Osteoporosis and vascular calcification in postmenopausal women: a cross-sectional study

MicroRNAs regulate the vicious cycle of vascular calcification-osteoporosis in postmenopausal women

Menopause is a normal physiological process accompanied by changes in various physiological states. The incidence of vascular calcification (VC) increases each year after menopause and is closely related to osteoporosis (OP). Although many studies have investigated the links between VC and OP, the interaction mechanism of the two under conditions of estrogen loss remains unclear. MicroRNAs (miRNAs), which are involved in epigenetic modification, play a critical role in estrogen-mediated mineralization. In the past several decades, miRNAs have been identified as biomarkers or therapeutic targets in diseases. Thus, we hypothesize that these small molecules can provide new diagnostic and therapeutic approaches. In this review, we summarize the close interactions between VC and OP and the role of miRNAs in their interplay.

Associated factors of osteoporosis and vascular calcification in patients awaiting kidney transplantation

INTRODUCTION

Pretransplant osteoporosis and vascular calcification probably increase the risk of fractures and cardiovascular events after kidney transplantation. In the present study, we investigated the related risk factors of osteoporosis and vascular calcification among end-stage renal disease (ESRD) patients awaiting kidney transplantation.

METHODS

A total of 221 ESRD patients (age, 43.4 ± 14.3 years; 125 males and 96 females; median dialysis duration, 61.0 m) awaiting kidney transplantation were enrolled in this cross-sectional study. Serum levels of bone turnover markers and intact parathyroid hormone (iPTH) were analyzed from fasting morning blood samples. Dual-energy X-ray absorptiometry was used to measure bone mineral density (BMD). Vascular calcification was evaluated by lateral abdominal radiography and plain radiographic films of the pelvis and hands.

RESULTS

The osteoporosis prevalence was 27.6% in this cohort of kidney transplantation candidates, and the prevalence of vascular calcification was 51.1%. The related factors for osteoporosis and vascular calcification were similar and included older age, longer dialysis duration, parathyroid hyperplasia, and higher levels of iPTH and bone turnover markers. In the multivariable regression model, age and iPTH were independent risk predictors of both vascular calcification and osteoporosis. There were strong, positive correlations between iPTH and all bone turnover markers. The moderate and severe hyperparathyroidism (iPTH 600-1499 pg/ml and iPTH 1500 pg/ml) were related to reduced serum albumin and hemoglobin levels.

CONCLUSION

The involvement of high iPTH levels in vascular calcification, osteoporosis, and malnutrition indicated the need of treating hyperparathyroidism early in patients awaiting kidney transplantation. Prospective studies are needed to further examine the utility of bone turnover markers.

Bile Acid Network and Vascular Calcification-Associated Diseases: Unraveling the Intricate Connections and Therapeutic Potential

Bile acids play a crucial role in promoting intestinal nutrient absorption and biliary cholesterol excretion, thereby protecting the liver from cholesterol accumulation and bile acid toxicity. Additionally, bile acids can bind to specific nuclear and membrane receptors to regulate energy expenditure and specific functions of particular tissues. Vascular calcification refers to the pathological process of calcium-phosphate deposition in blood vessel walls, which serves as an independent predictor for cardiovascular adverse events. In addition to aging, this pathological change is associated with aging-related diseases such as atherosclerosis, hypertension, chronic kidney disease, diabetes mellitus, and osteoporosis. Emerging evidence suggests a close association between the bile acid network and these aforementioned vascular calcification-associated conditions. Several bile acids have been proven to participate in calcium-phosphate metabolism, affecting the transdifferentiation of vascular smooth muscle cells and thus influencing vascular calcification. Targeting the bile acid network shows potential for ameliorating these diseases and their concomitant vascular calcification by regulating pathways such as energy metabolism, inflammatory response, oxidative stress, and cell differentiation. Here, we present a summary of the metabolism and functions of the bile acid network and aim to provide insights into the current research on the profound connections between the bile acid network and these vascular calcification-associated diseases, as well as the therapeutic potential.

Relationship between ectopic calcifications and bone fragility depicted on computed tomography scan in 70 patients with systemic sclerosis

Background

A higher risk of osteoporotic fracture was described in systemic sclerosis patients than in healthy patients.

Objective

To evaluate the relation between osteoporotic fracture risk measured by the scanographic bone attenuation coefficient of the first lumbar vertebra (SBAC-L1) on computed tomography (CT) scan and the presence of ectopic calcifications: vascular, valvular and spinal.

Methods

This monocentric retrospective study was performed on patients followed between 2000 and 2014 at Nancy University Hospital. Systemic sclerosis patients, according to ACR/EULAR 2013 criteria, followed from 2000 to 2014 and who underwent, during their follow-up, a CT including the first lumbar vertebra were included. The SBAC-L1 was measured with a threshold set at 145 Hounsfield units (HU). Vascular and spinal calcifications were studied on CT. For vascular calcifications, the Agatston score was used. Valvular calcifications were studied on echocardiography.

Results

A total of 70 patients were included (mean age: 62.3 (±15.6) years, women 88.5%). The mean SBAC-L1 was 157.26 (±52.1) HU, and 35 patients (50%) presented an SBAC-L1 ⩽ 145 HU. The reproducibility of the calcification evaluation was good, with kappa coefficients varying between 0.63 and 1. In univariate analysis, spinal and vascular calcifications were associated with an SBAC-L1 ⩽ 145 HU, with ORs of 13.6 (1.6-113.3) and 8 (95%CI: 2.5-25.5), respectively. In multivariate analysis, the SBAC-L1 was not associated with the presence of any ectopic calcifications. The SBAC-L1 decreased with age (p = 0.0001).

Conclusion

Patients with systemic sclerosis with an SBAC-L1 ⩽ 145 HU were older, but they did not have more ectopic calcification.

Trial registration

The ethics committee of Nancy Hospital agreed with this study (referral file number 166). This study was designed in accordance with the general ethical principles outlined in the Declaration of Helsinki.

Atherogenic Index of Plasma and Anthropometric Measurements among Osteoporotic Postmenopausal Sudanese Women: Possible Risk for Cardiovascular Disease

Introduction

Data examining the health of menopausal women and the prevalence of osteoporosis remain to be limited in Africa, especially in sub-Saharan countries. Thus, in this current study, we aimed to assess the atherogenic index of plasma (AIP) and anthropometric measurements of osteoporotic postmenopausal women and determine their risk for cardiovascular disease (CVD).

Methods

This is a cross-sectional, community-based study. Postmenopausal women (n = 300), aged ≥45 years, were recruited from Khartoum state, Sudan. Dual-energy X-ray absorptiometry was used to assess bone density. Weight, height, and waist circumference were measured twice. Fasting blood samples (5 ml) were collected to determine total cholesterol (TC), triglycerides (TG), low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C). AIP was calculated as an indicator of CVD risk.

Results

The mean age of the postmenopausal women was 61.6 ± 10.2 years (range 47–90 years). Women (n = 80) had the normal T-score, and an equal number had osteoporosis (n = 110) and osteopenia (n = 110). The prevalence of osteoporosis was 36.7%. Many postmenopausal women with normal T-scores suffered from general (71.2%) and central (94%) obesity. Postmenopausal women had high TC (24.4%), TG (25.6%), LDL-C (13.7%), and low HDL-C (76.0%) levels. Osteoporotic women (36.4%) were found to have a medium to high risk of CVD as determined by AIP. Women with normal T-scores had a higher number of CVD risk factors. A positive correlation was noted between AIP and TC among osteopenic (r = 0.292; P=0.002) and osteoporotic women (r = 0.265; P < 0.001).

Conclusion

Osteoporosis was prevalent among Sudanese postmenopausal women who also had an increased risk for CVD. Public health education about osteoporosis and CVD risk is thus recommended.

The Role of Sirtuins in Osteogenic Differentiation of Vascular Smooth Muscle Cells and Vascular Calcification

Vascular calcification (VC) is a common pathological change in many chronic diseases, such as diabetes and chronic kidney disease. It is mainly deposited in the intima and media of vessels in the form of hydroxyapatite. Recently, a lot of research has been performed to show that VC is associated with various cellular stresses, such as hyperphosphate, hyperglycemia and oxidative stress. Unfortunately, our understanding of the pathogenesis of calcification is far from comprehensive. Sirtuins belong to a family of class III highly conserved deacetylases that are involved in the regulation of biological and cellular processes including mitochondrial biogenesis, metabolism, oxidative stress, inflammatory response, DNA repair, etc. Numerous studies have shown that sirtuins might play protective roles in VC, and restoring the activity of sirtuins may be a potentially effective treatment for VC. However, the exact mechanism of their vascular protection remains unclear. Here, we reviewed the roles of sirtuins in the osteogenic transformation of vascular smooth muscle cells and the development of VC. We also elucidated the applications of sirtuins agonists for the treatment of VC.

Insights Into the Role of Mitochondria in Vascular Calcification

Vascular calcification (VC) is a growing burden in aging societies worldwide, and with a significant increase in all-cause mortality and atherosclerotic plaque rupture, it is frequently found in patients with aging, diabetes, atherosclerosis, or chronic kidney disease. However, the mechanism of VC is still not yet fully understood, and there are still no effective therapies for VC. Regarding energy metabolism factories, mitochondria play a crucial role in maintaining vascular physiology. Discoveries in past decades signifying the role of mitochondrial homeostasis in normal physiology and pathological conditions led to tremendous advances in the field of VC. Therapies targeting basic mitochondrial processes, such as energy metabolism, damage in mitochondrial DNA, or free-radical generation, hold great promise. The remarkably unexplored field of the mitochondrial process has the potential to shed light on several VC-related diseases. This review focuses on current knowledge of mitochondrial dysfunction, dynamics anomalies, oxidative stress, and how it may relate to VC onset and progression and discusses the main challenges and prerequisites for their therapeutic applications.

Resveratrol Ameliorates Aortic Calcification in Ovariectomized Rats via SIRT1 Signaling

Postmenopausal women are at an increased risk of vascular calcification which is defined as the pathological deposition of minerals in the vasculature, and is strongly linked with increased cardiovascular disease risk. Since estrogen-replacement therapy is associated with increased cancer risk, there is a strong need for safer therapeutic approaches. In this study we aimed to investigate the protective and therapeutic effects of the phytoestrogen resveratrol against vascular calcification in ovariectomized rats, a preclinical model of postmenopause. Furthermore, we aimed to compare the effects of resveratrol to those of estrogen and to explore the mechanisms underpinning those effects. Treatment with resveratrol or estrogen ameliorated aortic calcification in ovariectomized rats, as shown by reduced calcium deposition in the arterial wall. Mechanistically, the effects of resveratrol and estrogen were mediated via the activation of SIRT1 signaling. SIRT1 protein expression was downregulated in the aortas of ovariectomized rats, and upregulated in rats treated with resveratrol or estrogen. Moreover, resveratrol and estrogen reduced the levels of the osteogenic markers: runt-related transcription factor 2 (RUNX2), osteocalcin and alkaline phosphatase (ALP) which have been shown to play a role during vascular calcification. Additionally, the senescence markers (p53, p16 and p21) which were also reported to play a role in the pathogenesis of vascular calcification, were reduced upon treatment with resveratrol and estrogen. In conclusion, the phytoestrogen resveratrol may be a safer alternative to estrogen, as a therapeutic approach against the progression of vascular calcification during postmenopause.

Osteoporosis was associated with severe abdominal aortic calcification based on a cross-sectional study

Abdominal aortic calcification and osteoporosis are age-related diseases. Based on a nationally representative US population, we concluded that osteoporosis may be independently associated with severe abdominal aortic calcification, which could improve our insights into the prevention and management of vascular disease.

INTRODUCTION

Abdominal aortic calcification (AAC) and osteoporosis are age-related diseases and share similar pathological mechanisms. However, the association between osteoporosis and AAC is uncertain.

METHODS

A total of 3134 participants with complete record of AAC score calculated from dual-energy X-ray absorptiometry (DXA) were enrolled from the National Health and Nutrition Examination Survey (NHANES) 2013-2014. The diagnosis of osteoporosis was obtained from self-reported interview. The baseline covariates were compared between participants with and without osteoporosis. Multivariable logistic regression was performed to examine the association between abdominal aortic calcification and osteoporosis.

RESULTS

Compared with those without osteoporosis, participants with osteoporosis had higher AAC scores. Osteoporosis was positively associated with higher odds of severe AAC (OR = 2.65; 95%CI, 1.89-3.71; P < 0.001), and the association was not altered (OR = 2.17; 95%CI, 1.23-3.83; P = 0.008) after adjusting for numerous covariates.

CONCLUSIONS

Our findings suggest that osteoporosis may be independently associated with severe abdominal aortic calcification.

The Cell Origin and Role of Osteoclastogenesis and Osteoblastogenesis in Vascular Calcification

Arterial calcification refers to the abnormal deposition of calcium salts in the arterial wall, which results in vessel lumen stenosis and vascular remodeling. Studies increasingly show that arterial calcification is a cell mediated, reversible and active regulated process similar to physiological bone mineralization. The osteoblasts and chondrocytes-like cells are present in large numbers in the calcified lesions, and express osteogenic transcription factor and bone matrix proteins that are known to initiate and promote arterial calcification. In addition, osteoclast-like cells have also been detected in calcified arterial walls wherein they possibly inhibit vascular calcification, similar to the catabolic process of bone mineral resorption. Therefore, tilting the balance between osteoblast-like and osteoclast-like cells to the latter maybe a promising therapeutic strategy against vascular calcification. In this review, we have summarized the current findings on the origin and functions of osteoblast-like and osteoclast-like cells in the development and progression of vascular progression, and explored novel therapeutic possibilities.

Hypertension is associated with osteoporosis: a case-control study in Chinese postmenopausal women

BACKGROUND

Osteoporosis and cardiovascular disease (CVD) are age-related diseases. It is reported that patients with CVD have a higher risk of bone loss. This retrospective study sought to reveal the association between osteoporosis and CVD in Chinese women. Although epidemiological evidence has indicated a relationship between the two, clinical data in southeast China are lacking.

METHODS

In total, 2873 participants completed the baseline survey from January 2007 to October 2019, and 2039 were included in this retrospective study. We divided all subjects into an osteoporosis group and a non-osteoporosis group based on their bone mineral density (BMD). Dual-energy X-ray absorptiometry (DXA) was used to examine BMD. The general information came from the questionnaire survey. Cardiovascular diseases were defined by asking participants at the first visit and checking relevant medical records if they had suffered from hypertension, coronary heart disease, or cerebral infarction.

RESULTS

According to the criterion, the osteoporosis group had 678 subjects, and the non-osteoporosis group had 1361 subjects. Subjects in the osteoporosis group had a significantly higher prevalence of hypertension and coronary heart disease. Besides, the proportion of subjects who drank tea and drank milk were relatively higher in the osteoporosis group. The odds ratio (OR) for suffering from osteoporosis was high if the patients had hypertension.

CONCLUSIONS

This study indicated that Chinese postmenopausal women with osteoporosis had a higher prevalence of hypertension. Hypertension was significantly associated with osteoporosis.

A Novel Hypothesis: A Role for Follicle Stimulating Hormone in Abdominal Aortic Aneurysm Development in Postmenopausal Women

An abdominal aortic aneurysm (AAA) is a dilatation of the abdominal aorta, which can potentially be fatal due to exsanguination following rupture. Although AAA is less prevalent in women, women with AAA have a more severe AAA progression compared to men as reflected by enhanced aneurysm growth rates and a higher rupture risk. Women are diagnosed with AAA at an older age than men, and in line with increased osteoporosis and cardiovascular events, the delayed AAA onset has been attributed to the reduction of the protective effect of oestrogens during the menopausal transition. However, new insights have shown that a high follicle stimulating hormone (FSH) level during menopause may also play a key role in those diseases. In this report we hypothesize that FSH may aggravate AAA development and progression in postmenopausal women via a direct and/or indirect role, promoting aorta pathology. Since FSH receptors (FSHR) are reported on many other cell types than granulosa cells in the ovaries, it is feasible that FSH stimulation of FSHR-bearing cells such as aortic endothelial cells or inflammatory cells, could promote AAA formation directly. Indirectly, AAA progression may be influenced by an FSH-mediated increase in osteoporosis, which is associated with aortic calcification. Also, an FSH-mediated decrease in cholesterol uptake by the liver and an increase in cholesterol biosynthesis will increase the cholesterol level in the circulation, and subsequently promote aortic atherosclerosis and inflammation. Lastly, FSH-induced adipogenesis may lead to obesity-mediated dysfunction of the microvasculature of the aorta and/or modulation of the periaortic adipose tissue. Thus the long term increased plasma FSH levels during the menopausal transition may contribute to enhanced AAA disease in menopausal women and could be a potential novel target for treatment to lower AAA-related events in women.

An overview of the mechanisms in vascular calcification during chronic kidney disease

PURPOSE OF REVIEW

Chronic kidney disease (CKD) facilitates a unique environment to strongly accelerate vascular calcification - the pathological deposition of calcium-phosphate in the vasculature. These calcifications are associated with the excessive cardiovascular mortality of CKD patients.

RECENT FINDINGS

Vascular calcification is a multifaceted active process, mediated, at least partly, by vascular smooth muscle cells. These cells are able to transdifferentiate into cells with osteo/chondrogenic properties, which exert multiple effects to facilitate vascular tissue mineralization. As the understanding of the underlying pathophysiology increases, first therapeutic concepts begin to emerge.

SUMMARY

This brief review provides an overview on the so far known mechanisms involved in the initiation and progression of vascular calcification in CKD.

Induced osteogenic differentiation of human smooth muscle cells as a model of vascular calcification

Vascular calcification is a severe pathological event in the manifestation of atherosclerosis. Pathogenic triggers mediating osteogenic differentiation of arterial smooth muscle cells (SMC) in humans remain insufficiently understood and are to a large extent investigated in animal models or cells derived thereof. Here, we describe an in vitro model based on SMC derived from healthy and diseased humans that allows to comprehensively investigate vascular calcification mechanisms. Comparing the impact of the commonly used SMC culture media VascuLife, DMEM, and M199, cells were characterised by immunofluorescence, flow cytometry, qPCR, and regarding their contractility and proliferative capacity. Irrespective of the arterial origin, the clinical background and the expansion medium used, all cells expressed typical molecular SMC marker while contractility varied between donors. Interestingly, the ability to induce an osteogenic differentiation strongly depended on the culture medium, with only SMC cultured in DMEM depositing calcified matrix upon osteogenic stimulation, which correlated with increased alkaline phosphatase activity, increased inorganic phosphate level and upregulation of osteogenic gene markers. Our optimized model is suitable for donor-oriented as well as broader screening of potential pathogenic mediators triggering vascular calcification. Translational studies aiming to identify and to evaluate therapeutic targets in a personalized fashion would be feasible.

Carotid plaque and lumbar bone mineral density status in post-menopausal women: An age-matched, analytical cross-sectional study

Objective

To explore the association between carotid plaque and lumbar spine osteoporosis in post-menopausal women.

Study design

Age-matched, cross-sectional study.

Main outcome measures

Carotid plaque and carotid intima media thickness were measured with B-mode ultrasound. Lumbar spine bone mineral density was measured with dual-energy X-ray absorptiometry. Prevalence odds ratios and the respective 95% confidence intervals (95%CI) were calculated to determine the association.

Results

Seventy-two post-menopausal women with lumbar spine osteoporosis and 72 post-menopausal women with normal lumbar spine bone mineral density were enrolled. The adjusted prevalence odds ratio of carotid plaque presence in post-menopausal women with lumbar spine osteoporosis was 1.73 (95%CI; 0.60 to 4.94) when compared to post-menopausal women with normal lumbar spine bone mineral density. The presence of vulnerable plaque was greater in post-menopausal women with lumbar spine osteoporosis; however, the difference was not statistically significant after adjusting for other risk factors of cardiovascular disease (odds ratio 1.31; 95%CI; 0.39 to 4.43). There was no significant difference in carotid intima media thickness between the two groups. Multiple logistic regression analysis with backward elimination in assessment of potential risk factors for the presence of carotid plaque showed that the year since menopause, family history of cardiovascular disease and systolic blood pressure were nominally significant associated factors with a respective adjusted odds ratio of 1.06 (95%CI; 1.01 to 1.12), 6.23 (95%CI; 1.65 to 23.46) and 1.03 (95%CI; 1.01 to 1.06).

Conclusions

The current study indicates that lumbar spine osteoporosis is not associated with the presence of carotid plaque, whereas year since menopause, family history of cardiovascular disease and systolic blood pressure are associated factors.

The role of the gasotransmitter hydrogen sulfide in pathological calcification

Calcification is the deposition of minerals, mainly hydroxyapatite, inside the cell or in the extracellular matrix. Physiological calcification is central for many aspects of development including skeletal and tooth growth; conversely, pathological mineralization occurs in soft tissues and is significantly associated with malfunction and impairment of the tissue where it is located. Various mechanisms have been proposed to explain calcification. However, this research area lacks a more integrative, systemic, and global perspective that could explain both physiological and pathological processes. In this review, we propose such an integrated explanation. Hydrogen sulfide (H₂ S) is a newly recognized multifunctional gasotransmitters and tis actions have been studied in different physiological and pathological contexts, but little is known about its potential role on calcification. Interestingly, we found that H₂ S promotes calcification under physiological conditions and has an inhibitory effect on pathological processes. This makes H₂ S a potential therapy for diseases related to pathological calcification. LINKED ARTICLES: This article is part of a themed section on Hydrogen Sulfide in Biology & Medicine. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v177.4/issuetoc.

Osteoporosis complicating some inborn or acquired diseases

Osteoporosis in chronic diseases is very frequent and pathogenetically varied. It complicates the course of the underlying disease by the occurrence of fractures, which aggravate the quality of life and increase the mortality of patients from the underlying disease. The secondary deterioration of bone quality in chronic diseases, such as diabetes of type 1 and type 2 and/or other endocrine and metabolic disorders, as well as inflammatory diseases, including rheumatoid arthritis - are mostly associated with structural changes to collagen, altered bone turnover, increased cortical porosity and damage to the trabecular and cortical microarchitecture. Mechanisms of development of osteoporosis in some inborn or acquired disorders are discussed.

Vitamin D status and abdominal aortic calcification in postmenopausal women

Vitamin D has an important role in bone metabolism and may be involved in the process of vascular calcification. The objective of this study was to evaluate the effect of vitamin D status on the presence of abdominal aortic calcification (AAC). We enrolled, in a cross-sectional study, 429 postmenopausal women [mean age, weight, and BMI of 59.5 ± 8.3 (50-83) years, 75.8 ± 13.3 (35-165) kg, and 29.9 ± 5.2 (14.6-50.8) kg/m², respectively]. Lateral vertebral fracture assessment (VFA) images and scans of the lumbar spine and proximal femur were obtained using a Lunar Prodigy densitometer. Vertebral fractures (VFs) were defined using the Genant semiquantitative (SQ) approach. We used the Kauppila score to assess AAC extension. Clinical risk factors of osteoporosis were collected, and 25-hydroxy vitamin D was measured using electrochemiluminescence (Roche). Prevalence of osteoporosis and hypovitaminosis D (<20 ng/ml) was 21.0% and 78.1%, respectively. VFs grade 2/3 were identified in 76 patients (17.7%). Two thirds of the evaluable participants did not have any detectable AAC. The prevalence of significant atherosclerotic burden, defined as a radiographic 24-point AAC score of 5 or higher, was 7.9%. The group of women with extended AAC were older and had a statistically significant higher menopause duration and more prevalent grade 2/3 VFs. Compared to women with normal values of vitamin D, women with vitamin D insufficiency (<20 ng/ml) and deficiency (<10 ng/ml) had a lower BMD and more prevalent VFs. No difference was noted with regard to AAC among the three groups. Multiple stepwise conditional logistic regression analysis showed that the presence of AAC was associated significantly with age and the presence of VFs. Extended aortic calcifications are independently associated with prevalent VFA-identified VFs but not with serum vitamin D levels in postmenopausal women. VFA imaging using DXA may detect at the same time prevalent VFs and AAC, an important cardiovascular disease risk factor.

Diabetes and Abdominal Aortic Calcification-a Systematic Review

PURPOSE OF REVIEW

A systematic literature review was performed to evaluate diabetes mellitus (DM) as a risk factor of abdominal aortic calcification (AAC), and address factors that might contribute to the development of AAC in DM patients.

RECENT FINDINGS

DM is an independent risk factor of AAC development. Bone metabolism along with lifestyle factors among DM patients makes them more prone to AAC. Hip and vertebral fractures, high phosphate, smoking, hypertension, and low osteocalcin could make DM patients prone to AAC. Low levels of high-density lipoprotein (HDL), high low-density lipoprotein (LDL), high total cholesterol/HDL ratio, low bone mineral density (BMD) may be risk factors, but the literature is more ambiguous. Body mass index (BMI) does not appear to increase risk of AAC. High phosphate levels and low osteocalcin levels seem to be biomarkers of AAC in patients with diabetes. However, the association between DM and AAC is complicated.