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Qvist T, Nielsen BU, Olesen HV, Mathiesen IHM, Faurholt-Jepsen D, Katzenstein TL, Helweg-Larsen J, Rönsholt F, Jeppesen M, Olsen MF, Buchvald FF, Nielsen KG, Jensen-Fangel S, Pressler T, Skov M. Close monitoring and early intervention: management principles for cystic fibrosis in Denmark. APMIS 2024; 132:223-235. [PMID: 38267398 DOI: 10.1111/apm.13375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 12/20/2023] [Indexed: 01/26/2024]
Abstract
Cystic fibrosis (CF) care in Denmark has been characterized by close monitoring and pre-emptive treatment of lung disease and other CF-related complications. Continuous evaluation through data collection and commitment to clinical research has incrementally improved outcomes. This approach has been in line with best practices set forth by European Standards of Care but has also gone beyond Society standards particularly pertaining to early treatment with high-dose combination antimicrobial therapy. Despite a high prevalence of severe CF variants, lung function has been among the best in Europe. In this review, the Danish approach to management of CF prior to the introduction of new CF modulator treatment is explained and benchmarked. Downsides to the Danish approach are discussed and include increased burden of treatment, risk of antimicrobial resistance, side-effects and costs.
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Affiliation(s)
- Tavs Qvist
- Cystic Fibrosis Center Copenhagen, Department of Infectious Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Bibi Uhre Nielsen
- Cystic Fibrosis Center Copenhagen, Department of Infectious Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Hanne Vebert Olesen
- Cystic Fibrosis Center Aarhus, Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Inger Hee Mabuza Mathiesen
- Cystic Fibrosis Center Copenhagen, Department of Infectious Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Daniel Faurholt-Jepsen
- Cystic Fibrosis Center Copenhagen, Department of Infectious Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Terese L Katzenstein
- Cystic Fibrosis Center Copenhagen, Department of Infectious Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Jannik Helweg-Larsen
- Cystic Fibrosis Center Copenhagen, Department of Infectious Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Frederikke Rönsholt
- Department of Cardiology, Section for Lung Transplantation, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Majbritt Jeppesen
- Cystic Fibrosis Center Aarhus, Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Mette Frahm Olsen
- Cystic Fibrosis Center Copenhagen, Department of Infectious Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Frederik Fouirnaies Buchvald
- Cystic Fibrosis Center Copenhagen, Danish Pediatric Pulmonary Service, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Kim Gjerum Nielsen
- Cystic Fibrosis Center Copenhagen, Danish Pediatric Pulmonary Service, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Søren Jensen-Fangel
- Cystic Fibrosis Center Aarhus, Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Tania Pressler
- Cystic Fibrosis Center Copenhagen, Department of Infectious Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Cystic Fibrosis Center Copenhagen, Danish Pediatric Pulmonary Service, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Marianne Skov
- Cystic Fibrosis Center Copenhagen, Danish Pediatric Pulmonary Service, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
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Wu M, Bhimavarapu A, Alvarez JA, Hunt WR, Tangpricha V. Changes in bone turnover after high-dose vitamin D supplementation during acute pulmonary exacerbation in cystic fibrosis. Bone 2023; 174:116835. [PMID: 37390941 PMCID: PMC10428002 DOI: 10.1016/j.bone.2023.116835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 06/21/2023] [Accepted: 06/27/2023] [Indexed: 07/02/2023]
Abstract
In people with cystic fibrosis (CF), chronic inflammation and infection increase the risk for low bone mineral density and CF-related bone disease. During acute pulmonary exacerbations (APE), people with CF have increases in markers of bone resorption. Vitamin D has been proposed as a potential nutrient to lower inflammation. In this ancillary analysis of the Vitamin D for the Immune System in CF study, we hypothesized that vitamin D administered at the time of APE would have favorable changes on bone turnover markers compared to placebo. Participants with CF were randomized to receive a single dose of 250,000 IU of vitamin D or placebo during an APE and followed for 1 year for the primary outcome of APE or death after randomization. Bone turnover markers: C-terminal telopeptide (CTX-1) and procollagen type 1 intact N-terminal propetide (P1NP) were assessed at randomization (during APE) and after recovery from the APE in 45 participants. Participants randomized to vitamin D had significant decreases in markers of bone turnover; participants who received placebo had non-significant increases in markers of bone turnover. Vitamin D supplementation during an APE may help reduce the risk for CF-related bone disease.
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Affiliation(s)
- Malinda Wu
- Division of Endocrinology, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA,.
| | | | - Jessica A Alvarez
- Division of Endocrinology, Metabolism & Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - William R Hunt
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Vin Tangpricha
- Division of Endocrinology, Metabolism & Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA; Section of Endocrinology, Atlanta Veterans Affairs Medical Center, Decatur, GA, USA
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Mulrennan S, Sapru K, Tewkesbury D, Jones AM. Beyond the Lungs-Emerging Challenges in Adult Cystic Fibrosis Care. Semin Respir Crit Care Med 2023; 44:307-314. [PMID: 36535664 DOI: 10.1055/s-0042-1758734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Cystic fibrosis (CF) is a multisystem disease. This article provides an up-to-date review of many of the nonrespiratory complications of CF, including mental health issues, nutritional and gastrointestinal problems, fertility issues, diabetes mellitus, bone health and musculoskeletal problems, liver disease, renal problems, and risk of malignancy. It highlights the recent impact of new therapies, including CF transmembrane conductance regulator modulators, on the nonrespiratory complications of CF and provides insights into the potential challenges faced by an aging population of adults with CF and their caregivers, including the potential future risk for cardiovascular disease.
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Affiliation(s)
- Siobhain Mulrennan
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Australia.,Faculty of Health and Medical Sciences, University of Western Australia, Australia
| | - Karuna Sapru
- Manchester Adult Cystic Fibrosis Centre, Wythenshawe Hospital, Manchester, United Kingdom
| | - Daniel Tewkesbury
- Manchester Adult Cystic Fibrosis Centre, Wythenshawe Hospital, Manchester, United Kingdom
| | - Andrew M Jones
- Manchester Adult Cystic Fibrosis Centre, Wythenshawe Hospital, Manchester, United Kingdom
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Dury S, Ancel J, Ravoninjatovo B, Lambrecht I, Perotin JM, Mulette P, Lebargy F, Salmon JH, Deslée G, Launois C. Clinical relevance of low bone density in cystic fibrosis adult patients: A pilot study. Medicine (Baltimore) 2023; 102:e32227. [PMID: 36607849 PMCID: PMC9829254 DOI: 10.1097/md.0000000000032227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Survival improvement in cystic fibrosis (CF) is associated with more frequent long-term complications, including CF related bone disease (CFBD). Impact of CFBD on global health outcome remains poorly described. We aimed to assess the relationship between low bone mineral density (BMD) and spinal pain, disability, and quality of life in CF adult patients. This monocentric cross-sectional study with prospective data collection was conducted from November 2016 to December 2019 in the Department of Respiratory Diseases at the University Hospital of Reims (NCT02924818). BMD was assessed by X-ray absorptiometry (DXA). Disability was assessed by the Health Assessment Questionnaire (HAQ). Quality of life was assessed by both the St George's Respiratory Questionnaire and the Cystic Fibrosis Questionnaire for teenagers and adults (CFQ 14+). Forty patients were analyzed, 68% of men, with a median age of 25 years, a median body mass index of 21 kg/m² and a median FEV1% of 54%. Nine patients (23%) had spinal pain. Ten patients (25%) had a low BMD. Compared with patients with normal BMD, patients with low BMD had a significantly lower BMI (22 vs 19 kg/m²; P = .006) and less vitamin D supplementation (33% vs 0%; P = .035). Low BMD was not associated with spinal pain, disability and quality of life. Low BMD is frequent in CF, affecting 1-quarter of adult patients. No significant association was found between low BMD and spinal pain, disability or quality of life.
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Affiliation(s)
- Sandra Dury
- Department of Respiratory Diseases, Reims University Hospital
- EA7509 IRMAIC, University of Reims Champagne-Ardenne
- * Correspondence: Sandra Dury, Department of Respiratory Diseases, Maison Blanche University Hospital, 45, rue DE Cognacq-Jay, 51 092 Reims cedex, France (e-mail: )
| | - Julien Ancel
- Department of Respiratory Diseases, Reims University Hospital
| | | | | | - Jeanne-Marie Perotin
- Department of Respiratory Diseases, Reims University Hospital
- INSERM UMRS 1250, Reims University Hospital, Reims
| | - Pauline Mulette
- Department of Respiratory Diseases, Reims University Hospital
| | - François Lebargy
- Department of Respiratory Diseases, Reims University Hospital
- EA7509 IRMAIC, University of Reims Champagne-Ardenne
| | | | - Gaëtan Deslée
- Department of Respiratory Diseases, Reims University Hospital
- INSERM UMRS 1250, Reims University Hospital, Reims
| | - Claire Launois
- Department of Respiratory Diseases, Reims University Hospital
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Bass RM, Zemel BS, Stallings VA, Leonard MB, Tsao J, Kelly A. Bone accrual and structural changes over one year in youth with cystic fibrosis. J Clin Transl Endocrinol 2022; 28:100297. [PMID: 35433270 PMCID: PMC9006323 DOI: 10.1016/j.jcte.2022.100297] [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: 12/28/2021] [Revised: 03/21/2022] [Accepted: 03/24/2022] [Indexed: 11/06/2022] Open
Abstract
Background Pediatric bone accrual governs peak bone mass and strength. Longitudinal studies of bone health in youth with cystic fibrosis (CF) may provide insight into CF-related bone disease (CFBD), a prevalent co-morbidity in adults with CF. Methods This one-year longitudinal study of youth with pancreatic insufficient CF, enrolled in a nutrition intervention study [n = 62 (36 M/26F)] 1) examined dual-energy x-ray absorptiometry (DXA)-defined lumbar spine (LS) and total body less head (TBLH) bone accrual and 2) compared their changes in peripheral quantitative computed tomography (pQCT) cortical and trabecular tibial bone density and geometry to those of a healthy reference group [n = 143 (68 M/75F)]. Main outcome measures were 1) DXA: lumbar spine areal bone mineral density (LSaBMD) and total body less head bone mineral content (TBLH-BMC), sex- and pubertal status-specific, height velocity (HV)-adjusted or HV and lean body mass velocity (HV-LBMV)-adjusted annualized velocity-Z scores and 2) pQCT: age, sex, pubertal status and, when appropriate, tibial length adjusted Z-scores for bone architecture measures. DXA velocity-Z were compared to expected mean of 0 and correlations with clinical parameters (age, BMI-Z and FEV1%-predicted) tested. Within-subject comparisons of HV-adjusted and LBMV-HV-adjusted DXA velocity-Z were conducted in CF. pQCT Z-scores were compared between the two groups over one year using longitudinal models. Longitudinal relationships between measures of bone health and clinical parameters (age, BMI-Z and FEV1%-predicted) were examined in individuals with CF. Results DXA velocity-Z were higher than normal in females (p < 0.05) but not males with CF. HV-adjusted and LBMV-HV-adjusted velocity-Z did not differ for LSaBMD or TBLH-BMC. In males with CF, both HV-adjusted and LBMV-HV-adjusted LSaBMD velocity-Z scores correlated negatively with age (HV rho: −0.35; p = 0.045 and LBMV-HV rho: −0.47; p = 0.0046). In males with CF BMI-Z correlated positively with HV-adjusted LSaBMD velocity-Z (rho: 0.37; p = 0.034), but this relationship did not persist for LBMV-HV (rho: 0.14; p = 0.42). In females with CF, no correlations between LSaBMD velocity-Z scores and age or BMI-Z were found (all p > 0.05). No correlations between LSaBMD velocity-Z scores and FEV1%-predicted were seen in either sex (all p > 0.12). TBLH-BMC velocity Z-scores were not correlated with clinical parameters in either sex (all p > 0.1). At baseline, multiple pQCT parameters were lower in CF (p < 0.05). pQCT Z-scores did not differ between baseline and one-year in either CF or reference group. In a longitudinal model comparing pQCT-Z changes in CF and reference, multiple pQCT-Z outcomes remained lower in CF, but the changes in parameters did not differ in CF vs reference (all p > 0.26). Lower pQCT outcomes in CF were largely restricted to males (CF group*female sex interaction beta coefficients > 0). In this combined longitudinal model, of both CF and reference, BMI-Z was positively associated with pQCT-Z parameters(p < 0.001). Multiple pQCT-Z outcomes positively correlated with both BMI-Z and FEV1%-predicted in males with CF, and with FEV1%-predicted in females with CF (p < 0.05). Age was negatively associated with section modulus (p = 0.001) in males and with cortical density-Z in females (p < 0.001). Conclusions With improved longevity, bone health in CF is of increasing importance. On average, bone accrual was preserved in youth with CF, and while deficits in bone geometry and strength were found, these deficits did not worsen over the one-year study. Lower LS bone accrual with increasing age suggests emerging adulthood is a period of vulnerability in CF while the role of LBM in bone health is underscored by the lack of relationship between LBMV-adjusted accrual and BMI. These findings may be useful in targeting screening practices and interventions.
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Anabtawi A, Holyoak M, He J, Cristiano E, Polineni D, Graves L. Trabecular bone score in people with cystic fibrosis. Osteoporos Int 2022; 33:1137-1145. [PMID: 35013769 DOI: 10.1007/s00198-021-06290-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 12/22/2021] [Indexed: 10/19/2022]
Abstract
UNLABELLED People with cystic fibrosis (CF) are at increased risk of fractures. Our study found that low trabecular bone score (TBS) (a measure of bone strength) may help identify people with CF at risk of fractures especially when combined with bone density measured by DXA, age, hemoglobin A1c, and transplant status. INTRODUCTION People with cystic fibrosis (CF) are at increased risk of fractures. This study aims to evaluate the association of trabecular bone score (TBS) with fractures in CF. METHODS A cross-sectional study of adults with CF who completed bone density between 2009 and 2019. TBS was applied to lumbar spine studies. RESULTS A total of 202 people with CF were included. A history of fracture was present in 36 (17.8%) subjects. Patients with history of fractures had higher hemoglobin A1c (A1C) (7.8 ± 2.7% vs. 6.7 ± 1.7%, p = 0.024), lower femoral neck (FN) Z/T-score (- 1.05 ± 1.08 vs. - 0.44 ± 1.08, p = 0.012), and lower TBS (1.36 ± 0.13 vs. 1.40 ± 0.11, p = 0.05) compared to those without. Lung transplant recipients had a higher prevalence of fractures (50% vs. 14.1%, p < 0.001). The odds ratio (95%CI) of having a fracture for subjects with TBS (≤ 1.2 vs. > 1.2) stratified by FN Z/T-score (≤ - 2.0 or > - 2.0) was 3.88 (0.92, 16.35), p = 0.07. ROC analysis showed TBS was significantly associated with fractures (p < 0.05); however, FN BMD was superior. A model combining FN BMD, age, A1c, transplant, and TBS improved ROC compared to FN BMD + age (0.837 vs. 0.779, p = 0.031). CONCLUSIONS TBS ≤ 1.2 may identify people with CF at high risk of fractures. A model combining FN BMD, age, A1c, transplant, and TBS was significantly associated with fractures compared to FN BMD + age. Future studies are needed to evaluate the prediction of fractures in people with CF using clinical and bone parameters.
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Affiliation(s)
- A Anabtawi
- Department of Internal Medicine, Division of Endocrinology, Diabetes and Metabolism, University of Kansas Medical Center, 3901 Rainbow Blvd., Mail stop 2024, Kansas City, KS, 66160, USA.
| | - M Holyoak
- Department of Internal Medicine, Division of Endocrinology, Diabetes and Metabolism, University of Kansas Medical Center, 3901 Rainbow Blvd., Mail stop 2024, Kansas City, KS, 66160, USA
| | - J He
- Department of Biostatistics and Data Science, Medical Center, University of Kansas, Kansas City, KS, USA
| | - E Cristiano
- Department of Internal Medicine, Division of Endocrinology, Diabetes and Metabolism, University of Kansas Medical Center, 3901 Rainbow Blvd., Mail stop 2024, Kansas City, KS, 66160, USA
| | - D Polineni
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Medical Center, University of Kansas, Kansas City, KS, USA
| | - L Graves
- Department of Internal Medicine, Division of Endocrinology, Diabetes and Metabolism, University of Kansas Medical Center, 3901 Rainbow Blvd., Mail stop 2024, Kansas City, KS, 66160, USA
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Williams KM, Darukhanavala A, Hicks R, Kelly A. An update on methods for assessing bone quality and health in Cystic fibrosis. J Clin Transl Endocrinol 2022; 27:100281. [PMID: 34984171 PMCID: PMC8693345 DOI: 10.1016/j.jcte.2021.100281] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 10/18/2021] [Accepted: 11/27/2021] [Indexed: 11/15/2022] Open
Affiliation(s)
- Kristen M. Williams
- Division of Pediatric Endocrinology, Diabetes, and Metabolism, Columbia University Irving Medical Center, 1150 St Nicholas Avenue, New York, NY, USA
- Corresponding author at: Division of Pediatric Endocrinology, Diabetes, and Metabolism, Columbia University Irving Medical Center, 1150 St Nicholas Avenue, 2 Floor, New York, NY 10032, USA.
| | - Amy Darukhanavala
- Division of Pediatric Endocrinology, University of Massachusetts Medical Center, 55 Lake Ave North, Worcester, MA, USA
| | - Rebecca Hicks
- Division of Pediatric Endocrinology, David Geffen School of Medicine, UCLA, 10833 Le Conte Ave, MDCC 22-315, Los Angeles, CA, USA
| | - Andrea Kelly
- Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, 2716 South Street, Philadelphia, PA, USA
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Ratti GA, Fernandez GS, Schechter MS, Stalvey MS, Ostrenga J, Fink AK, Jain R. Bone mineral density screening by DXA for people with cystic fibrosis: A registry analysis of patient and program factors influencing rates of screening. J Cyst Fibros 2022; 21:784-791. [DOI: 10.1016/j.jcf.2022.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 12/13/2021] [Accepted: 01/19/2022] [Indexed: 10/19/2022]
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Putman MS, Greenblatt LB, Bruce M, Joseph T, Lee H, Sawicki G, Uluer A, Sicilian L, Neuringer I, Gordon CM, Bouxsein ML, Finkelstein JS. The Effects of Ivacaftor on Bone Density and Microarchitecture in Children and Adults with Cystic Fibrosis. J Clin Endocrinol Metab 2021; 106:e1248-e1261. [PMID: 33258950 PMCID: PMC7947772 DOI: 10.1210/clinem/dgaa890] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Indexed: 11/19/2022]
Abstract
CONTEXT Cystic fibrosis (CF) transmembrane conductance (CFTR) dysfunction may play a role in CF-related bone disease (CFBD). Ivacaftor is a CFTR potentiator effective in improving pulmonary and nutritional outcomes in patients with the G551D-CFTR mutation. The effects of ivacaftor on bone health are unknown. OBJECTIVE To determine the impact of ivacaftor on bone density and microarchitecture in children and adults with CF. DESIGN Prospective observational multiple cohort study. SETTING Outpatient clinical research center within a tertiary academic medical center. PATIENTS OR OTHER PARTICIPANTS Three cohorts of age-, race-, and gender-matched subjects were enrolled: 26 subjects (15 adults and 11 children) with CF and the G551D-CFTR mutation who were planning to start or had started treatment with ivacaftor within 3 months (Ivacaftor cohort), 26 subjects with CF were not treated with ivacaftor (CF Control cohort), and 26 healthy volunteers. INTERVENTIONS All treatments, including Ivacaftor, were managed by the subjects' pulmonologists. MAIN OUTCOME MEASURES Bone microarchitecture by high-resolution peripheral quantitative computed tomography (HR-pQCT), areal bone mineral density (aBMD) by dual-energy X-ray absorptiometry (DXA) and bone turnover markers at baseline, 1, and 2 years. RESULTS Cortical volume, area, and porosity at the radius and tibia increased significantly in adults in the Ivacaftor cohort. No significant differences were observed in changes in aBMD, trabecular microarchitecture, or estimated bone strength in adults or in any outcome measures in children. CONCLUSIONS Treatment with ivacaftor was associated with increases in cortical microarchitecture in adults with CF. Further studies are needed to understand the implications of these findings.
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Affiliation(s)
- Melissa S Putman
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Division of Endocrinology, Boston Children’s Hospital, Boston, MA, USA
- Correspondence and Reprint Requests: Melissa S. Putman, Endocrine Unit, Massachusetts General Hospital, 50 Blossom Street, THR-1051, Boston, MA 02114. E-mail:
| | - Logan B Greenblatt
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Michael Bruce
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Taisha Joseph
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Hang Lee
- Massachusetts General Hospital Biostatistics Center, Boston, MA, USA
| | - Gregory Sawicki
- Division of Pulmonology, Boston Children’s Hospital, Boston, MA, USA
| | - Ahmet Uluer
- Division of Pulmonology, Boston Children’s Hospital, Boston, MA, USA
- Division of Pulmonology and Critical Care, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Leonard Sicilian
- Division of Pulmonology and Critical Care, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Isabel Neuringer
- Division of Pulmonology and Critical Care, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Catherine M Gordon
- Division of Endocrinology, Boston Children’s Hospital, Boston, MA, USA
- Division of Adolescent and Young Adult Medicine, Boston Children’s Hospital, Boston, MA, USA
| | - Mary L Bouxsein
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Joel S Finkelstein
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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Anabtawi A, Le T, Putman M, Tangpricha V, Bianchi ML. Cystic fibrosis bone disease: Pathophysiology, assessment and prognostic implications. J Cyst Fibros 2019; 18 Suppl 2:S48-S55. [DOI: 10.1016/j.jcf.2019.08.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 08/19/2019] [Accepted: 08/19/2019] [Indexed: 12/25/2022]
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Robinson CA, Hofer M, Benden C, Schmid C. Evaluation of bone disease in patients with cystic fibrosis and end-stage lung disease. ACTA ACUST UNITED AC 2019; 45:e20170280. [PMID: 30843951 PMCID: PMC6534402 DOI: 10.1590/1806-3713/e20170280] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 04/10/2018] [Indexed: 11/22/2022]
Abstract
Objective: Bone disease is a common comorbidity in patients with cystic fibrosis (CF). We sought to determine risk factors and identify potential biochemical markers for CF-related bone disease (CFBD) in a unique cohort of CF patients with end-stage lung disease undergoing lung transplantation (LTx) evaluation. Methods: All of the CF patients who were evaluated for LTx at our center between November of 1992 and December of 2010 were included in the study. Clinical data and biochemical markers of bone turnover, as well as bone mineral density (BMD) at the lumbar spine and femoral neck, were evaluated. Spearman’s rho and multivariate logistic regression analysis were used. Results: A total of 102 adult CF patients were evaluated. The mean age was 28.1 years (95% CI: 26.7-29.5), and the mean body mass index was 17.5 kg/m2 (95% CI: 17.2-18.2). Mean T-scores were −2.3 and −1.9 at the lumbar spine and femoral neck, respectively, being lower in males than in females (−2.7 vs. −2.0 at the lumbar spine and −2.2 vs. −1.7 at the femoral neck). Overall, 52% had a T-score of < −2.5 at either skeletal site. The homozygous Phe508del genotype was found in 57% of patients without osteoporosis and in 60% of those with low BMD. Mean T-scores were not particularly low in patients with severe CFTR mutations. Although the BMI correlated with T-scores at the femoral neck and lumbar spine, serum 25-hydroxyvitamin D and parathyroid hormone levels did not. Conclusions: CFBD is common in CF patients with end-stage lung disease, particularly in males and patients with a low BMI. It appears that CF mutation status does not correlate with CFBD. In addition, it appears that low BMD does not correlate with other risk factors or biochemical parameters. The prevalence of CFBD appears to have recently decreased, most likely reflecting increased efforts at earlier diagnosis and treatment.
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Affiliation(s)
- Cécile A Robinson
- . Department of Pulmonology, University Hospital of Zurich, Zurich, Switzerland
| | - Markus Hofer
- . Department of Pulmonology, Cantonal Hospital of Winterthur, Winterthur, Switzerland
| | - Christian Benden
- . Department of Pulmonology, University Hospital of Zurich, Zurich, Switzerland
| | - Christoph Schmid
- . Department of Endocrinology, University Hospital of Zurich, Zurich, Switzerland
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Analysis of Bone Metabolism in Children with Cystic Fibrosis. Pril (Makedon Akad Nauk Umet Odd Med Nauki) 2018; 39:151-155. [PMID: 30110271 DOI: 10.2478/prilozi-2018-0035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Abstract
One of the most important CF-related conditions is the bone disease, which is nowadays acknowledged as a significant clinical complication of CF. Imbalance between bone formation and degradation in cystic fibrosis (CF) has become an important issue for developing osteopenia. The aim of the study was to assess bone formation and resorption process with bone markers in children with cystic fibrosis (CF). Materials and methods: The study included 35 clinically stable children with CF who regularly attended the Cystic fibrosis center at the University Pediatric Clinic in Skopje, R. Macedonia. The control group was presented with 21 healthy children at the same age. Serum osteocalcin (OC), β cross laps, 25OHD and PTH were determined by ELISA assays in the CF group (mean age 8.25±SD1.9 y.) and in age-match controls (7.5±1.9 y.). Results: Vitamin D in the CF group was (23.83±10.9 ng/ml versus 25.6±11.53 in the control group, p=0.57), OC (70.88±34.24 ng/ml v.100.02±47.98, p=0.01) βcrosslaps (1.35±0.72 ng/ml v.1.54±0.73, p=0.37) and PTH (37.39±25.5 pg/ml v. 36.76±25.73, p=0.92). In the study, we did not find a significant difference for 25OHD between CF and healthy controls. OC in children with CF correlates significantly with the control and indicates a decreased formation rate whereas resorption rate is normal. Conclusion: Our results suggest that bone turnover in CF is impaired in childhood. Serum markers for bone formation can be used for predicting osteopenia in children with CF.
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Nishiyama KK, Agarwal S, Kepley A, Rosete F, Hu Y, Guo XE, Keating CL, DiMango EA, Shane E. Adults with cystic fibrosis have deficits in bone structure and strength at the distal tibia despite similar size and measuring standard and relative sites. Bone 2018; 107:181-187. [PMID: 29154969 DOI: 10.1016/j.bone.2017.11.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 10/25/2017] [Accepted: 11/13/2017] [Indexed: 11/30/2022]
Abstract
Individuals with cystic fibrosis (CF) have lower bone mineral density (BMD) by DXA and are at higher risk of fracture than healthy controls. However, the 2-dimensional measurement of areal BMD (aBMD) provided by DXA is influenced by bone size and the true extent of the bone deficit is unclear. Our objective was to use high-resolution peripheral quantitative computed tomography (HR-pQCT) and individual trabecula segmentation (ITS) analysis to compare volumetric BMD (vBMD), microarchitecture and estimated strength at the distal radius and tibia in 26 young adults with CF and 26 controls matched for age, gender, and race. To assess the effect of limb length and minimize the confounding effects of size on HR-pQCT outcomes, we scanned participants at both the standard fixed HR-pQCT measurement sites and at a subject-specific relative site that varied according to limb length. CF participants did not differ significantly in age, height, weight, or BMI from controls. Ulnar and tibial lengths were 9mm shorter in CF patients, though differences were not significant. CF patients had significantly lower BMI-adjusted aBMD by DXA at the lumbar spine (8.9%, p<0.01), total hip (11.5%, p<0.01) and femoral neck (14.5%, p<0.01), but not at the forearm. At the fixed radius site, thickness of trabecular plates and torsional stiffness were significantly lower in CF participants than controls. At the relative radius site, only torsional stiffness was significantly lower in CF participants. At the tibia, total, trabecular and cortical vBMD were significantly lower at both fixed and relative sites in CF participants, with fewer, more widely-spaced trabecular plates, lower trabecular connectivity, and lower axial and torsional stiffness. Our results confirm that aBMD is lower at the spine and hip in young adults with CF, independent of BMI and body size. We also conclude that vBMD and stiffness are lower at the weight-bearing tibia. The pathogenesis of these differences in bone density and strength at the tibia appear to be related to trabecular drop-out and reduced trabecular connectivity and to be independent of differences in limb length, as assessed by scanning participants at both standard and relative sites. We concluded that significant deficits in bone structure and strength persist in young adults with CF, despite advances in care that permit them to attain relatively normal height and weight.
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Affiliation(s)
- Kyle K Nishiyama
- Division of Endocrinology, Department of Medicine, Columbia University, New York, NY, United States
| | - Sanchita Agarwal
- Division of Endocrinology, Department of Medicine, Columbia University, New York, NY, United States.
| | - Anna Kepley
- Division of Endocrinology, Department of Medicine, Columbia University, New York, NY, United States
| | - Fernando Rosete
- Division of Endocrinology, Department of Medicine, Columbia University, New York, NY, United States.
| | - Yizhong Hu
- Department of Biomedical Engineering, Columbia University, New York, NY, United States.
| | - X Edward Guo
- Department of Biomedical Engineering, Columbia University, New York, NY, United States.
| | - Claire L Keating
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University, New York, NY, United States.
| | - Emily A DiMango
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University, New York, NY, United States.
| | - Elizabeth Shane
- Division of Endocrinology, Department of Medicine, Columbia University, New York, NY, United States.
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14
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Multiple prevalent fractures in relation to macroscopic bone architecture in patients with cystic fibrosis. J Cyst Fibros 2018; 17:114-120. [DOI: 10.1016/j.jcf.2016.06.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 05/31/2016] [Accepted: 06/06/2016] [Indexed: 11/20/2022]
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Braun C, Bacchetta J, Braillon P, Chapurlat R, Drai J, Reix P. Children and adolescents with cystic fibrosis display moderate bone microarchitecture abnormalities: data from high-resolution peripheral quantitative computed tomography. Osteoporos Int 2017; 28:3179-3188. [PMID: 28795206 DOI: 10.1007/s00198-017-4179-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 07/25/2017] [Indexed: 12/15/2022]
Abstract
UNLABELLED We investigated whether bone microstructure assessed by high-resolution peripheral quantitative tomography (HR-pQCT) could be altered in children and teenagers with cystic fibrosis (CF). In comparison to their healthy counterparts, bone microstructure was mildly affected at the tibial level only. INTRODUCTION Cystic fibrosis-related bone disease (CFBD) may alter bone health, ultimately predisposing patients to bone fractures. Our aim was to assess bone microstructure using high-resolution peripheral quantitative tomography (HR-pQCT) in a cohort of children and teenagers with CF in comparison to age-, puberty-, and gender-matched healthy volunteers (HVs). METHODS In this single-center, prospective, cross-sectional study, we evaluated the HR-pQCT bone parameters of CF patients and compared them to those of the healthy volunteers. RESULTS At a median age of 15.4 [range, 10.5-17.9] years, 37 CF patients (21 boys) with 91% [range, 46-138%] median forced expiratory volume in 1 s were included. At the ultradistal tibia, CF patients had a smaller bone cross-sectional area (579 [range, 399-1087] mm2) than HVs (655 [range, 445-981] mm2) (p = 0.027), related to a decreased trabecular area, without any significant differences for height. No other differences were found (trabecular number, separation, thickness, or distribution) at the radial or tibial levels. Bone structure was different in patients receiving ursodeoxycholic acid and those bearing two F508del mutations. CONCLUSION In our cohort of children and teenagers with good nutritional and lung function status, bone microstructure evaluated with HR-pQCT was not severely affected. Minimal microstructure abnormalities observed at the tibial level may be related to the cystic fibrosis transmembrane conductance regulator defect alone; the long-term consequences of such impairment will require further evaluation.
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Affiliation(s)
- C Braun
- Pediatric Cystic Fibrosis Center, Hospices Civils de Lyon, Lyon, France.
- University Claude-Bernard Lyon 1, Lyon, France.
- Centre de Ressources et de Compétences de la Mucoviscidose, Hôpital Femme Mère Enfant, 69677, Bron, France.
| | - J Bacchetta
- University Claude-Bernard Lyon 1, Lyon, France
- INSERM UMR 1033, Lyon, France
- Rare Renal Diseases Reference Center Néphrogones, Hospices Civils de Lyon, Lyon, France
| | - P Braillon
- University Claude-Bernard Lyon 1, Lyon, France
- Pediatric Radiology Department, Hospices Civils de Lyon, Lyon, France
| | - R Chapurlat
- University Claude-Bernard Lyon 1, Lyon, France
- INSERM UMR 1033, Lyon, France
- Pediatric Radiology Department, Hospices Civils de Lyon, Lyon, France
| | - J Drai
- Rheumatology Department, Hospices Civils de Lyon, Lyon, France
| | - P Reix
- Pediatric Cystic Fibrosis Center, Hospices Civils de Lyon, Lyon, France
- University Claude-Bernard Lyon 1, Lyon, France
- Biochemistry Department, Hospices Civils de Lyon, Lyon, France
- UMR 5558 (EMET). CNRS, LBBE, Université de Lyon, Villeurbanne, France
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Mailhot G, Dion N, Farlay D, Rizzo S, Bureau NJ, Jomphe V, Sankhe S, Boivin G, Lands LC, Ferraro P, Ste-Marie LG. Impaired rib bone mass and quality in end-stage cystic fibrosis patients. Bone 2017; 98:9-17. [PMID: 28254466 DOI: 10.1016/j.bone.2017.02.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 02/13/2017] [Accepted: 02/20/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Advancements in research and clinical care have considerably extended the life expectancy of cystic fibrosis (CF) patients. However, with this extended survival come comorbidities. One of the leading co-morbidities is CF-related bone disease (CFBD), which progresses with disease severity and places patients at high risk for fractures, particularly of the ribs and vertebrae. Evidence that CF patients with vertebral fractures had higher bone mineral density (BMD) than the nonfracture group led us to postulate that bone quality is impaired in these patients. We therefore examined rib specimens resected at the time of lung transplant in CF patients to measure parameters of bone quantity and quality. METHODS In this exploratory study, we analysed 19 end-stage CF and 13 control rib specimens resected from otherwise healthy lung donors. BMD, bone microarchitecture, static parameters of bone formation and resorption and microcrack density of rib specimens were quantified by imaging, histomorphometric and histological methods. Variables reflecting the mineralization of ribs were assessed by digitized microradiography. The degree of bone mineralization (g/cm3) and the heterogeneity index of the mineralization (g/cm3) were calculated for trabecular and cortical bone. RESULTS Compared to controls, CF ribs exhibited lower areal and trabecular volumetric BMD, decreased trabecular thickness and osteoid parameters, and increased microcrack density, that was particularly pronounced in specimens from patients with CF-related diabetes. Static parameters of bone resorption were similar in both groups. Degree of mineralization of total bone, but not heterogeneity index, was increased in CF specimens. CONCLUSION The combination of reduced bone mass, altered microarchitecture, imbalanced bone remodeling (maintained bone resorption but decreased formation), increased microdamage and a small increase of the degree of mineralization, may lead to decreased bone strength, which, when coupled with chronic coughing and chest physical therapy, may provide an explanation for the increased incidence of rib fractures previously reported in this population.
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Affiliation(s)
- Geneviève Mailhot
- Research Centre, CHU Sainte-Justine, 3175 Cote Sainte-Catherine Rd, Montreal, Québec H3T 1C5, Canada; Department of Nutrition, Faculty of Medicine, Université de Montreal, 2405 Cote Sainte-Catherine Rd, Montreal, Québec H3T 1A8, Canada.
| | - Natalie Dion
- Department of Pathology, Centre Hospitalier de l'Université de Montréal, 1058 St-Denis Street, Montreal, Québec H2X 3J4, Canada.
| | - Delphine Farlay
- INSERM, UMR 1033, Univ Lyon, Université Claude Bernard Lyon 1, F69008 Lyon, France.
| | - Sébastien Rizzo
- INSERM, UMR 1033, Univ Lyon, Université Claude Bernard Lyon 1, F69008 Lyon, France.
| | - Nathalie J Bureau
- Research Center, Centre Hospitalier de l'Université de Montréal, 1058 St-Denis Street, Montreal, Québec H2X 3J4, Canada; Department of Radiology, Faculty of Medicine, Université de Montreal, 2900, Boulevard Édouard-Montpetit, Montréal, Québec H3T 1J4, Canada.
| | - Valérie Jomphe
- Lung transplant Program, Centre Hospitalier de l'Université de Montréal, 1560 Sherbrooke East Street, Montreal, Québec H2L 4M1, Canada.
| | - Safiétou Sankhe
- Research Centre, CHU Sainte-Justine, 3175 Cote Sainte-Catherine Rd, Montreal, Québec H3T 1C5, Canada.
| | - Georges Boivin
- INSERM, UMR 1033, Univ Lyon, Université Claude Bernard Lyon 1, F69008 Lyon, France.
| | - Larry C Lands
- Department of Pediatrics, Montreal Children's Hospital-McGill University Health Centre, Meakins Christie Laboratories, Research Institute of the McGill University Health Centre, 1001 Décarie Boulevard, Montreal, Québec H4A 3J1, Canada; Respiratory Medicine, Centre Hospitalier de l'Universite de Montreal, 1560 Sherbrooke East Street, Montreal, Québec H2L 4M1, Canada.
| | - Pasquale Ferraro
- Research Center, Centre Hospitalier de l'Université de Montréal, 1058 St-Denis Street, Montreal, Québec H2X 3J4, Canada; Lung transplant Program, Centre Hospitalier de l'Université de Montréal, 1560 Sherbrooke East Street, Montreal, Québec H2L 4M1, Canada; Division of Thoracic Surgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal, 1058 St-Denis Street, Montreal, Québec H2X 3J4, Canada.
| | - Louis-Georges Ste-Marie
- Department of Medicine, Centre Hospitalier de l'Université de Montréal, 1058 St-Denis Street, Montreal, Québec H2X 3J4, Canada.
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Gensburger D, Boutroy S, Chapurlat R, Nove-Josserand R, Roche S, Rabilloud M, Durieu I. Reduced bone volumetric density and weak correlation between infection and bone markers in cystic fibrosis adult patients. Osteoporos Int 2016; 27:2803-2813. [PMID: 27165286 DOI: 10.1007/s00198-016-3612-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 04/20/2016] [Indexed: 02/05/2023]
Abstract
UNLABELLED In our current adult CF population, low BMD prevalence was only 20 %, lower than that historically described. We found a mild increase of serum RANK-L levels, independent from the bone resorption level. The increased fracture risk in CF may be explained by a lower tibial cortical thickness and total vBMD. INTRODUCTION Bone disease is now well described in cystic fibrosis (CF) adult patients. CF bone disease is multifactorial but many studies suggested the crucial role of inflammation. The objectives of this study were, in a current adult CF population, to assess the prevalence of bone disease, to examine its relationship with infections and inflammation, and to characterize the bone microarchitecture using high resolution peripheral scanner (HR-pQCT). METHODS Fifty-six patients (52 % men, 26 ± 7 years) were assessed in clinically stable period, during a respiratory infection, and finally 14 days after the end of antibiotic therapy. At each time points, we performed a clinical evaluation, lung function tests, and biochemical tests. Absorptiometry and dorso-lumbar radiographs were also performed. A subgroup of 40 CF patients (63 % men, 29 ± 6 years) underwent bone microarchitecture assessment and was age- and gender-matched with 80 healthy controls. RESULTS Among the 56 CF patients, the prevalence of low areal BMD (T-score < -2 at any site), was 20 % (95 % CI: [10.2 %; 32.4 %]). After infections, serum RANK-L (+24 %, p = 0.08) and OPG (+13 %, p = 0.04) were increased with a stable ratio. Microarchitectural differences were mostly observed at the distal tibia, with lower total and cortical vBMD and trabecular thickness (respectively -9.9, -3.0, and -5 %, p < 0.05) in CF patients compared to controls, after adjustment for age, gender, weight, and height. CONCLUSIONS In this study, bone disease among adult CF patients was less severe than that previously described with only 20 % of CF patients with low BMD. We found a mild increase of biological marker levels and an impaired volumetric density of the tibia that may explain the increased fracture risk in CF population.
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Affiliation(s)
- D Gensburger
- INSERM UMR 1033, Université de Lyon, Lyon, France.
- Department of Rheumatology, Hôpital E. Herriot, Hospices Civils de Lyon, Lyon, France.
| | - S Boutroy
- INSERM UMR 1033, Université de Lyon, Lyon, France
| | - R Chapurlat
- INSERM UMR 1033, Université de Lyon, Lyon, France
- Department of Rheumatology, Hôpital E. Herriot, Hospices Civils de Lyon, Lyon, France
| | - R Nove-Josserand
- Cystic Fibrosis Adult Reference Centre, Department of Internal Medicine, Université de Lyon, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, France
| | - S Roche
- Department of Biostatistique, Hospices Civils de Lyon; Université de Lyon. Université Lyon 1, CNRS UMR558, Laboratoire de Biométrie et Biologie évolutive, Equipe Biostatistique-Santé, Villeurbanne, France
| | - M Rabilloud
- Department of Biostatistique, Hospices Civils de Lyon; Université de Lyon. Université Lyon 1, CNRS UMR558, Laboratoire de Biométrie et Biologie évolutive, Equipe Biostatistique-Santé, Villeurbanne, France
| | - I Durieu
- Cystic Fibrosis Adult Reference Centre, Department of Internal Medicine, Université de Lyon, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, France
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Putman MS, Greenblatt LB, Sicilian L, Uluer A, Lapey A, Sawicki G, Gordon CM, Bouxsein ML, Finkelstein JS. Young adults with cystic fibrosis have altered trabecular microstructure by ITS-based morphological analysis. Osteoporos Int 2016; 27:2497-505. [PMID: 26952010 PMCID: PMC4947435 DOI: 10.1007/s00198-016-3557-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 03/01/2016] [Indexed: 01/22/2023]
Abstract
UNLABELLED Young adults with cystic fibrosis have compromised plate-like trabecular microstructure, altered axial alignment of trabeculae, and reduced connectivity between trabeculae that may contribute to the reduced bone strength and increased fracture risk observed in this patient population. INTRODUCTION The risk of fracture is increased in patients with cystic fibrosis (CF). Individual trabecular segmentation (ITS)-based morphological analysis of high-resolution peripheral quantitative computed tomography (HR-pQCT) images segments trabecular bone into individual plates and rods of different alignment and connectivity, which are important determinants of trabecular bone strength. We sought to determine whether alterations in ITS variables are present in patients with CF and may help explain their increased fracture risk. METHODS Thirty patients with CF ages 18-40 years underwent DXA scans of the hip and spine and HR-pQCT scans of the radius and tibia with further assessment of trabecular microstructure by ITS. These CF patients were compared with 60 healthy controls matched for age (±2 years), race, and gender. RESULTS Plate volume fraction, thickness, and density as well as plate-plate and plate-rod connectivity were reduced, and axial alignment of trabeculae was lower in subjects with CF at both the radius and the tibia (p < 0.05 for all). At the radius, adjustment for BMI eliminated most of these differences. At the tibia, however, reductions in plate volume fraction and number, axially aligned trabeculae, and plate-plate connectivity remained significant after adjustment for BMI alone and for BMI and aBMD (p < 0.05 for all). CONCLUSIONS Young adults with CF have compromised plate-like and axially aligned trabecular morphology and reduced connectivity between trabeculae. ITS analysis provides unique information about bone integrity, and these trabecular deficits may help explain the increased fracture risk in adults with CF not accounted for by BMD and/or traditional bone microarchitecture measurements.
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Affiliation(s)
- M S Putman
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital, 50 Blossom Street, THR-1051, Boston, MA, 02114, USA.
- Division of Endocrinology, Boston Children's Hospital, Boston, MA, USA.
| | - L B Greenblatt
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital, 50 Blossom Street, THR-1051, Boston, MA, 02114, USA
| | - L Sicilian
- Pulmonary Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - A Uluer
- Division of Respiratory Diseases, Boston Children's Hospital, Boston, MA, USA
| | - A Lapey
- Pulmonary Division, Department of Pediatrics, Massachusetts General Hospital, Boston, MA, USA
| | - G Sawicki
- Division of Respiratory Diseases, Boston Children's Hospital, Boston, MA, USA
| | - C M Gordon
- Division of Adolescent and Transition Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - M L Bouxsein
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital, 50 Blossom Street, THR-1051, Boston, MA, 02114, USA
- Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Orthopedic Surgery, Harvard Medical School, Boston, MA, USA
| | - J S Finkelstein
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital, 50 Blossom Street, THR-1051, Boston, MA, 02114, USA
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Braun C, Bacchetta J, Reix P. [Insights into cystic fibrosis-related bone disease]. Arch Pediatr 2016; 23:857-66. [PMID: 27345551 DOI: 10.1016/j.arcped.2016.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 03/17/2016] [Accepted: 05/11/2016] [Indexed: 02/04/2023]
Abstract
With the increasing life expectancy of patients with cystic fibrosis (CF), prevalence of late complications such as CF-related bone disease (CFBD) has increased. It was initially described in 24% of the adult population with CF and has also been reported in the pediatric population. CFBD is multifactorial and progresses in different steps. Both decreased bone formation and increased bone resorption (in different amounts) are observed. CFBD is likely primitive (directly related to the CFTR defect itself), but is also worsened by acquired secondary factors such as lung infections, chronic inflammation, denutrition, vitamin deficiency, and decreased physical activity. CFBD may be clinically apparent (i.e., mainly vertebral and costal fractures), or clinically asymptomatic (therefore corresponding to abnormalities in bone density and architecture). CFBD management mainly aims to prevent the occurrence of fractures. Prevention and regular monitoring of bone disease as early as 8 years of age is of the utmost importance, as is the control of possible secondary deleterious CFBD factors. New radiological tools, such as high-resolution peripheral quantitative computed tomography, allow an accurate evaluation of cortical and trabecular bone micro-architecture in addition to compartmental density; as such, they will likely improve the assessment of the bone fracture threat in CF patients in the near future.
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Affiliation(s)
- C Braun
- Université Claude-Bernard Lyon 1, 43, boulevard du 11-Novembre-1918, 69100 Villeurbanne, France
| | - J Bacchetta
- Université Claude-Bernard Lyon 1, 43, boulevard du 11-Novembre-1918, 69100 Villeurbanne, France; Centre de référence des maladies rénales rares, hôpital femme mère enfant, 69500 Bron, France; Inserm 1033 LYOS, prévention des maladies osseuses, 69008 Lyon, France
| | - P Reix
- Université Claude-Bernard Lyon 1, 43, boulevard du 11-Novembre-1918, 69100 Villeurbanne, France; Centre de ressources et de compétences de la mucoviscidose, hôpital femme mère enfant, 69500 Bron, France; UMR 5558, équipe EMET, 43, boulevard du 11-Novembre-1918, 69100 Villeurbanne, France.
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Oei L, Zillikens MC, Rivadeneira F, Oei EHG. Osteoporotic Vertebral Fractures as Part of Systemic Disease. J Clin Densitom 2016; 19:70-80. [PMID: 26376171 DOI: 10.1016/j.jocd.2015.08.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 08/13/2015] [Indexed: 12/31/2022]
Abstract
Our understanding of the genetic control of skeletogenesis and bone remodeling is expanding, and normally, bone resorption and bone formation are well balanced through regulation by hormones, growth factors, and cytokines. Osteoporosis is considered a systemic disease characterized by low bone mass and microarchitectural deterioration of bone tissue. Consequent increased bone fragility results in higher fracture risk. The most common osteoporotic fractures are located in the spine, and they form a significant health issue. A large variety of systemic diseases are associated with risk of osteoporotic vertebral fractures, illustrating its multifactorial etiology. Prevalences of these conditions vary from common to extremely rare, and incidence peaks differ according to etiology. This review appreciates different aspects of osteoporotic vertebral fractures as part of systemic disease, including genetic, immunologic, inflammatory, metabolic, and endocrine pathways. It seems impossible to be all-comprehensive on this topic; nevertheless, we hope to provide a reasonably thorough overview. Plenty remains to be elucidated in this field, identifying even more associated diseases and further exposing pathophysiological mechanisms underlying osteoporotic vertebral fractures.
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Affiliation(s)
- Ling Oei
- Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands; Department of Epidemiology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands; Netherlands Genomics Initiative-sponsored Netherlands Consortium for Healthy Aging, The Netherlands; Department of Internal Medicine, IJsselland Hospital, Capelle aan den IJssel, The Netherlands
| | - M Carola Zillikens
- Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands; Netherlands Genomics Initiative-sponsored Netherlands Consortium for Healthy Aging, The Netherlands
| | - Fernando Rivadeneira
- Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands; Department of Epidemiology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands; Netherlands Genomics Initiative-sponsored Netherlands Consortium for Healthy Aging, The Netherlands
| | - Edwin H G Oei
- Department of Radiology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.
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Putman MS, Baker JF, Uluer A, Herlyn K, Lapey A, Sicilian L, Tillotson AP, Gordon CM, Merkel PA, Finkelstein JS. Trends in bone mineral density in young adults with cystic fibrosis over a 15 year period. J Cyst Fibros 2015; 14:526-32. [PMID: 25698451 PMCID: PMC4485936 DOI: 10.1016/j.jcf.2015.01.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Revised: 12/11/2014] [Accepted: 01/30/2015] [Indexed: 10/24/2022]
Abstract
BACKGROUND Improvements in clinical care have led to increased life expectancy in patients with cystic fibrosis (CF) over the past several decades. Whether these improvements have had significant effects on bone health in patients with CF is unclear. METHODS This is a cross-sectional study comparing clinical characteristics and bone mineral density (BMD) measured by dual energy X-ray absorptiometry (DXA) in adults with CF evaluated in 1995-1999 to age-, race-, and gender-matched patients with CF evaluated in 2011-2013 at the same center on calibrated DXA machines. RESULTS The cohorts were similar in terms of age, BMI, pancreatic insufficiency, presence of F508del mutation, and reproductive history. In the most recent cohort, pulmonary function was superior, and fewer patients had vitamin D deficiency or secondary hyperparathyroidism. Areal BMD measures of the PA spine, lateral spine, and distal radius were similarly low in the two cohorts. CONCLUSIONS Although pulmonary function and vitamin D status were better in patients in the present-day cohort, areal BMD of the spine was reduced in a significant number of patients and was no different in patients with CF today than in the late 1990s. Further attention to optimizing bone health may be necessary to prevent CF-related bone disease.
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Affiliation(s)
- Melissa S Putman
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States; Division of Endocrinology, Boston Children's Hospital, Boston, MA, United States.
| | - Joshua F Baker
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, United States
| | - Ahmet Uluer
- Division of Respiratory Diseases, Boston Children's Hospital, Boston, MA, United States
| | - Karen Herlyn
- Poliklinik fuer Rheumatologie, University Hospital Schleswig-Holstein, Campus Luebeck, Germany
| | - Allen Lapey
- Pulmonary Division, Department of Pediatrics, Massachusetts General Hospital, Boston, MA, United States
| | - Leonard Sicilian
- Pulmonary Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
| | | | - Catherine M Gordon
- Division of Endocrinology, Boston Children's Hospital, Boston, MA, United States; Divisions of Adolescent Medicine and Endocrinology, Hasbro Children's Hospital, Providence, RI, United States
| | - Peter A Merkel
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, United States
| | - Joel S Finkelstein
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
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Brookes DSK, Briody JN, Munns CF, Davies PSW, Hill RJ. Cystic fibrosis-related bone disease in children: Examination of peripheral quantitative computed tomography (pQCT) data. J Cyst Fibros 2015; 14:668-77. [PMID: 25957706 DOI: 10.1016/j.jcf.2015.04.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 04/02/2015] [Accepted: 04/20/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND The investigation of skeletal health data beyond dual X-ray absorptiometry (DXA) is limited in young individuals with CF. We assessed volumetric bone mineral densities (BMD), and bone and muscle parameters using peripheral quantitative computed tomography (pQCT) in individuals with CF and controls, 7.00-17.99 years. METHODS Peripheral QCT (XCT 3000, Stratec) measurements were made in 53 individuals with CF and 53 controls. Bone mineral content (BMC), total volumetric BMD (vBMD) and cross sectional area (CSA) of the bone were measured at the 4% and 66% sites of the non-dominant tibia and radius. Additionally, trabecular vBMD and bone strength index (BSIc) were measured at the 4% sites, and cortical vBMD, muscle CSA (mCSA) and strength strain index (SSI) were measured at the 66% sites. RESULTS Pre-pubertal males with CF had greater trabecular vBMD (p=0.01) and total vBMD (p=0.00) at 4% tibia, and greater total vBMD (p=0.02) at 4% radius. Pre-pubertal females with CF had greater total vBMD at 66% tibia (p=0.02) and radius (p=0.04), and cortical vBMD (p=0.04) at the radius. At puberty, the CF cohort had less BMC at 4% tibia (males, p=0.02; females, p=0.01), and smaller mCSA at 66% tibia (males, p=0.02; females, p=0.01). Pubertal CF females had a smaller bone CSA (p=0.01) at 4% tibia, and lower bone strength (SSI) at the tibia (p=0.00) and radius (p=0.05) sites. CONCLUSIONS Bone strength parameters were not compromised prior to puberty in this CF cohort. At puberty, the bone phenotype changed for this CF cohort, showing several deficits compared to the controls. However, bone strength was adapting to the mechanical demands of the muscle. Altered bone parameters and their implications for lowered bone strength with increased age may be greatly influenced by: the CF cohort remaining smaller for age and/or a reduced bone strain, secondary to reduced muscle force.
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Affiliation(s)
- Denise S K Brookes
- The University of Queensland, Queensland Children's Medical Research Institute, Children's Nutrition Research Centre, Brisbane, Australia; The University of Queensland, School of Medicine, Brisbane, Australia.
| | | | - Craig F Munns
- The Children's Hospital at Westmead, Sydney, Australia; University of Sydney, School of Medicine, Sydney, Australia
| | - Peter S W Davies
- The University of Queensland, Queensland Children's Medical Research Institute, Children's Nutrition Research Centre, Brisbane, Australia; The University of Queensland, School of Medicine, Brisbane, Australia
| | - Rebecca J Hill
- The University of Queensland, Queensland Children's Medical Research Institute, Children's Nutrition Research Centre, Brisbane, Australia; The University of Queensland, School of Medicine, Brisbane, Australia
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Putman MS, Milliren CE, Derrico N, Uluer A, Sicilian L, Lapey A, Sawicki G, Gordon CM, Bouxsein ML, Finkelstein JS. Compromised bone microarchitecture and estimated bone strength in young adults with cystic fibrosis. J Clin Endocrinol Metab 2014; 99:3399-407. [PMID: 24926955 PMCID: PMC4154107 DOI: 10.1210/jc.2014-1982] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Young adults with cystic fibrosis (CF) are at risk for low bone density and fractures, but the underlying alterations in bone microarchitecture that may contribute to their increased fracture risk are currently unknown. OBJECTIVE The main goal of this study was to use high-resolution peripheral quantitative computed tomography (HR-pQCT) to characterize the bone microarchitecture, volumetric bone mineral density (vBMD), and estimated strength of the radius and tibia in young adults with CF compared with healthy volunteers. DESIGN AND SETTING This was a cross-sectional study at an outpatient clinical research center within a tertiary academic medical center. PARTICIPANTS Thirty young adults with CF, 18 to 40 years of age, were evaluated and compared with 60 healthy volunteers matched by age (±2 years), gender, and race. MAIN OUTCOME MEASURES The primary outcomes were HR-pQCT-derived cortical and trabecular vBMD, bone microarchitecture, and estimates of bone strength. RESULTS At the radius and tibia, young adults with CF had smaller bone cross-sectional area and lower vBMD. Cortical and trabecular microarchitecture were compromised at both sites, most notably involving the trabecular bone of the tibia. These differences translated into lower estimated bone strength both at the radius and tibia. After accounting for body mass index differences, young adults with CF had lower bone area and estimated bone strength at the radius and had compromised trabecular microarchitecture and lower total and trabecular vBMD and estimated bone strength at the tibia. Alterations in trabecular bone density and microarchitecture and estimated strength measures of the tibia were also greater than expected based on dual-energy x-ray absorptiometry-derived areal BMD differences. CONCLUSIONS Young adults with CF have compromised bone microarchitecture and lower estimated bone strength at both the radius and tibia, even after accounting for their smaller body size. These skeletal deficits likely explain the higher fracture risk observed in young adults with CF.
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Affiliation(s)
- Melissa S Putman
- Endocrine Unit (M.S.P., N.D., M.L.B., J.S.F.), and Pulmonary Division (L.S.), Department of Medicine, Massachusetts General Hospital; Pulmonary Division (A.L.), Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts 02114; Divisions of Endocrinology (M.S.P., C.M.G.) and Respiratory Diseases (A.U., G.S.) and Clinical Research Center (C.E.M.), Boston Children's Hospital, Boston, Massachusetts 02115; and Divisions of Adolescent Medicine and Endocrinology (C.M.G.), Hasbro Children's Hospital, Providence, Rhode Island 02903
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Cystic fibrosis-related bone disease explored using a four step algorithm. J Cyst Fibros 2014; 14:127-34. [PMID: 25169790 DOI: 10.1016/j.jcf.2014.07.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 06/24/2014] [Accepted: 07/24/2014] [Indexed: 11/21/2022]
Abstract
BACKGROUND A suboptimal bone accrual in young individuals with cystic fibrosis (CF) may be related to the development of a premature CF-related bone disease. Dual energy X-ray absorptiometry (DXA) is the mainstream measure of bone health; however, the influence of body size and lean tissue mass (LTM) on bone data is poorly interpreted. METHODS Total body dual-energy X-ray absorptiometry (DXA) measurements of bone mineral content (BMC) and LTM in 53 individuals with CF (7.00-17.99years) were compared to 53 sex-matched controls. BMC, height, and LTM in relation to height and BMC Z-scores were calculated and used in a 4-step algorithm. RESULTS Pubertal females with CF had less total body BMC for age (p=0.02); pre-pubertal males (p=0.05) and pubertal females with CF (p=0.03) were shorter; and pubertal females with CF showed less total body BMC for LTM (p=0.01). CONCLUSIONS The algorithm showed the following: (1) prior to puberty lowered total body BMC was primarily due to short stature, (2) LTM was appropriate for body size, and (3) pubertal females with CF had significantly less total body BMC for their LTM. Longer controlled trials are needed to clinically interpret CF-related bone disease using DXA derived data that considers patient size and body composition.
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Vanacor R, Raimundo FV, Marcondes NA, Corte BP, Ascoli AM, Azambuja AZD, Scopel L, Santos PVD, Dalcin PTR, Faulhaber GAM, Furlanetto TW. Prevalence of low bone mineral density in adolescents and adults with cystic fibrosis. Rev Assoc Med Bras (1992) 2014; 60:53-8. [PMID: 24918853 DOI: 10.1590/1806-9282.60.01.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Accepted: 07/01/2013] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE The aim of this cross-sectional study was to evaluate the prevalence of low bone mass density in cystic fibrosis patients as well as to evaluate the factors associated with bone mass in such patients. METHODS Bone mass density was measured by dual-photon X-ray absorptiometry of lumbar spine (L1-L4), in patients ≤19 years old, or lumbar spine and femur (total and neck) in patients ≥20 years old. Evaluations of nutritional status, biochemical parameters, and lung function were performed. Medication data were obtained from medical records. RESULTS Fifty-eight patients were included in the study (25 males/ 33 females), mean age 23.9 years (16-53 years). The prevalence of bone mass below the expected range for age at any site was 20.7%. None of the subjects had history of fracture. Lumbar spine Z-score in cystic fibrosis patients correlated positively with body mass index (r= 0.3, p=0.001), and forced expiratory volume in the first second (% predicted) (r=0.415, p=0.022). Mean lumbar spine Z-score was higher in women (p=0.001), in patients with no pancreatic insufficiency (p=0.032), and in patients with no hospitalization in the last 3 months (p=0.02). After multivariate analysis, body mass index (p= 0.001) and sex (p=0.001) were independently associated with Z-score in lumbar spine. CONCLUSION Low bone mass is a frequent problem in patients with CF, being independently associated with body mass index, and male sex.
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Affiliation(s)
- Roberta Vanacor
- Postgraduate Program, Medicine, Medical Sciences, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Fabiana V Raimundo
- Postgraduate Program, Medicine, Medical Sciences, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Natália A Marcondes
- Postgraduate Program, Medicine, Medical Sciences, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Bruno P Corte
- Division of Internal Medicine, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Aline M Ascoli
- Division of Internal Medicine, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Aline Z de Azambuja
- Division of Internal Medicine, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Luciano Scopel
- Division of Internal Medicine, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Patrícia V Dos Santos
- Division of Internal Medicine, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Paulo T R Dalcin
- Division of Pneumology, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Gustavo A M Faulhaber
- Division of Internal Medicine, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Tânia W Furlanetto
- Division of Internal Medicine, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
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Neuringer IP, Noone P, Cicale RK, Davis K, Aris RM. Managing complications following lung transplantation. Expert Rev Respir Med 2012; 3:403-23. [PMID: 20477331 DOI: 10.1586/ers.09.27] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Lung transplantation has become a proven therapeutic option for patients with end-stage lung disease, extending life and providing improved quality of life to those who otherwise would continue to be breathless and oxygen-dependent. Over the past 20 years, considerable experience has been gained in understanding the multitude of medical and surgical issues that impact upon patient survival. Today, clinicians have an armamentarium of tools to manage diverse problems such as primary graft dysfunction, acute and chronic allograft rejection, airway anastomotic issues, infectious complications, renal dysfunction, diabetes and osteoporosis, hematological and gastrointestinal problems, malignancy, and other unique issues that confront immunosuppressed solid organ transplant recipients.
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Affiliation(s)
- Isabel P Neuringer
- Division of Pulmonary and Critical Care Medicine and the Cystic Fibrosis/Pulmonary Research and Treatment Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7524, USA.
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Lopez-Rodriguez MJ, Lavado-Garcia JM, Canal-Macias ML, Calderon-Garcia JF, Moran JM, Pedrera-Zamorano JD. Quantitative Ultrasound in Spanish Children and Young Adults With Cystic Fibrosis. Biol Res Nurs 2012; 15:280-4. [DOI: 10.1177/1099800412441500] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We studied the relationship between bone density and cystic fibrosis in Spanish children and young adults. We measured the phalangeal bone amplitude-dependent speed of sound (Ad-SoS) in 35 patients with cystic fibrosis and in 30 healthy controls matched for gender, age, and body mass index (BMI). Participants were subjects with normal levels of 25(OH) Vitamin D. We found no difference in Ad-SoS between patients and controls. The only difference between the groups was that the patients had a significantly higher daily caloric intake than the controls ( p < .05) as a result of the patient group's greater intake of fats ( p < .05). There was a positive correlation between Ad-SoS and weight ( p < .0001), but after adjusting for potential confounding factors such as age, the correlation was lost. The percentage of ideal weight did not differ between the two groups. We conclude that well-nourished CF patients had similar Ad-SoS to controls.
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Affiliation(s)
| | - Jesus M. Lavado-Garcia
- Metabolic Bone Diseases Research Group, School of Nursing, University of Extremadura, Caceres, Spain
| | - Maria L. Canal-Macias
- Metabolic Bone Diseases Research Group, School of Nursing, University of Extremadura, Caceres, Spain
| | - Julian F. Calderon-Garcia
- Metabolic Bone Diseases Research Group, School of Nursing, University of Extremadura, Caceres, Spain
| | - Jose M. Moran
- Metabolic Bone Diseases Research Group, School of Nursing, University of Extremadura, Caceres, Spain
| | - Juan D. Pedrera-Zamorano
- Metabolic Bone Diseases Research Group, School of Nursing, University of Extremadura, Caceres, Spain
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Legroux-Gérot I, Leroy S, Prudhomme C, Perez T, Flipo RM, Wallaert B, Cortet B. Bone loss in adults with cystic fibrosis: Prevalence, associated factors, and usefulness of biological markers. Joint Bone Spine 2012; 79:73-7. [DOI: 10.1016/j.jbspin.2011.05.009] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2011] [Indexed: 10/18/2022]
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De Schepper J, Roggen I, Van Biervliet S, Robberecht E, Gies I, De Waele K, De Wachter E, Malfroot A, De Baets F, Toye K, Goemaere S, Louis O. Comparative bone status assessment by dual energy X-ray absorptiometry, peripheral quantitative computed tomography and quantitative ultrasound in adolescents and young adults with cystic fibrosis. J Cyst Fibros 2011; 11:119-24. [PMID: 22119452 DOI: 10.1016/j.jcf.2011.10.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2011] [Revised: 09/12/2011] [Accepted: 10/21/2011] [Indexed: 10/14/2022]
Abstract
PURPOSE Quantitative ultrasound bone sonometry (QUS) might be a promising screening method for cystic fibrosis (CF)-related bone disease, given its absence of radiation exposure, portability of the equipment and low cost.The value of axial transmission forearm QUS in detecting osteopenia in CF was therefore studied. METHODS We investigated the application of QUS in the evaluation of bone status in a group of 64 adolescents (>12 years) and young adults (<40 years) with CF in a comparison with a dual X-ray absorptiometry (DXA) of the whole body and peripheral quantitative computed tomography (pQCT) of the radius at 4% and 66% sites. RESULTS Mean (SD) Z-scores of speed of sound (SOS), whole body bone mineral content (BMC), radial trabecular bone mineral density (BMD), and radial cortical BMD were respectively -0.31 (0.78), -0.09 (1.28), 0.10 (1.16) and -0.62 (2.88). The pQCT determined bone geometry values (cortical bone area and cortical thickness) were more depressed than the BMD data. QUS had a sensitivity and specificity of respectively 0% and 96% for diagnosing osteopenia (based on a whole body BMC Z-score<-2). CONCLUSIONS QUS cannot replace DXA, but can screen out patients with normal bone mass. Further and larger studies are needed to examine if QUS may reflect other aspects than bone mass, or if it is possible to improve its sensitivity by supplementing the SOS results with clinical risk factors.
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Affiliation(s)
- Jean De Schepper
- Department of Pediatric Endocrinology, UZ Brussel, Brussels, Belgium.
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Abstract
Patients with cystic fibrosis (CF) are at risk of developing low bone mineral density (BMD) and fragility fractures. This paper presents consensus statements that summarise current knowledge of the epidemiology and pathophysiology of CF-related skeletal deficits and provides guidance on its assessment, prevention and treatment. The statements were validated using a modified Delphi methodology.
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Tejero García S, Giráldez Sánchez MA, Cejudo P, Quintana Gallego E, Dapena J, García Jiménez R, Cano Luis P, Gómez de Terreros I. Bone Health, Daily Physical Activity, and Exercise Tolerance in Patients With Cystic Fibrosis. Chest 2011; 140:475-481. [DOI: 10.1378/chest.10-1508] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Robertson J, Macdonald K. Prevalence of bone loss in a population with cystic fibrosis. ACTA ACUST UNITED AC 2010; 19:636-9. [PMID: 20622759 DOI: 10.12968/bjon.2010.19.10.48202] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The adverse effect of an increased life expectancy for people with cystic fibrosis (CF) is the increased risk of complications, such as CF-related low bone mineral density (BMD). Diagnosis of CF-related low BMD is confirmed by a dual-energy X-ray absorptiometry (DXA) scan. This study reports the results of an audit of DXA scans in 108 adults with CF in our clinic. The most common risk factors for bone loss were vitamin D deficiency (89%), CF-related diabetes (53%), low body mass index (39%) and post-lung transplant (25%); half of those with bone loss were genotype homozygous DF508. Overall fracture incidence was 5.5%; low BMD was not associated with high fracture rates. Thus BMD may not be a good predictor of fracture risk. Treatment includes bisphosphonates, which are difficult to take and have uncertain long-term effects. It is unknown whether bisphosphonate therapy is justified in this already overburdened group.
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Bone mineral and body composition alterations in paediatric cystic fibrosis patients. Pediatr Radiol 2010; 40:301-8. [PMID: 19956937 DOI: 10.1007/s00247-009-1446-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2009] [Revised: 09/18/2009] [Accepted: 09/22/2009] [Indexed: 12/20/2022]
Abstract
BACKGROUND With the increased life span of cystic fibrosis (CF) patients, CF-related bone diseases could have an increased prevalence and morbidity in this group. In children, previous retrospective and prospective studies have yielded conflicting results on bone mineralization. OBJECTIVE To monitor body composition and bone mineral status of children with CF. MATERIALS AND METHODS We reviewed the dual-energy X-ray absorptiometry (DXA) data of 161 children with CF (age 10 +/- 4.8 years). Total body bone mineral content (BMCt), total lean tissue mass (LTMt) and total fat mass (FMt) were measured and compared to expected data calculated from ideal weight for height (Wi; e.g. BMCti, LTMti, FMti). The bt (BMCt/BMCti), lt (LTMt/LTMti) and ft (FMt/FMti) ratios were used as quantitative variables. RESULTS Low bt ratio was found at all ages (mean bt ratio 0.94 +/- 0.10; P < 0.001), even in children <6 years of age. However, the children's BMCt was satisfactorily adapted to their weight. lt and ft ratios were not constant across age groups. Children <10 years had 8% reduction of their lt ratio, maintaining normal levels thereafter. The opposite trend was found for ft ratio. Poor clinical, nutritional status and vitamin A levels were correlated with bt and lt ratios. CONCLUSION Our results indicate that children with CF could have early alterations in their bone status and that lt and ft ratios did not have constant values across ages. Interpreting DXA data using this approach is suitable in children with CF.
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Paccou J, Zeboulon N, Combescure C, Gossec L, Cortet B. The prevalence of osteoporosis, osteopenia, and fractures among adults with cystic fibrosis: a systematic literature review with meta-analysis. Calcif Tissue Int 2010; 86:1-7. [PMID: 19949942 DOI: 10.1007/s00223-009-9316-9] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2009] [Accepted: 10/26/2009] [Indexed: 11/26/2022]
Abstract
Observational studies have indicated a high but heterogeneous prevalence of low bone mineral density for adult patients with cystic fibrosis. Fracture complications were also described. The objective of this study was to determine the prevalence of osteoporosis, osteopenia, and fractures among adult patients with cystic fibrosis. A systematic literature review was conducted using electronic databases. The keywords used were "cystic fibrosis [MeSH] AND bone density." Original studies were eligible if they reported the prevalence of osteoporosis and/or osteopenia and/or fractures in adult patients with cystic fibrosis. A meta-analysis of pooled proportions was performed. Heterogeneity was tested with the Cochran Q statistic, and in the case of heterogeneity a random effect model was used. Of 117 studies, 12 were selected, i.e., that represented a total of 1055 patients. Mean age ranged from 18.5 to 32 years (median: 28.2 years). Mean body mass index ranged from 19.9 to 22.4 (median: 20.7); 53.8% were men. The pooled prevalence of osteoporosis in adults with cystic fibrosis was 23.5% (95% CI, 16.6-31.0). The pooled prevalence of osteopenia was 38% (95% CI, 28.2-48.3). The pooled prevalences of radiological vertebral fractures and nonvertebral fractures were 14% (95% CI, 7.8-21.7) and 19.7% (95% CI, 6.0-38.8), respectively. In conclusion, this systematic literature review with meta-analysis emphasized the high prevalence of osteopenia and osteoporosis in young adults with cystic fibrosis. The prevalence of fracture was also high.
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Affiliation(s)
- J Paccou
- Département Universitaire de Rhumatologie, Centre Hospitalier et Universitaire, Hôpital Roger Salengro, Lille, France.
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Stalvey MS, Flotte TR. Endocrine parameters of cystic fibrosis: Back to basics. J Cell Biochem 2009; 108:353-61. [DOI: 10.1002/jcb.22284] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Lucidi V, Bizzarri C, Alghisi F, Bella S, Russo B, Ubertini G, Cappa M. Bone and body composition analyzed by Dual-energy X-ray Absorptiometry (DXA) in clinical and nutritional evaluation of young patients with Cystic Fibrosis: a cross-sectional study. BMC Pediatr 2009; 9:61. [PMID: 19785733 PMCID: PMC2760551 DOI: 10.1186/1471-2431-9-61] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2009] [Accepted: 09/28/2009] [Indexed: 11/10/2022] Open
Abstract
Background the improved general therapy has led to reduced morbidity and mortality from Cystic Fibrosis (CF), and bone status may have a potentially greater clinical impact. We investigated the correlation between the severity of the clinical condition, bone status and body composition parameters, in a group of children and young adults with CF. Methods we measured lumbar spine bone density and total body composition by dual energy x-ray absorptiometry (DXA) in 82 consecutive CF patients (42 males; median age: 13 years - range: 5-30). Eighty-two healthy subjects, matched for age, gender, height and pubertal stage were recruited as a control group. Results 37 patients (45.1%) had a normal bone mineral density (BMD). A BMD reduction were observed in 45 (54.8%) patients. Lumbar spine Z score was positively related to Body Mass Index (BMI) and a higher Shwachman-Kulczycki score, and negatively related to Crispin-Norman score. A positive and significant correlation was also observed between lumbar spine Z score and total body composition. Conclusion a significant BMD reduction can be present early in CF children and adolescents. A careful follow up of bone status is required starting in childhood.
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Affiliation(s)
- Vincenzina Lucidi
- Unit of Cystic Fibrosis, Department of Pediatric Medicine - Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
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Chapman I, Greville H, Ebeling PR, King SJ, Kotsimbos T, Nugent P, Player R, Topliss DJ, Warner J, Wilson JW. Intravenous zoledronate improves bone density in adults with cystic fibrosis (CF). Clin Endocrinol (Oxf) 2009; 70:838-46. [PMID: 18823395 DOI: 10.1111/j.1365-2265.2008.03434.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Reduced bone mineral density (BMD) and increased rates of atraumatic fracture are observed in cystic fibrosis (CF) patients, causing increasing morbidity as this population ages. The study aimed to assess the safety, tolerability and effect on BMD of intravenous zoledronate in adults with CF and osteopaenia. DESIGN Randomized, double-blind, placebo-controlled clinical trial. SETTING Adult CF outpatient clinics at two hospitals. PATIENTS Twenty-two non-transplanted CF patients aged > or = 18 years with a bone densitometry T-score of < -1.5 at one of three sites (lumbar spine, femoral neck, distal forearm) were studied. Participants were randomized to receive either 2 mg zoledronate i.v. (n = 10) or normal saline (placebo, n = 12) every 3 months for 2 years (8 infusions). All participants received calcium and vitamin D supplements twice daily. MEASUREMENTS Percentage change in areal BMD from baseline. RESULTS Lumbar spine BMD increased from baseline more with zoledronate than placebo at 6 months (5.35 +/- 0.76 vs. 1.19 +/- 1.20%, P = 0.012), 12 months (6.6 +/- 1.5 vs. 0.35 +/- 1.55%, P = 0.011) and 24 months (6.14 +/- 1.86 vs. 0.44 +/- 0.10, P = 0.021). Femoral neck BMD increased more after zoledronate than placebo at 6 months (3.2 +/- 1.6 vs.-1.43 +/- 0.43%, P = 0.019), 12 months (4.12 +/- 1.8 vs.-1.59 +/- 1.4%, P = 0.024) and 24 months (4.23 +/- 1.3 vs.-2.5 +/- 1.41%, P = 0.0028). Forearm BMD did not change. Zoledronate was associated with flu-like and musculoskeletal side effects, particularly after the first infusion. There were no fractures in either group. CONCLUSION Intravenous zoledronate was significantly more effective than placebo for increasing BMD in adults with CF and osteopaenia, but side effects limited its tolerability.
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Affiliation(s)
- Ian Chapman
- Endocrinology Department, Royal Adelaide Hospital, North Terrace, Adelaide, Australia
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Papaioannou A, Kennedy CC, Ioannidis G, Sawka A, Hopman WM, Pickard L, Brown JP, Josse RG, Kaiser S, Anastassiades T, Goltzman D, Papadimitropoulos M, Tenenhouse A, Prior JC, Olszynski WP, Adachi JD. The impact of incident fractures on health-related quality of life: 5 years of data from the Canadian Multicentre Osteoporosis Study. Osteoporos Int 2009; 20:703-14. [PMID: 18802659 PMCID: PMC5101052 DOI: 10.1007/s00198-008-0743-7] [Citation(s) in RCA: 121] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2008] [Accepted: 07/21/2008] [Indexed: 11/27/2022]
Abstract
UNLABELLED Using prospective data from the Canadian Multicentre Osteoporosis Study (CaMos), we compared health utilities index (HUI) scores after 5 years of follow-up among participants (50 years and older) with and without incident clinical fractures. Incident fractures had a negative impact on HUI scores over time. INTRODUCTION This study examined change in health-related quality of life (HRQL) in those with and without incident clinical fractures as measured by the HUI. METHODS The study cohort was 4,820 women and 1,783 men (50 years and older) from the CaMos. The HUI was administered at baseline and year 5. Participants were sub-divided into incident fracture groups (hip, rib, spine, forearm, pelvis, other) and were compared with those without these fractures. The effects of both time and fracture type on HUI scores were examined in multivariable regression analyses. RESULTS Men and women with hip fractures, compared to those without, had lower HUI measures that ranged from -0.05 to -0.25. Both women and men with spine fractures had significant deficits on the pain attributes (-0.07 to -0.12). In women, self-care (-0.06), mobility and ambulation (-0.05) were also negatively impacted. Women with rib fractures had deficits similar to women with spine fractures, and these effects persisted over time. In men, rib fractures did not significantly affect HUI scores. Pelvic and forearm fractures did not substantially influence HUI scores. CONCLUSION The HUI was a sensitive measure of HRQL change over time. These results will inform economic analyses evaluating osteoporosis therapies.
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Affiliation(s)
- A Papaioannou
- McMaster University, Hamilton Health Sciences-Chedoke Site, Hamilton, ON, Canada.
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Louis O, Clerinx P, Gies I, De Wachter E, De Schepper J. Well-nourished cystic fibrosis patients have normal mineral density, but reduced cortical thickness at the forearm. Osteoporos Int 2009; 20:309-14. [PMID: 18536951 DOI: 10.1007/s00198-008-0646-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2007] [Accepted: 04/28/2008] [Indexed: 01/08/2023]
Abstract
UNLABELLED Our goal was to assess mineral density and geometry of the cortex at the level of the forearm in adolescents and young adults with cystic fibrosis, using peripheral quantitative computed tomography. We found that density was normal, but cortical thickness significantly reduced, as well in males as in females. INTRODUCTION Our goal was to measure bone mineral density as a volumetric density, as well as total cross-sectional area, cortical area and cortical thickness, using peripheral quantitative computed tomography (pQCT) at the forearm in adolescents and young adults with cystic fibrosis. We evaluated relationships between forearm bone measurements and body composition assessed using dual energy X-ray absorptiometry (DXA). METHODS An XCT 2000 pQCT (Stratec, Pforzheim, Germany) and a QDR 4500 A-upgraded to Discovery DXA device (Hologic, Waltham, MA, USA) were used. RESULTS Forty-eight patients (31 males,17 females, mean+/-SD 20+/5 years) were studied. Anthropometric features were: height 169+/- 10 cm, SDS 0.05+/-0.12, body mass index 19.8+/- 2.5 kg/m(2), SDS -0.56+/-0.14. Bone mineral density and total cross-sectional area of the forearm and body composition were normal, whereas cortical thickness was significantly reduced in males (mean Z-score - 1.22, p < 0.05), and in females (mean Z-score - 1.61, p < 0.05). Total body lean mass correlated more strongly with cortical thickness (r = 0.72, p < 0.001) than with total bone mineral density at the proximal radius (r = 0.39, p < 0.05). CONCLUSIONS Adolescents and young adults with cystic fibrosis, presenting with only a slight degree of underweight, have at the radius a preserved bone mineral density but a reduced cortical thickness.
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Affiliation(s)
- O Louis
- Department of Radiology, UZ Brussel, Vrije Universiteit Brussel, Laarbeeklaan, Belgium.
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Grey V, Atkinson S, Drury D, Casey L, Ferland G, Gundberg C, Lands LC. Prevalence of low bone mass and deficiencies of vitamins D and K in pediatric patients with cystic fibrosis from 3 Canadian centers. Pediatrics 2008; 122:1014-20. [PMID: 18977981 DOI: 10.1542/peds.2007-2336] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE In this cross-sectional observational study, we assessed both vitamins D and K status and bone health in pancreatic insufficient pediatric patients with cystic fibrosis from 3 Canadian cystic fibrosis centers. METHODS Eighty-one patients who had cystic fibrosis and were clinically stable for at least 3 months were enrolled. At the time of the clinic visit, anthropometric variables, lung function, pubertal status, intake of calcium and vitamins D and K, and physical activity were assessed. Blood was taken for analysis of biochemical biomarkers of bone turnover and status of vitamins D and K, and a urine sample was obtained for calcium, creatinine, sodium, and deoxypyridoline analyses. Whole-body bone mineral content and lumbar spine (L1-L4) bone mineral density were measured. RESULTS The children were relatively well nourished and had moderate to mild lung disease. Low bone mineral mass defined as a z score between -1.0 and -2.0, for gender and age was detected in 38% of the children for whole body and in 28% for lumbar spine. z score less than -2.0 was observed in 7 children for both bone measures. Suboptimal vitamin D status occurred in 95% of patients; suboptimal vitamin K status occurred in 82% of patients. Measures of plasma osteocalcin and carboxy-terminal propeptide type 1 procollagen and urinary deoxypyridoline compared with reference values for age, gender, and pubertal status reflected a state of suppressed bone formation and elevated bone resorption in a large proportion of the patients. CONCLUSIONS Bone mass of the whole body and spine was lower than expected for chronological age in approximately one third of pediatric patients with cystic fibrosis irrespective of gender or age. This may be explained by the observation of low bone turnover for developmental stage as indicated by bone biomarkers. Suboptimal status of vitamins D and K may be key causative factors of the low bone status for age.
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Papaioannou A, Kennedy CC, Freitag A, O'Neill J, Pui M, Ioannidis G, Webber C, Pathak A, Hansen S, Hennessey R, Adachi JD. Longitudinal analysis of vertebral fracture and BMD in a Canadian cohort of adult cystic fibrosis patients. BMC Musculoskelet Disord 2008; 9:125. [PMID: 18801200 PMCID: PMC2567975 DOI: 10.1186/1471-2474-9-125] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2008] [Accepted: 09/19/2008] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Vertebral fractures in patients with cystic fibrosis (CF) may contribute to an accelerated decline in lung function and can be a contraindication to lung transplantation. In this study, we examined longitudinal change in bone mineral density (BMD) and the prevalence of vertebral fractures in adult CF patients, without lung-transplant, attending a Canadian specialty clinic. METHODS Retrospective chart review of all patients attending an Adult Cystic Fibrosis Clinic at Hamilton Health Sciences in Hamilton, Canada. Forty-nine of 56 adults met inclusion criteria. Chest radiographs were graded by consensus approach using Genant's semi-quantitative method to identify and grade fractured vertebrae. Dual x-ray absorptiometry (DXA) scans were also reviewed. RESULTS The mean age of the cohort was 25.2 years (SD 9.4), 43% were male. The mean body mass index (BMI) was 19.8 (2.8) for males and 21.7 (5.1) for females. At baseline, the rate of at least one vertebral fracture was 16.3%; rising to 21.3% (prevalent and incident) after a 3-year follow-up. The mean BMD T-or Z-scores at baseline were -0.80 (SD 1.1) at the lumbar spine, -0.57 (SD 0.97) at the proximal femur, and -0.71 (SD 1.1) at the whole body. Over approximately 4-years, the mean percent change in BMD was -1.93% at the proximal femur and -0.73% at the lumbar spine. CONCLUSION Approximately one in five CF patients demonstrated at least one or more vertebral fractures. Moderate declines in BMD were observed. Given the high rate of vertebral fractures noted in this cohort of adult CF patients, and the negative impact they have on compromised lung functioning, regular screening for vertebral fractures should be considered on routine chest radiographs.
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Affiliation(s)
- Alexandra Papaioannou
- Department of Medicine, McMaster University, 1200 Main St W., Hamilton ON, L8N 3Z5, Canada.
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Avaliação da densidade mineral óssea em doentes com fibrose quística. REVISTA PORTUGUESA DE PNEUMOLOGIA 2008. [DOI: 10.1016/s0873-2159(15)30273-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Abstract
As the longevity of all patients with cystic fibrosis (CF) continues to increase (median 2005 survival=36.8 years), more adult patients will be receiving their medical care from nonpediatric adult-care providers. Cystic fibrosis remains a fatal disease, with more than 80% of patients dying after the age of 18 years, and most deaths resulting from pulmonary disease. The changing epidemiology requires adult-care providers to become knowledgeable and competent in the clinical management of adults with CF. Physicians must understand the influence of specific genotype on phenotypic disease presentation and severity, the pathogenic factors determining lung disease onset and progression, the impact of comorbid disease factors such as CF-related diabetes and malnutrition upon lung disease severity, and the currently approved or standard accepted therapies used for chronic management of CF lung disease. This knowledge is critical to help alleviate morbidity and improve mortality for the rapidly expanding population of adults with CF.
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Affiliation(s)
- Robert L Vender
- Division of Pulmonary Allergy and Critical Care Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA 17033, USA.
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Viswanathan A, Sylvester FA. Chronic pediatric inflammatory diseases: effects on bone. Rev Endocr Metab Disord 2008; 9:107-22. [PMID: 18165904 DOI: 10.1007/s11154-007-9070-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2007] [Accepted: 12/06/2007] [Indexed: 10/22/2022]
Abstract
In children, chronic inflammatory diseases present a significant challenge to long-term skeletal health. These conditions are often associated with poor appetite and suboptimal overall nutrition, altered nutrient utilization, delayed puberty, inactivity, and reduced muscle mass, all of which can alter bone metabolism. In addition, bone cell activity is susceptible to the effects of the immune response that characterizes these diseases. Moreover, drugs used to treat these maladies, notably glucocorticoids, may have negative effects on bone formation and on linear growth in developing children. As a result, predicted peak bone mass may not be achieved, and fracture risk may be increased in the short term or in the future. Studies using primarily dual energy X-ray absorptiometry have documented that deficits in bone mass are common in these diseases. However, there are wide variations in the prevalence of low bone mass, largely due to differences in the characteristics of each study population. Recent studies provide insight into the pathogenesis of decreased bone mass in these conditions. In this paper we will provide an overview of the effects of chronic inflammatory conditions on bone mass in children. We will also present relevant data from adult patients, when pediatric data are scant or not available.
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Dubner SE, Shults J, Leonard MB, Zemel BS, Sembhi H, Burnham JM. Assessment of spine bone mineral density in juvenile idiopathic arthritis: impact of scan projection. J Clin Densitom 2008; 11:302-8. [PMID: 18164636 DOI: 10.1016/j.jocd.2007.10.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2007] [Revised: 10/15/2007] [Accepted: 10/29/2007] [Indexed: 10/22/2022]
Abstract
Although children with juvenile idiopathic arthritis (JIA) are at risk for vertebral fractures, recent conventional posterior-anterior (PA) spine dual-energy X-ray absorptiometry studies reported minimal areal bone mineral density (aBMD, g/cm2) deficits. Width-adjusted BMD (WA-BMD, g/cm3) represents the bone mineral content (BMC) from the lateral projection, excluding the dense cortical spinous processes, divided by the estimated vertebral body volume based on paired PA-lateral bone dimensions. Therefore, WA-BMD may be more sensitive to JIA effects on the predominantly trabecular vertebral body. Age- and sex-specific Z-scores for spine aBMD and WA-BMD were generated in 84 JIA subjects compared with healthy controls, aged 5-21 yr. JIA was associated with lower mean WA-BMD Z-scores (-0.78, 95% CI: -1.03, -0.53; p<0.001) and aBMD Z-scores (-0.26, 95% CI: -0.49, -0.02; p<0.05), compared with controls. WA-BMD Z-scores were significantly lower than aBMD Z-scores in JIA (p<0.001). A significant JIA by age interaction (p<0.001) indicated that the magnitude of the difference between WA-BMD and aBMD Z-scores was greater in younger subjects. In conclusion, WA-BMD may be more sensitive to disease effects in children because it selectively measures the trabecular-rich vertebral body and is independent of growth-related changes in BMC of the dense spinous processes.
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Affiliation(s)
- Sarah E Dubner
- University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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Sermet-Gaudelus I, Nove-Josserand R, Loeille GA, Dacremont G, Souberbielle JC, Fritsch J, Laurans M, Moulin P, Cortet B, Salles JP, Ginies JL, Guillot M, Perez-Martin S, Ruiz JC, Montagne V, Cohen-Solal M, Cormier C, Garabédian M, Mallet E. Recommandations pour la prise en charge de la déminéralisation osseuse dans la mucoviscidose. Arch Pediatr 2008; 15:301-12. [DOI: 10.1016/j.arcped.2007.12.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2007] [Revised: 11/30/2007] [Accepted: 12/11/2007] [Indexed: 11/26/2022]
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Saeed Z, Guilbault C, De Sanctis JB, Henri J, Marion D, St-Arnaud R, Radzioch D. Fenretinide prevents the development of osteoporosis in Cftr-KO mice. J Cyst Fibros 2007; 7:222-30. [PMID: 17988958 DOI: 10.1016/j.jcf.2007.09.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2007] [Revised: 09/07/2007] [Accepted: 09/10/2007] [Indexed: 11/27/2022]
Abstract
BACKGROUND The most recently described phenotype associated with Cystic Fibrosis (CF) is reduced bone mineral density which results in osteopenia and osteoporosis. The etiology of the early onset of osteoporosis in CF patients has remained to be established. It has been suggested that inadequate nutritional absorption of essential fatty acids may play a role in the altered bone metabolism. In this study, we characterized the protective effect of fenretinide [N-(4-hydroxyphenyl) retinamide], a vitamin A derivative, on the early onset of osteoporosis in cystic fibrosis transmembrane conductance regulator knockout (Cftr-KO) mice. METHODS Using micro-computed-tomography we examined the effect of fenretinide on the bone composition and architecture in a Cftr-KO mouse model which was then confirmed with histological analyses. Plasma fatty acids were quantified using thin layer chromatography-ELISA method. RESULTS Twice-weekly treatments with fenretinide, over four weeks dramatically increased trabecular bone volume compared to controls. This increase in bone volume was also related to an increased concentration of ceramide in the plasma resulting in the down regulation of phospholipid-bound AA in Cftr-KO mice. CONCLUSIONS To our knowledge, this is the first time that fenretinide's protective effect against osteoporosis has been demonstrated. The results of this study strongly suggest that fenretinide has potential to be used as a prophylaxis by preventing the early onset of osteoporosis.
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Affiliation(s)
- Zienab Saeed
- McGill University Health Centre, Montreal General Hospital, Montreal, Qc, Canada
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Abstract
PURPOSE OF REVIEW We critique recent advances in nutritional care of patients with cystic fibrosis focusing on our understanding of the role of fecal elastase as a pancreatic function test, enzyme replacement therapy and bone health. RECENT FINDINGS Fecal elastase measured by the monoclonal antibody method is a useful screening test for delineating cystic fibrosis patients with pancreatic insufficiency (needing enzyme replacement therapy) from those with pancreatic sufficiency. Cutoff levels, however, have not been clearly defined, particularly in infancy. Newer enzyme products that attempt to improve the intralumenal intestinal pH with bicarbonate or using a combination of unprotected and enteric coated products fail to completely correct nutrient maldigestion. Compromised bone health in cystic fibrosis patients may be due to multiple factors including calcium, vitamin D, and vitamin K deficiencies and lung inflammation. Current recommendations for treatment of bone health in cystic fibrosis are not evidence-based. SUMMARY Fecal elastase is a useful marker of pancreatic function but limitations for this test exist. The presence of an acidic intestinal milieu and hitherto poorly defined intestinal factors may contribute to the failure of current enzyme preparations to correct nutrient assimilation in cystic fibrosis. The many factors that contribute to bone health must be evaluated when developing treatment strategies.
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Affiliation(s)
- Daina Kalnins
- Respiratory Medicine, The Research Institute, Division of Gastroenterology and Nutrition, Department of Pediatrics, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario, Canada
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