and show maximum stimulation at a pH of about 6·9. Bone resorption is most sensitive to changes in H+concentration at a pH of about 7·1 (which may be close to the interstitial pH in bone). In this region pH shifts of <0·05 units can cause a doubling or halving of pit formation. In whole-bone cultures, chronic HCO3-acidosis results in similar stimulations of osteoclast-mediated Ca2+release, with a negligible physico-chemical component.In vivo, severe systemic acidosis (pH change of about –0·05 to –0·20) often results from renal disease; milder chronic acidosis (pH change of about –0·02 to –0·05) can be caused by excessive protein intake, acid feeding, prolonged exercise, ageing, airway diseases or the menopause. Acidosis can also occur locally as a result of inflammation, infection, wounds, tumours or diabetic ischaemia. Cell function, including that of osteoblasts, is normally impaired by acid; the unusual stimulatory effect of acid on osteoclasts may represent a primitive ‘fail-safe’ that evolved with terrestrial vertebrates to correct systemic acidosis by ensuring release of alkaline bone mineral when the lungs and kidneys are unable to remove sufficient H+equivalent. The present results suggest that even subtle chronic acidosis could be sufficient to cause appreciable bone loss over time.