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Lindsay Mart F, Winer KK, Johnson K, Wasserman H. Initiation of Continuous rhPTH Infusion With Insulin Pump in an Inpatient Setting. JCEM Case Rep 2023; 1:luad136. [PMID: 37954834 PMCID: PMC10634629 DOI: 10.1210/jcemcr/luad136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Indexed: 11/14/2023]
Abstract
Hypoparathyroidism is one of the few remaining hormonal insufficiencies not treated with replacement of its missing hormone. Conventional therapy involves multiple daily oral doses of calcium, active vitamin D, and magnesium, which is not only cumbersome for patients, but carries risk of nephrocalcinosis and is inadequate in patients with enteral malabsorption. Subcutaneous parathyroid hormone 1-34 (PTH[1-34]) has been tested as a hormonal replacement therapy for treatment of hypoparathyroidism. PTH(1-34) delivered by continuous infusion via insulin pump decreases or eliminates the need for oral medications, stabilizes serum and urine calcium at normal levels with minimal fluctuation, and significantly reduces PTH doses. In this case report, we describe the clinical application of PTH(1-34) via insulin pump in an adolescent with autoimmune polyendocrinopathy syndrome type 1 (APS1). Transition to a PTH pump reduced hospital admissions for calcium abnormalities and allowed our patient to discontinue all scheduled daily conventional therapy.
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Affiliation(s)
- Faith Lindsay Mart
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Karen K Winer
- National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20817, USA
| | - Karla Johnson
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Halley Wasserman
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
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2
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Zemel BS, Shepherd JA, Grant SFA, Lappe JM, Oberfield SE, Mitchell JA, Winer KK, Kelly A, Kalkwarf HJ. Reference ranges for body composition indices by dual energy X-ray absorptiometry from the Bone Mineral Density in Childhood Study Cohort. Am J Clin Nutr 2023; 118:792-803. [PMID: 37598746 PMCID: PMC10579045 DOI: 10.1016/j.ajcnut.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 08/08/2023] [Accepted: 08/15/2023] [Indexed: 08/22/2023] Open
Abstract
BACKGROUND Body composition assessment aids evaluation of energy stores and the impact of diseases and interventions on child growth. Current United States pediatric reference ranges from the National Health and Nutrition Examination Survey (NHANES) include 20% of children with obesity, body mass index of ≥95th percentile. OBJECTIVES This study aimed to develop dual energy X-ray absorptiometry (DXA) based reference ranges in a diverse cohort with low-obesity prevalence from the Bone Mineral Density in Childhood Study (BMDCS). METHODS This is a secondary analysis of a longitudinal, prospective, observational cohort. Healthy children (height and BMI within 3rd to 97th percentiles, ages 5-19 y at enrollment), from 5 United States centers were measured annually for ≤7 visits. Whole body scans were acquired using Hologic scanners. A subsample underwent repeat measurements to determine precision. We generated reference ranges for appendicular and total lean soft tissue mass index (LSTM Index), fat mass index (FMI), and other body composition measures. Resulting curves were compared to NHANES and across subgroups. Sex and age-specific equations were developed to adjust body composition Z-scores for height Z score. RESULTS We obtained 9846 scans of 2011 participants (51% female, 22% Black, 17% Hispanic, 48% White, 7% Asian/Pacific Islander, and 6% with obesity). Precision (percent coefficient of variation) ranged from 0.7% to 1.96%. Median and-2 standard deviation curves for BMDCS and NHANES were similar, but NHANES +2 standard deviation LSTM Index and FMI curves were distinctly greater than the respective BMDCS curves. Subgroup differences were more extreme for appendicular LSTM Index-Z (mean ± SD: Asian -0.52 ± 0.93 compared with Black 0.77 ± 0.87) than for FMI-Z (Hispanic 0.29 ± 0.98 compared with Black -0.14 ± 1.1) and were smaller for Z-scores adjusted for height Z-score. CONCLUSIONS These reference ranges add to sparse normative data regarding body composition in children and adolescents and are based on a cohort with an obesity prevalence similar to current BMI charts. Awareness of subgroup differences aids in interpreting results.
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Affiliation(s)
- Babette S Zemel
- Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States.
| | - John A Shepherd
- Cancer Center, University of Hawaii, Honolulu, HI, United States
| | - Struan F A Grant
- Division of Human Genetics, The Children's Hospital of Philadelphia, Department of Pediatrics, and Genetics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Joan M Lappe
- Department of Medicine, Creighton University, Omaha, NB, United States
| | - Sharon E Oberfield
- Division of Pediatric Endocrinology, Diabetes, and Metabolism, Department of Pediatrics, Columbia University Medical Center, New York, NY, United States
| | - Jonathan A Mitchell
- Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Karen K Winer
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
| | - Andrea Kelly
- Division of Pediatric Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Heidi J Kalkwarf
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati Medical Center, Cincinnati, OH, United States
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3
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Khan AA, Guyatt G, Ali DS, Bilezikian JP, Collins MT, Dandurand K, Mannstadt M, Murphy D, M'Hiri I, Rubin MR, Sanders R, Shrayyef M, Siggelkow H, Tabacco G, Tay YKD, Van Uum S, Vokes T, Winer KK, Yao L, Rejnmark L. Management of Hypoparathyroidism. J Bone Miner Res 2022; 37:2663-2677. [PMID: 36161671 DOI: 10.1002/jbmr.4716] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 09/19/2022] [Accepted: 09/22/2022] [Indexed: 12/24/2022]
Abstract
Hypoparathyroidism (HypoPT) is a rare disorder characterized by hypocalcemia in the presence of a low or inappropriately normal parathyroid hormone level. HypoPT is most commonly seen after neck surgery, which accounts for approximately 75% of cases, whereas approximately 25% have HypoPT due to nonsurgical causes. In both groups of patients, conventional therapy includes calcium and active vitamin D analogue therapy aiming to maintain serum calcium concentration in the low normal or just below the normal reference range and normalize serum phosphorus, magnesium concentrations, and urine calcium levels. The limitations of conventional therapy include wide fluctuations in serum calcium, high pill burden, poor quality of life, and renal complications. Parathyroid hormone (PTH) replacement therapy may improve the biochemical profile in those in whom conventional therapy proves unsatisfactory. Based on a systematic review and meta-analysis of the literature, the panel made a graded recommendation suggesting conventional therapy as first line therapy rather than administration of PTH (weak recommendation, low quality evidence). When conventional therapy is deemed unsatisfactory, the panel considers use of PTH. Because pregnancy and lactation are associated with changes in calcium homeostasis, close monitoring is required during these periods with appropriate adjustment of calcium and active vitamin D analogue therapy to ensure that serum calcium remains in the mid to low normal reference range in order to avoid maternal and fetal complications. Emerging therapies include molecules with prolonged PTH action as well as different mechanisms of action that may significantly enhance drug efficacy and safety. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Aliya A Khan
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Dalal S Ali
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada
| | - John P Bilezikian
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Michael T Collins
- National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Karel Dandurand
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, Canada
| | - Michael Mannstadt
- Endocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Iman M'Hiri
- Bone Research and Education Centre, Oakville, Canada
| | - Mishaela R Rubin
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | | | | | - Heide Siggelkow
- Clinic of Gastroenterology, Gastrointestinal Oncology and Endocrinology, University Medical Center Goettingen, Goettingen, Germany.,MVZ Endokrinologikum Goettingen, Goettingen, Germany
| | - Gaia Tabacco
- Unit of Metabolic Bone and Thyroid Diseases, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy.,Unit of Endocrinology and Diabetes, Campus Bio-Medico University of Rome, Rome, Italy
| | - Yu-Kwang Donovan Tay
- Department of Medicine, Sengkang General Hospital, Singhealth and Duke-NUS Medical School, Singapore, Singapore
| | - Stan Van Uum
- Department of Medicine, Western University, London, Canada
| | - Tamara Vokes
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Karen K Winer
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Liang Yao
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Lars Rejnmark
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
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4
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Van Uum S, Shrayyef M, M'Hiri I, Dandurand K, Ali DS, Bilezikian JP, Collins MT, Mannstadt M, Rubin MR, Siggelkow H, Tabacco G, Tay YKD, Vokes T, Winer KK, Yao L, Guyatt G, Rejnmark L, Khan AA. Initial Assessment and Monitoring of Patients with Chronic Hypoparathyroidism: A Systematic Current Practice Survey. J Bone Miner Res 2022; 37:2630-2641. [PMID: 36066096 DOI: 10.1002/jbmr.4698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 08/26/2022] [Accepted: 08/31/2022] [Indexed: 11/05/2022]
Abstract
Chronic hypoparathyroidism (HypoPT) is associated with significant morbidity and impaired quality of life (QoL). The goals of management for chronic HypoPT include improvement in QoL and the prevention of both hypo- and hypercalcemia symptoms and long-term complications. Several groups have provided consensus statements and guidelines on the management of HypoPT; however, due to limited evidence, these recommendations have largely been based on literature reviews, expert opinion, and consensus statements. The objective of this study was to use a systematic approach to describe current practice for the initial assessment and follow-up of patients with chronic HypoPT. We developed a survey asking experts in the field to select the responses that best reflect their current practice. The survey found no differences in responses between nonsurgical and postsurgical patient assessment. For new patients, respondents usually performed an assessment of serum lab profile (calcium [either albumin-adjusted or ionized], magnesium, creatinine, phosphate, 25-hydroxyvitamin D), 24-hour urine (creatinine, calcium), and a renal ultrasound to evaluate for the presence of nephrocalcinosis or nephrolithiasis. For follow-up patients, most respondents perform blood tests and urine tests every 6 months or less frequently. The reported clinical practice patterns for monitoring for complications of chronic HypoPT vary considerably among respondents. Based on the responses in this systematic expert practice survey, we provide practice suggestions for initial assessment and follow-up of patients with chronic HypoPT. In addition, we highlight areas with significant variation in practice and identify important areas for future research. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Stan Van Uum
- Department of Medicine, Western University, London, ON, Canada
| | | | - Iman M'Hiri
- Bone Research and Education Centre, Oakville, ON, Canada
| | - Karel Dandurand
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, ON, Canada
| | - Dalal S Ali
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, ON, Canada
| | - John P Bilezikian
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Michael T Collins
- National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Michael Mannstadt
- Endocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Mishaela R Rubin
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Heide Siggelkow
- Clinic of Gastroenterology, Gastrointestinal Oncology and Endocrinology, University Medical Center Goettingen, Goettingen, Germany.,MVZ Endokrinologikum Goettingen, Goettingen, Germany
| | - Gaia Tabacco
- Unit of Endocrinology and Diabetes, Campus Bio-Medico University of Rome, Rome, Italy
| | - Yu-Kwang Donovan Tay
- Department of Medicine, Sengkang General Hospital, Singhealth and Duke-NUS Medical School, Singapore, Singapore
| | | | - Karen K Winer
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Liang Yao
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Lars Rejnmark
- Dept of Endocrinology and Internal Medicine, Aarhus University hospital, Aarhus, Denmark
| | - Aliya A Khan
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, ON, Canada
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5
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Kalkwarf HJ, Shepherd JA, Hans D, Gonzalez Rodriguez E, Kindler JM, Lappe JM, Oberfield S, Winer KK, Zemel BS. Trabecular Bone Score Reference Values for Children and Adolescents According to Age, Sex, and Ancestry. J Bone Miner Res 2022; 37:776-785. [PMID: 35118727 PMCID: PMC9018558 DOI: 10.1002/jbmr.4520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 01/18/2022] [Accepted: 01/25/2022] [Indexed: 11/10/2022]
Abstract
Trabecular bone score (TBS) is used for fracture prediction in adults, but its utility in children is limited by absence of appropriate reference values. We aimed to develop reference ranges for TBS by age, sex, and population ancestry for youth ages 5 to 20 years. We also investigated the association between height, body mass index (BMI), and TBS, agreement between TBS and lumbar spine areal bone mineral density (aBMD) and bone mineral apparent density (BMAD) Z-scores, tracking of TBS Z-scores over time, and precision of TBS measurements. We performed secondary analysis of spine dual-energy X-ray absorptiometry (DXA) scans from the Bone Mineral Density in Childhood Study (BMDCS), a mixed longitudinal cohort of healthy children (n = 2014) evaluated at five US centers. TBS was derived using a dedicated TBS algorithm accounting for tissue thickness rather than BMI. TBS increased only during ages corresponding to pubertal development with an earlier increase in females than males. There were no differences in TBS between African Americans and non-African Americans. We provide sex-specific TBS reference ranges and LMS values for calculation of TBS Z-scores by age and means and SD for calculation of Z-scores by pubertal stage. TBS Z-scores were positively associated with height Z-scores at some ages. TBS Z-scores explained only 27% and 17% of the variance of spine aBMD and BMAD Z-scores. Tracking of TBS Z-scores over 6 years was lower (r = 0.47) than for aBMD or BMAD Z-scores (r = 0.74 to 0.79), and precision error of TBS (2.87%) was greater than for aBMD (0.85%) and BMAD (1.22%). In sum, TBS Z-scores provide information distinct from spine aBMD and BMAD Z-scores. Our robust reference ranges for TBS in a well-characterized pediatric cohort and precision error estimates provide essential tools for clinical assessment using TBS and determination of its value in predicting bone fragility in childhood and adolescence. © 2022 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Heidi J Kalkwarf
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | | | - Didier Hans
- Interdisciplinary Center for Bone Diseases, Bone and Joint Department, Lausanne University and Lausanne University Hospital, Lausanne, Switzerland
| | - Elena Gonzalez Rodriguez
- Interdisciplinary Center for Bone Diseases, Bone and Joint Department, Lausanne University and Lausanne University Hospital, Lausanne, Switzerland
| | - Joseph M Kindler
- Department of Nutritional Sciences, University of Georgia, Athens, GA, USA
| | - Joan M Lappe
- Department of Medicine, Creighton University, Omaha, NE, USA
| | - Sharon Oberfield
- Division of Pediatric Endocrinology, Diabetes, and Metabolism, Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - Karen K Winer
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Babette S Zemel
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Laakso S, Holopainen E, Betterle C, Saari V, Vogt E, Schmitt MM, Winer KK, Kareva M, Sabbadin C, Husebye ES, Orlova E, Lionakis MS, Mäkitie O. Pregnancy Outcome in Women With APECED (APS-1): A Multicenter Study on 43 Females With 83 Pregnancies. J Clin Endocrinol Metab 2022; 107:e528-e537. [PMID: 34570215 PMCID: PMC8764323 DOI: 10.1210/clinem/dgab705] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Indexed: 01/19/2023]
Abstract
CONTEXT Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED; also known as autoimmune polyendocrine syndrome type 1) has a severe, unpredictable course. Autoimmunity and disease components may affect fertility and predispose to maternal and fetal complications, but pregnancy outcomes remain unknown. OBJECTIVE To assess fetal and maternal outcomes and course of clinical APECED manifestations during pregnancy in women with APECED. DESIGN AND SETTING A multicenter registry-based study including 5 national patient cohorts. PATIENTS 321 females with APECED. MAIN OUTCOME MEASURE Number of pregnancies, miscarriages, and deliveries. RESULTS Forty-three patients had altogether 83 pregnancies at median age of 27 years (range, 17-39). Sixty (72%) pregnancies led to a delivery, including 2 stillbirths (2.4%) and 5 (6.0%) preterm livebirths. Miscarriages, induced abortions, and ectopic pregnancies were observed in 14 (17%), 8 (10%), and 1 (1.2%) pregnancies, respectively. Ovum donation resulted in 5 (6.0%) pregnancies. High maternal age, premature ovarian insufficiency, primary adrenal insufficiency, or hypoparathyroidism did not associate with miscarriages. Women with livebirth had, on average, 4 APECED manifestations (range 0-10); 78% had hypoparathyroidism, and 36% had primary adrenal insufficiency. APECED manifestations remained mostly stable during pregnancy, but in 1 case, development of primary adrenal insufficiency led to adrenal crisis and stillbirth. Birth weights were normal in >80% and apart from 1 neonatal death of a preterm baby, no serious perinatal complications occurred. CONCLUSIONS Outcome of pregnancy in women with APECED was generally favorable. However, APECED warrants careful maternal multidisciplinary follow-up from preconceptual care until puerperium.
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Affiliation(s)
- Saila Laakso
- Children’s Hospital and Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Folkhälsan Research Center, Helsinki, Finland
- Correspondence: Saila Laakso, MD, PhD, Children’s Hospital, Stenbäckinkatu 9, FI-00290 Helsinki, Finland.
| | - Elina Holopainen
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Corrado Betterle
- Endocrine Unit, Department of Medicine (DIMED), University of Padua, Padua,Italy
| | - Viivi Saari
- Children’s Hospital and Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Elinor Vogt
- Department of Clinical Science and K.G. Jebsen Center for Autoimmune Diseases, University of Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Monica M Schmitt
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy & Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Karen K Winer
- Eunice Kennedy Shriver National Institutes of Child Health and Human Development (NICHD), National Institutes of Health, Bethesda, MD,USA
| | | | - Chiara Sabbadin
- Endocrine Unit, Department of Medicine (DIMED), University of Padua, Padua,Italy
| | - Eystein S Husebye
- Department of Clinical Science and K.G. Jebsen Center for Autoimmune Diseases, University of Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | | | - Michail S Lionakis
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy & Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Outi Mäkitie
- Children’s Hospital and Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Folkhälsan Research Center, Helsinki, Finland
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Winer KK, Ye S, Ferré EMN, Schmitt MM, Zhang B, Cutler GB, Lionakis MS. Therapy with PTH 1-34 or calcitriol and calcium in diverse etiologies of hypoparathyroidism over 27 years at a single tertiary care center. Bone 2021; 149:115977. [PMID: 33932619 DOI: 10.1016/j.bone.2021.115977] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 04/14/2021] [Accepted: 04/22/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Hypoparathyroidism has heterogeneous genetic and acquired etiologies with a broad spectrum of severity. Herein we describe the clinical outcomes of the largest cohort of hypoparathyroid patients reported to date, who were followed over 27-years. DESIGN Pooled analysis of current and past studies describing the differential responses to PTH 1-34 injections vs conventional therapy among the varied hypoPT etiologies. METHODS 192 participants (ages 2-74 years) with hypoparathyroidism who received either calcitriol and calcium or PTH 1-34 by subcutaneous injection. RESULTS Among the 4 main etiologic categories of hypoparathyroidism (autoimmune polyglandular failure type 1, activating mutation of the calcium receptor, surgical, and idiopathic hypoparathyroidism), we reveal significant differences in PTH 1-34 dose requirements, prevalence of nephrocalcinosis, biomarkers of mineral homeostasis, and pharmacodynamic profiles. Serum 1,25-dihydroxyvitamin D3 increased significantly (P < 0.001) and 25-hydroxyvitamin D levels decreased during PTH 1-34 injections compared to calcitriol therapy (P < 0.01). Post-surgical patients achieved consistently lower urine calcium excretion over long-term PTH 1-34 therapy compared to conventional therapy (p < 0.001), but this was not achieved in the other etiologies. At study entry, patients had a high prevalence of renal insufficiency and nephrocalcinosis which were directly related to the duration of hypoparathyroidism (P < 0.03). Renal function remained stable during participation in our studies for both PTH 1-34 and conventional therapies. CONCLUSIONS We conclude that the effects and dose-response of PTH 1-34 treatment differ according to the etiology of hypoparathyroidism. Postsurgical hypoPT maintained mean serum calcium levels in the mid- to low-normal range while concurrently maintaining normal mean urine calcium during long-term twice-daily PTH 1-34 therapy.
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Affiliation(s)
- Karen K Winer
- Eunice Kennedy Shriver National Institutes of Child Health and Human Development (NICHD), NIH, Bethesda, MD, USA.
| | - Shangyuan Ye
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, USA
| | - Elise M N Ferré
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, MD, USA
| | - Monica M Schmitt
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, MD, USA
| | - Bo Zhang
- Department of Neurology and ICCTR Biostatistics and Research Design Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Gordon B Cutler
- Eunice Kennedy Shriver National Institutes of Child Health and Human Development (NICHD), NIH, Bethesda, MD, USA
| | - Michail S Lionakis
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, MD, USA
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8
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Winer KK, Schmitt MM, Ferre EMN, Fennelly KP, Olivier KN, Heller T, Lionakis MS. Impact of periprocedural subcutaneous parathyroid hormone on control of hypocalcaemia in APS-1/APECED patients undergoing invasive procedures. Clin Endocrinol (Oxf) 2021; 94:377-383. [PMID: 32955743 DOI: 10.1111/cen.14335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/09/2020] [Accepted: 09/01/2020] [Indexed: 12/11/2022]
Abstract
CONTEXT The monogenic disorder autoimmune polyendocrine syndrome type 1 (APS-1) or autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) manifests frequently with hypoparathyroidism, which requires treatment with oral supplementation with calcium and active vitamin D analogs. The majority of APS-1/APECED patients also suffer from intestinal malabsorption, which complicates the management of hypoparathyroidism and may lead to refractory severe hypocalcaemia. In such situations, reliance on intravenous calcium carries a high risk of nephrocalcinosis and renal damage. METHODS Here, we report our experience of periprocedural subcutaneous administration of recombinant human parathyroid hormone (rhPTH 1-34) in APS-1/APECED patients. Serum calcium was measured up to five times within the 36-hour period starting the evening before the scheduled procedure and ending the morning following the procedure. RESULTS Twenty-seven APS-1/APECED patients with hypoparathyroidism (aged 4-67 years) underwent 31 invasive gastrointestinal and/or pulmonary procedures. The patients received an average rhPTH1-34 dose of 9.6 ± 1.4 µg by subcutaneous injection. 92% of the adults and 54% of children in our cohort had evidence of nephrocalcinosis. Mean calcium levels remained stable and ranged from 2.06 to 2.17 mmol/L with minimal fluctuation. None of our patients experienced periprocedural adverse events connected with hypocalcaemia. CONCLUSION rhPTH 1-34 is an alternative to conventional therapy in patients with APS-1/APECED and hypoparathyroidism undergoing invasive procedures. Subcutaneous PTH1-34 given directly before and after procedures resulted in well-controlled serum calcium levels maintained in the low-normal range and avoided the need for intravenous calcium which may contribute to renal calcifications and tubular damage.
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Affiliation(s)
- Karen K Winer
- Eunice Kennedy Shriver National Institutes of Child Health and Human Development (NICHD), NIH, Bethesda, MD, USA
| | - Monica M Schmitt
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, MD, USA
| | - Elise M N Ferre
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, MD, USA
| | - Kevin P Fennelly
- Laboratory of Chronic Airway Infection, Pulmonary Branch, National Heart, Lung, and Blood Institute (NHLBI), Bethesda, MD, USA
| | - Kenneth N Olivier
- Laboratory of Chronic Airway Infection, Pulmonary Branch, National Heart, Lung, and Blood Institute (NHLBI), Bethesda, MD, USA
| | - Theo Heller
- Translational Hepatology Section, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), NIH, Bethesda, MD, USA
| | - Michail S Lionakis
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, MD, USA
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9
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Zemel BS, Wasserman H, Kelly A, Fan B, Shepherd J, Lappe J, Gilsanz V, Oberfield S, Winer KK, Kalkwarf HJ. Intermachine differences in DXA measurements vary by skeletal site, and impact the assessment of low bone density in children. Bone 2020; 141:115581. [PMID: 32795677 PMCID: PMC7680379 DOI: 10.1016/j.bone.2020.115581] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 07/29/2020] [Accepted: 08/07/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Bone mineral content (BMC) and areal-bone mineral density (aBMD) measurements of the lumbar spine (LS) and whole body less head (WBLH) by dual energy X-ray absorptiometry (DXA) are recommended for bone health assessment in children. Intermachine differences were not considered previously in formulating these recommendations. METHODOLOGY DXA measurements of the LS, WBLH, total hip, femoral neck and distal 1/3 radius from the Bone Mineral Density in Childhood Study were examined. Healthy children, ages 6 to 16 years, from five clinical centers participated. The same spine, whole body, and femur phantoms were measured on each Center's DXA machine. Percentage of individuals with low BMC or aBMD (Z-score < -1.5) was determined. Clinical center differences were evaluated by analysis of covariance adjusting for height and BMI Z-score, calcium intake, physical activity, Tanner stage and bone age. Logistic regression assessed odds of low BMC or aBMD across clinical centers. RESULTS Significant differences among Clinical Centers (p < 0.05) were evident in adjusted mean BMC and aBMD Z-scores (n = 1503) for all skeletal sites. WBLH BMC and aBMD Z-scores had the greatest range across centers (-0.13 to 0.24, and -0.17 to 0.56, respectively). The percentage of children with Z-scores less than -1.5 varied among Clinical Centers from 1.9 [95%CI 0.8, 4.5] to 8.1 [95%CI 5.7, 11.3] for WBLH BMC, 1.1 [95%CI 0.4, 3.5] to 6.3 [95%CI 3.8, 10.1] for WBLH aBMD, and from 4.4 [95%CI 2.8, 7.0] to 12.6 [95%CI 9.3, 16.9] for distal 1/3 radius aBMD. For each skeletal site except total hip aBMD and femoral neck BMC, at least one center had significantly lower odds of low bone density. CONCLUSIONS By design, our reference ranges capture intermachine variability. Most clinical centers don't know where their machine falls within the range of intermachine variability, and this may affect diagnosis of children evaluated for conditions that threaten bone health. Total hip scans showed the least, and whole body scans showed the most intermachine variability. Pediatric bone health assessment recommendations should recognize intermachine differences and address this important issue.
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Affiliation(s)
- Babette S Zemel
- Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, United States of America; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, United States of America.
| | - Halley Wasserman
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, United States of America; Department of Pediatrics, University of Cincinnati College of Medicine, United States of America
| | - Andrea Kelly
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, United States of America; Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, United States of America
| | - Bo Fan
- Department of Radiology, University of California San Francisco, San Francisco, United States of America
| | - John Shepherd
- University of Hawaii Cancer Center, University of Hawaii (Manoa), United States of America
| | - Joan Lappe
- Division of Endocrinology, Department of Medicine, Creighton University, Omaha, United States of America
| | - Vicente Gilsanz
- Departments of Orthopaedic Surgery and Radiology, Children's Hospital Los Angeles, Los Angeles, CA, United States of America
| | - Sharon Oberfield
- Division of Pediatric Endocrinology, Diabetes, and Metabolism, Department of Pediatrics, Columbia University Medical Center, New York, United States of America
| | - Karen K Winer
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States of America
| | - Heidi J Kalkwarf
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, United States of America; Department of Pediatrics, University of Cincinnati College of Medicine, United States of America
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10
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Kindler JM, Kalkwarf HJ, Lappe JM, Gilsanz V, Oberfield S, Shepherd JA, Kelly A, Winer KK, Zemel BS. Pediatric Reference Ranges for Ultradistal Radius Bone Density: Results from the Bone Mineral Density in Childhood Study. J Clin Endocrinol Metab 2020; 105:5860168. [PMID: 32561914 PMCID: PMC7465545 DOI: 10.1210/clinem/dgaa380] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 06/12/2020] [Indexed: 01/22/2023]
Abstract
CONTEXT The ultradistal (UD) radius is rich in trabecular bone and is easily measured by dual energy X-ray absorptiometry (DXA). UD radius areal bone mineral density (aBMD) may help identify trabecular bone deficits, but reference data are needed for research and clinical interpretation of this measure. OBJECTIVE We developed age-, sex-, and population ancestry-specific reference ranges for UD radius aBMD assessed by DXA and calculated Z-scores. We examined tracking of UD radius aBMD Z-scores over 6 years and determined associations between UD radius aBMD Z-scores and other bone measures by DXA and peripheral quantitative computed tomography. DESIGN Multicenter longitudinal study. PARTICIPANTS A total of 2014 (922 males, 22% African American) children ages 5 to 19 years at enrollment who participated in the Bone Mineral Density in Childhood Study. MAIN OUTCOME MEASURE UD radius aBMD. RESULTS UD radius aBMD increased nonlinearly with age (P < 0.001) and tended to be greater in males versus females (P = 0.054). Age-, sex-, and ancestry-specific UD radius aBMD reference curves were constructed. UD radius aBMD Z-scores positively associated with Z-scores at other skeletal sites (r = 0.54-0.64, all P < 0.001) and peripheral quantitative computed tomography measures of distal radius total volumetric BMD (r = 0.68, P < 0.001) and trabecular volumetric BMD (r = 0.70, P < 0.001), and was weakly associated with height Z-score (r = 0.09, P = 0.015). UD radius aBMD Z-scores tracked strongly over 6 years, regardless of pubertal stage (r = 0.66-0.69; all P < 0.05). CONCLUSION UD radius aBMD Z-scores strongly associated with distal radius trabecular bone density, with marginal confounding by stature. These reference data may provide a valuable resource for bone health assessment in children.
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Affiliation(s)
- Joseph M Kindler
- Division of Gastroenterology, Hepatology and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Heidi J Kalkwarf
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Joan M Lappe
- Division of Endocrinology, Department of Medicine, Creighton University, Omaha, Nebraska
| | - Vicente Gilsanz
- Department of Radiology, Children’s Hospital Los Angeles, Los Angeles, California
| | - Sharon Oberfield
- Division of Pediatric Endocrinology, Diabetes, and Metabolism, Department of Pediatrics, Columbia University Medical Center, New York, New York
| | | | - Andrea Kelly
- Division of Endocrinology and Diabetes, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Karen K Winer
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Babette S Zemel
- Division of Gastroenterology, Hepatology and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- Correspondence and Reprint Requests: Babette S. Zemel, PhD, Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia, Roberts Center for Pediatric Research, 2716 South Street, 14th Floor/Room 14471, Philadelphia, PA 19146, USA. E-mail:
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11
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Ferré EMN, Break TJ, Burbelo PD, Allgäuer M, Kleiner DE, Jin D, Xu Z, Folio LR, Mollura DJ, Swamydas M, Gu W, Hunsberger S, Lee CCR, Bondici A, Hoffman KW, Lim JK, Dobbs K, Niemela JE, Fleisher TA, Hsu AP, Snow LN, Darnell DN, Ojaimi S, Cooper MA, Bozzola M, Kleiner GI, Martinez JC, Deterding RR, Kuhns DB, Heller T, Winer KK, Rajan A, Holland SM, Notarangelo LD, Fennelly KP, Olivier KN, Lionakis MS. Lymphocyte-driven regional immunopathology in pneumonitis caused by impaired central immune tolerance. Sci Transl Med 2020; 11:11/495/eaav5597. [PMID: 31167928 DOI: 10.1126/scitranslmed.aav5597] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 04/05/2019] [Indexed: 12/19/2022]
Abstract
Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED), a monogenic disorder caused by AIRE mutations, presents with several autoimmune diseases. Among these, endocrine organ failure is widely recognized, but the prevalence, immunopathogenesis, and treatment of non-endocrine manifestations such as pneumonitis remain poorly characterized. We enrolled 50 patients with APECED in a prospective observational study and comprehensively examined their clinical and radiographic findings, performed pulmonary function tests, and analyzed immunological characteristics in blood, bronchoalveolar lavage fluid, and endobronchial and lung biopsies. Pneumonitis was found in >40% of our patients, presented early in life, was misdiagnosed despite chronic respiratory symptoms and accompanying radiographic and pulmonary function abnormalities, and caused hypoxemic respiratory failure and death. Autoantibodies against BPIFB1 and KCNRG and the homozygous c.967_979del13 AIRE mutation are associated with pneumonitis development. APECED pneumonitis features compartmentalized immunopathology, with accumulation of activated neutrophils in the airways and lymphocytic infiltration in intraepithelial, submucosal, peribronchiolar, and interstitial areas. Beyond APECED, we extend these observations to lung disease seen in other conditions with secondary AIRE deficiency (thymoma and RAG deficiency). Aire-deficient mice had similar compartmentalized cellular immune responses in the airways and lung tissue, which was ameliorated by deficiency of T and B lymphocytes. Accordingly, T and B lymphocyte-directed immunomodulation controlled symptoms and radiographic abnormalities and improved pulmonary function in patients with APECED pneumonitis. Collectively, our findings unveil lung autoimmunity as a common, early, and unrecognized manifestation of APECED and provide insights into the immunopathogenesis and treatment of pulmonary autoimmunity associated with impaired central immune tolerance.
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Affiliation(s)
- Elise M N Ferré
- Fungal Pathogenesis Section, LCIM, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Timothy J Break
- Fungal Pathogenesis Section, LCIM, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Peter D Burbelo
- Dental Clinical Research Core, National Institute of Dental and Craniofacial Research (NIDCR), NIH, Bethesda, MD 20892, USA
| | - Michael Allgäuer
- Laboratory of Pathology, Center for Cancer Research, NCI, NIH, Bethesda, MD 20892, USA.,Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany
| | - David E Kleiner
- Laboratory of Pathology, Center for Cancer Research, NCI, NIH, Bethesda, MD 20892, USA
| | - Dakai Jin
- Radiology and Imaging Sciences, NIH Clinical Center (CC), NIH, Bethesda, MD 20892, USA
| | - Ziyue Xu
- Radiology and Imaging Sciences, NIH Clinical Center (CC), NIH, Bethesda, MD 20892, USA
| | - Les R Folio
- Radiology and Imaging Sciences, NIH Clinical Center (CC), NIH, Bethesda, MD 20892, USA
| | - Daniel J Mollura
- Radiology and Imaging Sciences, NIH Clinical Center (CC), NIH, Bethesda, MD 20892, USA
| | - Muthulekha Swamydas
- Fungal Pathogenesis Section, LCIM, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Wenjuan Gu
- Biostatistics Research Branch, Division of Clinical Research (DCR), NIAID, NIH, Bethesda, MD 20892, USA
| | - Sally Hunsberger
- Biostatistics Research Branch, Division of Clinical Research (DCR), NIAID, NIH, Bethesda, MD 20892, USA
| | - Chyi-Chia R Lee
- Laboratory of Pathology, Center for Cancer Research, NCI, NIH, Bethesda, MD 20892, USA
| | - Anamaria Bondici
- Fungal Pathogenesis Section, LCIM, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Kevin W Hoffman
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Jean K Lim
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Kerry Dobbs
- Immune Deficiency Genetics Section, LCIM, NIAID, NIH, Bethesda, MD 20892, USA
| | - Julie E Niemela
- Immunology Service, Department of Laboratory Medicine (DLM), NIH CC, NIH, Bethesda, MD 20892, USA
| | - Thomas A Fleisher
- Immunology Service, Department of Laboratory Medicine (DLM), NIH CC, NIH, Bethesda, MD 20892, USA
| | - Amy P Hsu
- Immunopathogenesis Section, LCIM, NIAID, NIH, Bethesda, MD 20892, USA
| | - Laquita N Snow
- Fungal Pathogenesis Section, LCIM, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Dirk N Darnell
- Fungal Pathogenesis Section, LCIM, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Samar Ojaimi
- Department of Infectious Diseases, Monash Health, Melbourne, VIC 3800, Australia.,Centre for Inflammatory Diseases, Monash University, Melbourne, VIC 3800, Australia
| | - Megan A Cooper
- Department of Pediatrics, Division of Rheumatology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Martin Bozzola
- Department of Pediatrics, British Hospital, Perdriel 74, CABA-Buenos Aires, Argentina
| | - Gary I Kleiner
- University of Miami Department of Pediatrics, Miami, FL 33136, USA
| | - Juan C Martinez
- Cystic Fibrosis, Pulmonary, and Sleep Division, Joe DiMaggio Children's Hospital, Hollywood, FL 33021, USA
| | - Robin R Deterding
- Department of Pediatrics, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO 80045, USA
| | - Douglas B Kuhns
- Neutrophil Monitoring Laboratory, Applied/Developmental Research Directorate, Frederick National Laboratory for Cancer Research, Leidos Biomedical Research Inc., Frederick, MD 21701, USA
| | - Theo Heller
- Translational Hepatology Section, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD 20892, USA
| | - Karen K Winer
- Pediatric Growth and Nutrition Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Bethesda, MD 20892, USA
| | - Arun Rajan
- Thoracic and Gastrointestinal Malignancies Branch, Center for Cancer Research, NCI, NIH, Bethesda, MD 20892, USA
| | - Steven M Holland
- Immunopathogenesis Section, LCIM, NIAID, NIH, Bethesda, MD 20892, USA
| | - Luigi D Notarangelo
- Immune Deficiency Genetics Section, LCIM, NIAID, NIH, Bethesda, MD 20892, USA
| | - Kevin P Fennelly
- Laboratory of Chronic Airway Infection, Pulmonary Branch, National Heart, Lung, and Blood Institute (NHLBI), Bethesda, MD 20892, USA
| | - Kenneth N Olivier
- Laboratory of Chronic Airway Infection, Pulmonary Branch, National Heart, Lung, and Blood Institute (NHLBI), Bethesda, MD 20892, USA
| | - Michail S Lionakis
- Fungal Pathogenesis Section, LCIM, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA.
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12
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Kindler JM, Lappe JM, Gilsanz V, Oberfield S, Shepherd JA, Kelly A, Winer KK, Kalkwarf HJ, Zemel BS. Lumbar Spine Bone Mineral Apparent Density in Children: Results From the Bone Mineral Density in Childhood Study. J Clin Endocrinol Metab 2019; 104:1283-1292. [PMID: 30265344 PMCID: PMC6397436 DOI: 10.1210/jc.2018-01693] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 09/24/2018] [Indexed: 12/31/2022]
Abstract
CONTEXT Dual-energy X-ray absorptiometry (DXA) is a cornerstone of pediatric bone health assessment, yet differences in height-for-age confound the interpretation of areal bone mineral density (aBMD) measures. To reduce the confounding of short stature on spine bone density, use of bone mineral apparent density (BMAD) and height-for-age Z-score (HAZ)‒adjusted aBMD (aBMDHAZ) are recommended. However, spine BMAD reference data are sparse, and the degree to which BMAD and aBMDHAZ account for height-related artifacts in bone density remains unclear. OBJECTIVE We developed age-, sex-, and population ancestry‒specific spine BMAD reference ranges; compared height-adjustment methods in accounting for shorter stature; and assessed the stability of these measures over time. DESIGN Secondary analysis of data from a previous longitudinal study. PARTICIPANTS Children and adolescents aged 5 to 19 years at baseline (n = 2014; 922 males; 22% black) from the Bone Mineral Density in Childhood Study. MAIN OUTCOME MEASURES Lumbar spine BMAD and aBMDHAZ from DXA. RESULTS Spine BMAD increased nonlinearly with age and was greater in blacks and females (all P < 0.001). Age-specific spine BMAD z-score reference curves were constructed for black and non‒black males and females. Overall, both BMAD and aBMDHAZz scores reduced the confounding influence of shorter stature, but neither was consistently unbiased across all age ranges. Both BMAD and aBMDHAZz scores tracked strongly over 6 years (r = 0.70 to 0.80; all P < 0.001). CONCLUSION This study provided robust spine BMAD reference ranges and demonstrated that BMAD and aBMDHAZ partially reduced the confounding influence of shorter stature on bone density.
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Affiliation(s)
- Joseph M Kindler
- Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Joan M Lappe
- Division of Endocrinology, Department of Medicine, Creighton University, Omaha, Nebraska
| | - Vicente Gilsanz
- Department of Radiology, Children's Hospital Los Angeles, Los Angeles, California
| | - Sharon Oberfield
- Division of Pediatric Endocrinology, Diabetes, and Metabolism, Department of Pediatrics, Columbia University Medical Center, New York, New York
| | | | - Andrea Kelly
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Karen K Winer
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Heidi J Kalkwarf
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Babette S Zemel
- Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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13
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Abstract
Hypoparathyroidism is a rare disorder of calcium metabolism which is treated with calcium and vitamin D analogs. Although conventional therapy effectively raises serum calcium, it bypasses the potent calcium reabsorption effects of PTH on the kidney which leads to hypercalciuria and an increased risk of nephrocalcinosis and renal insufficiency. Twenty-five years ago, we launched the first systematic investigation into synthetic human PTH 1-34 replacement therapy in both adults and children. These studies led to our current understanding of the complex nature of PTH 1-34 therapy and to the challenges we still face in our pursuit of a safe and effective physiologic replacement therapy for hypoparathyroidism. The normalization and minimal fluctuation of serum and urine calcium levels were the primary management goals. As the frequency of PTH 1-34 injections increased, the total daily dose required to normalize calcium homeostasis decreased and episodes of hypercalcemia and hypercalciuria diminished, producing a more physiologic biochemical profile. Twice-daily injections achieved simultaneous normalization of serum and urine calcium levels in many patients but the persistent elevation of bone markers and the difficulty in reducing urine calcium to normal levels in the more severe cases, suggested an alternative to PTH 1-34 injections was needed. The studies with PTH 1-34 delivered by insulin pump represent an important advance in the management of hypoparathyroidism. PTH 1-34 delivered by insulin pump normalized serum and urine calcium and markers of bone turnover. Additionally, pump delivery of PTH 1-34 produced stable magnesium values within the normal range and reduced magnesium excretion. Currently, PTH 1-34 delivery by pump is the only alternative to PTH injections that has been tested in both adults and children and proven to achieve a physiologic biochemical profile.
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Affiliation(s)
- Karen K Winer
- Eunice Kennedy Shriver National Institutes of Child health and Human Development, NIH, Bethesda, MD, United States.
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14
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Kelly A, Shults J, Mostoufi-Moab S, McCormack SE, Stallings VA, Schall JI, Kalkwarf HJ, Lappe JM, Gilsanz V, Oberfield SE, Shepherd JA, Winer KK, Leonard MB, Zemel BS. Pediatric Bone Mineral Accrual Z-Score Calculation Equations and Their Application in Childhood Disease. J Bone Miner Res 2019; 34:195-203. [PMID: 30372552 PMCID: PMC7794655 DOI: 10.1002/jbmr.3589] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Revised: 08/25/2018] [Accepted: 09/10/2018] [Indexed: 12/30/2022]
Abstract
Annual gains in BMC and areal bone mineral density (aBMD) in children vary with age, pubertal status, height-velocity, and lean body mass accrual (LBM velocity). Evaluating bone accrual in children with bone health-threatening conditions requires consideration of these determinants. The objective of this study was to develop prediction equations for calculating BMC/aBMD velocity SD scores (velocity-Z) and to evaluate bone accrual in youth with health conditions. Bone and body compositions via DXA were obtained for up to six annual intervals in healthy youth (n = 2014) enrolled in the Bone Mineral Density in Childhood Study (BMDCS) . Longitudinal statistical methods were used to develop sex- and pubertal-status-specific reference equations for calculating velocity-Z for total body less head-BMC and lumbar spine (LS), total hip (TotHip), femoral neck, and 1/3-radius aBMD. Equations accounted for (1) height velocity, (2) height velocity and weight velocity, or (3) height velocity and LBM velocity. These equations were then applied to observational, single-center, 12-month longitudinal data from youth with cystic fibrosis (CF; n = 65), acute lymphoblastic leukemia (ALL) survivors (n = 45), or Crohn disease (CD) initiating infliximab (n = 72). Associations between BMC/aBMD-Z change (conventional pediatric bone health monitoring method) and BMC/aBMD velocity-Z were assessed. The BMC/aBMD velocity-Z for CF, ALL, and CD was compared with BMDCS. Annual changes in the BMC/aBMD-Z and the BMC/aBMD velocity-Z were strongly correlated, but not equivalent; LS aBMD-Z = 1 equated with LS aBMD velocity-Z = -3. In CF, BMC/aBMD velocity-Z was normal. In posttherapy ALL, BMC/aBMD velocity-Z was increased, particularly at TotHip (1.01 [-.047; 1.7], p < 0.0001). In CD, BMC/aBMD velocity-Z was increased at all skeletal sites. LBM-velocity adjustment attenuated these increases (eg, TotHip aBMD velocity-Z: 1.13 [0.004; 2.34] versus 1.52 [0.3; 2.85], p < 0.0001). Methods for quantifying the BMC/aBMD velocity that account for maturation and body composition changes provide a framework for evaluating childhood bone accretion and may provide insight into mechanisms contributing to altered accrual in chronic childhood conditions. © 2018 American Society for Bone and Mineral Research.
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Affiliation(s)
- Andrea Kelly
- Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Justine Shults
- Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Sogol Mostoufi-Moab
- Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Shana E McCormack
- Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Virginia A Stallings
- Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Joan I Schall
- Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Heidi J Kalkwarf
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Joan M Lappe
- College of Nursing, Creighton University, Omaha, NE, USA
| | - Vicente Gilsanz
- Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | - John A Shepherd
- Bioengineering, University of California-San Francisco, San Francisco, CA, USA
| | - Karen K Winer
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Mary B Leonard
- Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Department of Pediatrics, Stanford School of Medicine, Palo Alto, CA, USA
| | - Babette S Zemel
- Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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15
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Winer KK, Kelly A, Johns A, Zhang B, Dowdy K, Kim L, Reynolds JC, Albert PS, Cutler GB. Long-Term Parathyroid Hormone 1-34 Replacement Therapy in Children with Hypoparathyroidism. J Pediatr 2018; 203:391-399.e1. [PMID: 30470382 PMCID: PMC6298875 DOI: 10.1016/j.jpeds.2018.08.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 07/26/2018] [Accepted: 08/08/2018] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To determine whether multiple daily injections of parathyroid hormone (PTH) 1-34 are safe and effective as long-term therapy for children with hypoparathyroidism. STUDY DESIGN Linear growth, bone accrual, renal function, and mineral homeostasis were studied in a long-term observational study of PTH 1-34 injection therapy in 14 children. METHODS Subjects were 14 children with hypoparathyroidism attributable to autoimmune polyglandular syndrome type 1 (N = 5, ages 7-12 years) or calcium receptor mutation (N = 9, ages 7-16 years). Mean daily PTH 1-34 dose was 0.75 ± 0.15 µg/kg/day. Treatment duration was 6.9 ± 3.1 years (range 1.5-10 years). Patients were evaluated semiannually at the National Institutes of Health Clinical Center. RESULTS Mean height velocity and lumbar spine, whole body, and femoral neck bone accretion velocities were normal throughout the study. In the first 2 years, distal one-third radius bone accrual velocity was reduced compared with normal children (P < .003). Serum alkaline phosphatase correlated with PTH 1-34 dose (P < .006) and remained normal (235.3 ± 104.8 [SD] U/L, N: 51-332 U/L). Mean serum and 24-hour urine calcium levels were 2.05 ± 0.11 mmol/L (N: 2.05-2.5 mmol/L) and 6.93 ± 1.3 mmol/24 hour (N: 1.25-7.5 mmol/24 hour), respectively-with fewer high urine calcium levels vs baseline during calcitriol and calcium treatment (P < .001). Nephrocalcinosis progressed in 5 of 12 subjects who had repeated renal imaging although renal function remained normal. CONCLUSIONS Twice-daily or thrice-daily subcutaneous PTH 1-34 injections provided safe and effective replacement therapy for up to 10 years in children with hypoparathyroidism because of autoimmune polyglandular syndrome type 1 or calcium receptor mutation.
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Affiliation(s)
- Karen K. Winer
- Eunice Kennedy Shriver NICHD/ National Institutes of Health 6710B Rockledge Dr, Bethesda MD
20892
| | - Andrea Kelly
- Division of Endocrinology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Alicia Johns
- PreDoctoral (AJ) and Postdoc (BZ) students in the Division of Intramural Population Health Research, NICHD at
the time of the studies. BZ current address: Dept. of Quantitative Health Sciences, University of Massachusetts Medical School,
Worcester, MA
| | - Bo Zhang
- PreDoctoral (AJ) and Postdoc (BZ) students in the Division of Intramural Population Health Research, NICHD at
the time of the studies. BZ current address: Dept. of Quantitative Health Sciences, University of Massachusetts Medical School,
Worcester, MA
| | | | - Lauren Kim
- NIH Clinical Center, Radiology and Imaging Sciences, Bethesda, MD; James Reynolds: Nuclear Medicine
Division
| | - James C. Reynolds
- NIH Clinical Center, Radiology and Imaging Sciences, Bethesda, MD; James Reynolds: Nuclear Medicine
Division
| | - Paul S. Albert
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH
| | - Gordon B. Cutler
- GBC: Involved in designing and implementing the study, now independent consultant, Deltaville, VA
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16
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Winer KK. Does PTH Replacement Therapy Improve Quality of Life in Patients With Chronic Hypoparathyroidism? J Clin Endocrinol Metab 2018; 103:2752-2755. [PMID: 29897557 PMCID: PMC6276667 DOI: 10.1210/jc.2017-02593] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 04/17/2018] [Indexed: 12/28/2022]
Abstract
Studies have examined the impact of PTH on QoL but have not demonstrated improvements compared with controls. Vokes et al. and Palermo et al. have explored QoL in hypoparathyroidism in response to PTH.
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Affiliation(s)
- Karen K Winer
- Pediatric Growth and Nutrition Branch, National Institute of Child Health and
Human Development, National Institutes of Health, Bethesda, Maryland
- Correspondence and Reprint Requests: Karen K. Winer, MD, Pediatric Growth and Nutrition Branch (PGNB), The Eunice
Kennedy Shriver National Institute of Child Health and Human Development, National
Institutes of Health, 6710B Rockledge Drive, Room 2126, Bethesda, Maryland 20892-7002.
E-mail:
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17
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Mannstadt M, Bilezikian JP, Thakker RV, Hannan FM, Clarke BL, Rejnmark L, Mitchell DM, Vokes TJ, Winer KK, Shoback DM. Hypoparathyroidism. Nat Rev Dis Primers 2017; 3:17080. [PMID: 28980621 DOI: 10.1038/nrdp.2017.80] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
This corrects the article DOI: 10.1038/nrdp.2017.55.
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18
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McCormack SE, Cousminer DL, Chesi A, Mitchell JA, Roy SM, Kalkwarf HJ, Lappe JM, Gilsanz V, Oberfield SE, Shepherd JA, Winer KK, Kelly A, Grant SFA, Zemel BS. Association Between Linear Growth and Bone Accrual in a Diverse Cohort of Children and Adolescents. JAMA Pediatr 2017; 171:e171769. [PMID: 28672287 PMCID: PMC5632753 DOI: 10.1001/jamapediatrics.2017.1769] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE Prevention of osteoporosis in adulthood begins with optimizing bone health in early life. The longitudinal association between growth and bone accretion during childhood is not fully understood. OBJECTIVES To assess the acquisition of whole-body (WB) and skeletal site-specific bone mineral content (BMC) relative to linear growth in a healthy, diverse, longitudinal cohort of children, adolescents, and young adults and to test for differences related to sex and African American race. DESIGN, SETTING, AND PARTICIPANTS This investigation was a mixed longitudinal study with annual assessments for up to 7 years at 5 US clinical centers. Participants were healthy children, adolescents, and young adults. The study dates were July 2002 through March 2010. The dates of the analysis were June through December 2016. MAIN OUTCOMES AND MEASURES Anthropometrics, BMC, and body composition via dual-energy x-ray absorptiometry. The superimposition by translation and rotation (SITAR) analysis method was used to define the mean trajectories for height, WB lean soft tissue, appendicular lean soft tissue, and WB and skeletal site-specific BMC acquisition and to measure the age and magnitude of peak velocity for each parameter. The SITAR modeling was performed separately by sex and self-reported race. RESULTS Among 2014 healthy children, adolescents, and young adults (1022 [50.7%] female and 479 [23.8%] African American) aged 5 to 19 years at study entry, the mean age of peak height velocity was 13.1 years (95% CI, 13.0-13.2 years) in African American boys vs 13.4 years (95% CI, 13.3-13.4 years) in non-African American boys (difference, -0.3 years; 95% CI, -0.4 to -0.1 years) and 11.0 years (95% CI, 10.8-11.1 years) in African American girls vs 11.6 years (95% CI, 11.5-11.6 years) in non-African American girls (difference, -0.6 years; 95% CI, -0.7 to -0.5 years). Age of peak acquisition of WB BMC was 14.0 years (95% CI, 13.8-14.1 years) in African American boys vs 14.0 years (95% CI, 13.9-14.1 years) in non-African American boys (difference, -0.0 years; 95% CI, -0.2 to 0.2 years) and 12.1 years (95% CI, 12.0-12.3 years) in African American girls vs 12.4 years (95% CI, 12.3-12.5 years) in non-African American girls (difference, -0.3 years; 95% CI, -0.4 to -0.1 years). At age 7 years, children had acquired 69.5% to 74.5% of maximal observed height but only 29.6% to 38.1% of maximal observed WB BMC. Adolescents gained 32.7% to 35.8% of maximal observed WB BMC during the 2 years before and 2 years after peak height velocity. Another 6.9% to 10.7% of maximal observed WB BMC occurred after linear growth had ceased. In the group at highest risk for fracture, non-African American boys, peak fracture incidence occurred approximately 1 year before peak height velocity. CONCLUSIONS AND RELEVANCE In this longitudinal study, height gains substantially outpaced gains in BMC during childhood, which could contribute to fracture risk. A significant proportion of bone is accrued after adult height is achieved. Therefore, late adolescence represents a potentially underrecognized window of opportunity to optimize bone mass.
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Affiliation(s)
- Shana E. McCormack
- Division of Endocrinology and Diabetes, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Diana L. Cousminer
- Division of Human Genetics, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Alessandra Chesi
- Division of Human Genetics, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jonathan A. Mitchell
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Sani M. Roy
- Division of Endocrinology, Department of Pediatrics, Cook Children’s Medical Center, Fort Worth, Texas
| | - Heidi J. Kalkwarf
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Joan M. Lappe
- College of Nursing, Creighton University, Omaha, NebraskaOsteoporosis Research Center, School of Medicine, Creighton University, Omaha, Nebraska
| | - Vicente Gilsanz
- Department of Radiology, Children’s Hospital Los Angeles, Keck School of Medicine of USC, University of Southern California, Los AngelesDepartment of Pediatrics, Children’s Hospital Los Angeles, Keck School of Medicine of USC, University of Southern California, Los Angeles
| | - Sharon E. Oberfield
- Division of Pediatric Endocrinology, Diabetes and Metabolism, Department of Pediatrics, Columbia University, New York, New York
| | - John A. Shepherd
- Department of Radiology and Biomedical Imaging, University of California, San Francisco
| | - Karen K. Winer
- Pediatric Growth and Nutrition Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health, Bethesda, Maryland
| | - Andrea Kelly
- Division of Endocrinology and Diabetes, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Struan F. A. Grant
- Division of Endocrinology and Diabetes, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, PhiladelphiaDivision of Human Genetics, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Babette S. Zemel
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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McCormack SE, Chesi A, Mitchell JA, Roy SM, Cousminer DL, Kalkwarf HJ, Lappe JM, Gilsanz V, Oberfield SE, Shepherd JA, Mahboubi S, Winer KK, Kelly A, Grant SF, Zemel BS. Relative Skeletal Maturation and Population Ancestry in Nonobese Children and Adolescents. J Bone Miner Res 2017; 32:115-124. [PMID: 27419386 PMCID: PMC5257250 DOI: 10.1002/jbmr.2914] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 07/05/2016] [Accepted: 07/14/2016] [Indexed: 12/12/2022]
Abstract
More rapid skeletal maturation in African-American (AA) children is recognized and generally attributed to an increased prevalence of obesity. The objective of the present study was to evaluate the effects of population ancestry on relative skeletal maturation in healthy, non-obese children and adolescents, accounting for body composition and sexual maturation. To do this, we leveraged a multiethnic, mixed-longitudinal study with annual assessments for up to 7 years (The Bone Mineral Density in Childhood Study and its ancillary cohort) conducted at five US clinical centers. Participants included 1592 children, skeletally immature (45% females, 19% AA) who were aged 5 to 17 years at study entry. The primary outcome measure was relative skeletal maturation as assessed by hand-wrist radiograph. Additional covariates measured included anthropometrics, body composition by dual-energy X-ray absorptiometry (DXA), and Tanner stage of sexual maturation. Using mixed effects longitudinal models, without covariates, advancement in relative skeletal maturation was noted in self-reported AA girls (∼0.33 years, p < 0.001) and boys (∼0.43 years, p < 0.001). Boys and girls of all ancestry groups showed independent positive associations of height, lean mass, fat mass, and puberty with relative skeletal maturation. The effect of ancestry was attenuated but persistent after accounting for covariates: for girls, 0.19 years (ancestry by self-report, p = 0.02) or 0.29 years (ancestry by admixture, p = 0.004); and for boys, 0.20 years (ancestry by self-report, p = 0.004), or 0.29 years (ancestry by admixture, p = 0.004). In summary, we conclude that advancement in relative skeletal maturation was associated with AA ancestry in healthy, non-obese children, independent of growth, body composition, and puberty. Further research into the mechanisms underlying this observation may provide insights into the regulation of skeletal maturation. © 2016 American Society for Bone and Mineral Research.
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Affiliation(s)
- Shana E McCormack
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Alessandra Chesi
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jonathan A Mitchell
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sani M Roy
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Diana L Cousminer
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Heidi J Kalkwarf
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Joan M Lappe
- Division of Endocrinology, Department of Medicine, Creighton University, Omaha, NE, USA
| | - Vicente Gilsanz
- Department of Radiology, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Sharon E Oberfield
- Division of Pediatric Endocrinology, Diabetes, and Metabolism, Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - John A Shepherd
- Department of Radiology, University of California San Francisco, San Francisco, CA, USA
| | - Soroosh Mahboubi
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Karen K Winer
- Pediatric Growth and Nutrition Branch (PGNB), Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Andrea Kelly
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Struan Fa Grant
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Babette S Zemel
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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20
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Gordon CM, Zemel BS, Wren TAL, Leonard MB, Bachrach LK, Rauch F, Gilsanz V, Rosen CJ, Winer KK. The Determinants of Peak Bone Mass. J Pediatr 2017; 180:261-269. [PMID: 27816219 DOI: 10.1016/j.jpeds.2016.09.056] [Citation(s) in RCA: 113] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 08/19/2016] [Accepted: 09/26/2016] [Indexed: 02/07/2023]
Affiliation(s)
- Catherine M Gordon
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH.
| | - Babette S Zemel
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Tishya A L Wren
- Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA
| | | | | | - Frank Rauch
- Shriners Hospital for Children, McGill University, Montreal, Canada
| | - Vicente Gilsanz
- Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA
| | | | - Karen K Winer
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
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21
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Ferre EMN, Rose SR, Rosenzweig SD, Burbelo PD, Romito KR, Niemela JE, Rosen LB, Break TJ, Gu W, Hunsberger S, Browne SK, Hsu AP, Rampertaap S, Swamydas M, Collar AL, Kong HH, Lee CCR, Chascsa D, Simcox T, Pham A, Bondici A, Natarajan M, Monsale J, Kleiner DE, Quezado M, Alevizos I, Moutsopoulos NM, Yockey L, Frein C, Soldatos A, Calvo KR, Adjemian J, Similuk MN, Lang DM, Stone KD, Uzel G, Kopp JB, Bishop RJ, Holland SM, Olivier KN, Fleisher TA, Heller T, Winer KK, Lionakis MS. Redefined clinical features and diagnostic criteria in autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy. JCI Insight 2016; 1. [PMID: 27588307 DOI: 10.1172/jci.insight.88782] [Citation(s) in RCA: 165] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is a rare primary immunodeficiency disorder typically caused by homozygous AIRE mutations. It classically presents with chronic mucocutaneous candidiasis and autoimmunity that primarily targets endocrine tissues; hypoparathyroidism and adrenal insufficiency are most common. Developing any two of these classic triad manifestations establishes the diagnosis. Although widely recognized in Europe, where nonendocrine autoimmune manifestations are uncommon, APECED is less defined in patients from the Western Hemisphere. We enrolled 35 consecutive American APECED patients (33 from the US) in a prospective observational natural history study and systematically examined their genetic, clinical, autoantibody, and immunological characteristics. Most patients were compound heterozygous; the most common AIRE mutation was c.967_979del13. All but one patient had anti-IFN-ω autoantibodies, including 4 of 5 patients without biallelic AIRE mutations. Urticarial eruption, hepatitis, gastritis, intestinal dysfunction, pneumonitis, and Sjögren's-like syndrome, uncommon entities in European APECED cohorts, affected 40%-80% of American cases. Development of a classic diagnostic dyad was delayed at mean 7.38 years. Eighty percent of patients developed a median of 3 non-triad manifestations before a diagnostic dyad. Only 20% of patients had their first two manifestations among the classic triad. Urticarial eruption, intestinal dysfunction, and enamel hypoplasia were prominent among early manifestations. Patients exhibited expanded peripheral CD4+ T cells and CD21loCD38lo B lymphocytes. In summary, American APECED patients develop a diverse syndrome, with dramatic enrichment in organ-specific nonendocrine manifestations starting early in life, compared with European patients. Incorporation of these new manifestations into American diagnostic criteria would accelerate diagnosis by approximately 4 years and potentially prevent life-threatening endocrine complications.
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Affiliation(s)
- Elise M N Ferre
- Fungal Pathogenesis Unit, Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland, USA
| | - Stacey R Rose
- Fungal Pathogenesis Unit, Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland, USA
| | - Sergio D Rosenzweig
- Immunology Service, Department of Laboratory Medicine, NIH Clinical Center, NIH, Bethesda, Maryland, USA
| | - Peter D Burbelo
- Dental Clinical Research Core, National Institute of Dental and Craniofacial Research, NIH, Bethesda, Maryland, USA
| | - Kimberly R Romito
- Immunology Service, Department of Laboratory Medicine, NIH Clinical Center, NIH, Bethesda, Maryland, USA
| | - Julie E Niemela
- Immunology Service, Department of Laboratory Medicine, NIH Clinical Center, NIH, Bethesda, Maryland, USA
| | - Lindsey B Rosen
- Immunopathogenesis Section, Laboratory of Clinical Infectious Diseases, NIAID, NIH, Bethesda, Maryland, USA
| | - Timothy J Break
- Fungal Pathogenesis Unit, Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland, USA
| | - Wenjuan Gu
- Clinical Research Directorate/Clinical Monitoring Research Program, Leidos Biomedical Research, Inc., National Cancer Institute (NCI) Campus at Frederick, Frederick, Maryland, USA
| | - Sally Hunsberger
- Biostatistics Research Branch, Division of Clinical Research, NIAID, NIH, Bethesda, Maryland, USA
| | - Sarah K Browne
- Immunopathogenesis Section, Laboratory of Clinical Infectious Diseases, NIAID, NIH, Bethesda, Maryland, USA
| | - Amy P Hsu
- Immunopathogenesis Section, Laboratory of Clinical Infectious Diseases, NIAID, NIH, Bethesda, Maryland, USA
| | - Shakuntala Rampertaap
- Immunology Service, Department of Laboratory Medicine, NIH Clinical Center, NIH, Bethesda, Maryland, USA
| | - Muthulekha Swamydas
- Fungal Pathogenesis Unit, Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland, USA
| | - Amanda L Collar
- Fungal Pathogenesis Unit, Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland, USA
| | - Heidi H Kong
- Dermatology Branch, Center for Cancer Research, NCI, NIH, Bethesda, Maryland, USA
| | - Chyi-Chia Richard Lee
- Laboratory of Pathology, Center for Cancer Research, NCI, NIH, Bethesda, Maryland, USA
| | - David Chascsa
- Translational Hepatology Unit, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, Maryland, USA
| | - Thomas Simcox
- Translational Hepatology Unit, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, Maryland, USA
| | - Angela Pham
- Fungal Pathogenesis Unit, Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland, USA
| | - Anamaria Bondici
- Fungal Pathogenesis Unit, Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland, USA
| | - Mukil Natarajan
- Fungal Pathogenesis Unit, Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland, USA
| | - Joseph Monsale
- Immunology Service, Department of Laboratory Medicine, NIH Clinical Center, NIH, Bethesda, Maryland, USA
| | - David E Kleiner
- Dermatology Branch, Center for Cancer Research, NCI, NIH, Bethesda, Maryland, USA
| | - Martha Quezado
- Dermatology Branch, Center for Cancer Research, NCI, NIH, Bethesda, Maryland, USA
| | - Ilias Alevizos
- Sjögren's Syndrome and Salivary Gland Dysfunction Unit, National Institute of Dental and Craniofacial Research, NIH, Bethesda, Maryland, USA
| | - Niki M Moutsopoulos
- Oral Immunity and Inflammation Unit, National Institute of Dental and Craniofacial Research, NIH, Bethesda, Maryland, USA
| | - Lynne Yockey
- Fungal Pathogenesis Unit, Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland, USA; Immunopathogenesis Section, Laboratory of Clinical Infectious Diseases, NIAID, NIH, Bethesda, Maryland, USA
| | - Cathleen Frein
- Clinical Research Directorate/Clinical Monitoring Research Program, Leidos Biomedical Research, Inc., National Cancer Institute (NCI) Campus at Frederick, Frederick, Maryland, USA
| | - Ariane Soldatos
- Undiagnosed Diseases Program, Common Fund, NIH Office of the Director and National Human Genome Research Institute, Bethesda, Maryland, USA
| | - Katherine R Calvo
- Hematology Section, Department of Laboratory Medicine, NIH Clinical Center, NIH, Bethesda, Maryland, USA
| | - Jennifer Adjemian
- Epidemiology Unit, Laboratory of Clinical Infectious Diseases, NIH, Bethesda, Maryland, USA
| | | | - David M Lang
- Pediatric Consult Service, NIH Clinical Center, NIH, Bethesda, Maryland, USA
| | - Kelly D Stone
- Laboratory of Allergic Diseases, NIAID, NIH, Bethesda, Maryland, USA
| | - Gulbu Uzel
- Immunopathogenesis Section, Laboratory of Clinical Infectious Diseases, NIAID, NIH, Bethesda, Maryland, USA
| | - Jeffrey B Kopp
- Kidney Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, Maryland, USA
| | - Rachel J Bishop
- Consult Services Section, National Eye Institute, NIH, Bethesda, Maryland, USA
| | - Steven M Holland
- Immunopathogenesis Section, Laboratory of Clinical Infectious Diseases, NIAID, NIH, Bethesda, Maryland, USA
| | - Kenneth N Olivier
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, NIH, Bethesda, Maryland, USA
| | - Thomas A Fleisher
- Immunology Service, Department of Laboratory Medicine, NIH Clinical Center, NIH, Bethesda, Maryland, USA
| | - Theo Heller
- Translational Hepatology Unit, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, Maryland, USA
| | - Karen K Winer
- Pediatric Growth and Nutrition Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, Maryland, USA
| | - Michail S Lionakis
- Fungal Pathogenesis Unit, Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland, USA
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22
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Bilezikian JP, Brandi ML, Cusano NE, Mannstadt M, Rejnmark L, Rizzoli R, Rubin MR, Winer KK, Liberman UA, Potts JT. Management of Hypoparathyroidism: Present and Future. J Clin Endocrinol Metab 2016; 101:2313-24. [PMID: 26938200 PMCID: PMC5393596 DOI: 10.1210/jc.2015-3910] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
CONTEXT Conventional management of hypoparathyroidism has focused upon maintaining the serum calcium with oral calcium and active vitamin D, often requiring high doses and giving rise to concerns about long-term consequences including renal and brain calcifications. Replacement therapy with PTH has recently become available. This paper summarizes the results of the findings and recommendations of the Working Group on Management of Hypoparathyroidism. EVIDENCE ACQUISITION Contributing authors reviewed the literature regarding physiology, pathophysiology, and nutritional aspects of hypoparathyroidism, management of acute hypocalcemia, clinical aspects of chronic management, and replacement therapy of hypoparathyroidism with PTH peptides. PubMed and other literature search engines were utilized. EVIDENCE SYNTHESIS Under normal circumstances, interactions between PTH and active vitamin D along with the dynamics of calcium and phosphorus absorption, renal tubular handing of those ions, and skeletal responsiveness help to maintain calcium homeostasis and skeletal health. In the absence of PTH, the gastrointestinal tract, kidneys, and skeleton are all affected, leading to hypocalcemia, hyperphosphatemia, reduced bone remodeling, and an inability to conserve filtered calcium. Acute hypocalcemia can be a medical emergency presenting with neuromuscular irritability. The recent availability of recombinant human PTH (1-84) has given hope that management of hypoparathyroidism with the missing hormone in this disorder will provide better control and reduced needs for calcium and vitamin D. CONCLUSIONS Hypoparathyroidism is associated with abnormal calcium and skeletal homeostasis. Control with calcium and active vitamin D can be a challenge. The availability of PTH (1-84) replacement therapy may usher new opportunities for better control with reduced supplementation requirements.
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Affiliation(s)
- John P Bilezikian
- Columbia University College of Physicians & Surgeons (J.P.B., N.E.C., M.R.R.), New York, New York 10032; Department of Surgery and Translational Medicine (M.L.B.), University of Florence, 50121 Florence, Italy; Massachusetts General Hospital (M.M., J.T.P.), Boston, Massachusetts 02114; Aarhus University Hospital (L.R.), 8000 Aarhus, Denmark; Geneva University Hospitals and Faculty of Medicine (R.R.), 1205 Geneva, Switzerland; Eunice Kennedy Shriver National Institute of Child Health and Human Development (K.K.W.), National Institutes of Health, Bethesda, Maryland 20892; and Sackler School of Medicine (U.A.L.), Tel Aviv University, Tel Aviv 6997801, Israel
| | - Maria Luisa Brandi
- Columbia University College of Physicians & Surgeons (J.P.B., N.E.C., M.R.R.), New York, New York 10032; Department of Surgery and Translational Medicine (M.L.B.), University of Florence, 50121 Florence, Italy; Massachusetts General Hospital (M.M., J.T.P.), Boston, Massachusetts 02114; Aarhus University Hospital (L.R.), 8000 Aarhus, Denmark; Geneva University Hospitals and Faculty of Medicine (R.R.), 1205 Geneva, Switzerland; Eunice Kennedy Shriver National Institute of Child Health and Human Development (K.K.W.), National Institutes of Health, Bethesda, Maryland 20892; and Sackler School of Medicine (U.A.L.), Tel Aviv University, Tel Aviv 6997801, Israel
| | - Natalie E Cusano
- Columbia University College of Physicians & Surgeons (J.P.B., N.E.C., M.R.R.), New York, New York 10032; Department of Surgery and Translational Medicine (M.L.B.), University of Florence, 50121 Florence, Italy; Massachusetts General Hospital (M.M., J.T.P.), Boston, Massachusetts 02114; Aarhus University Hospital (L.R.), 8000 Aarhus, Denmark; Geneva University Hospitals and Faculty of Medicine (R.R.), 1205 Geneva, Switzerland; Eunice Kennedy Shriver National Institute of Child Health and Human Development (K.K.W.), National Institutes of Health, Bethesda, Maryland 20892; and Sackler School of Medicine (U.A.L.), Tel Aviv University, Tel Aviv 6997801, Israel
| | - Michael Mannstadt
- Columbia University College of Physicians & Surgeons (J.P.B., N.E.C., M.R.R.), New York, New York 10032; Department of Surgery and Translational Medicine (M.L.B.), University of Florence, 50121 Florence, Italy; Massachusetts General Hospital (M.M., J.T.P.), Boston, Massachusetts 02114; Aarhus University Hospital (L.R.), 8000 Aarhus, Denmark; Geneva University Hospitals and Faculty of Medicine (R.R.), 1205 Geneva, Switzerland; Eunice Kennedy Shriver National Institute of Child Health and Human Development (K.K.W.), National Institutes of Health, Bethesda, Maryland 20892; and Sackler School of Medicine (U.A.L.), Tel Aviv University, Tel Aviv 6997801, Israel
| | - Lars Rejnmark
- Columbia University College of Physicians & Surgeons (J.P.B., N.E.C., M.R.R.), New York, New York 10032; Department of Surgery and Translational Medicine (M.L.B.), University of Florence, 50121 Florence, Italy; Massachusetts General Hospital (M.M., J.T.P.), Boston, Massachusetts 02114; Aarhus University Hospital (L.R.), 8000 Aarhus, Denmark; Geneva University Hospitals and Faculty of Medicine (R.R.), 1205 Geneva, Switzerland; Eunice Kennedy Shriver National Institute of Child Health and Human Development (K.K.W.), National Institutes of Health, Bethesda, Maryland 20892; and Sackler School of Medicine (U.A.L.), Tel Aviv University, Tel Aviv 6997801, Israel
| | - René Rizzoli
- Columbia University College of Physicians & Surgeons (J.P.B., N.E.C., M.R.R.), New York, New York 10032; Department of Surgery and Translational Medicine (M.L.B.), University of Florence, 50121 Florence, Italy; Massachusetts General Hospital (M.M., J.T.P.), Boston, Massachusetts 02114; Aarhus University Hospital (L.R.), 8000 Aarhus, Denmark; Geneva University Hospitals and Faculty of Medicine (R.R.), 1205 Geneva, Switzerland; Eunice Kennedy Shriver National Institute of Child Health and Human Development (K.K.W.), National Institutes of Health, Bethesda, Maryland 20892; and Sackler School of Medicine (U.A.L.), Tel Aviv University, Tel Aviv 6997801, Israel
| | - Mishaela R Rubin
- Columbia University College of Physicians & Surgeons (J.P.B., N.E.C., M.R.R.), New York, New York 10032; Department of Surgery and Translational Medicine (M.L.B.), University of Florence, 50121 Florence, Italy; Massachusetts General Hospital (M.M., J.T.P.), Boston, Massachusetts 02114; Aarhus University Hospital (L.R.), 8000 Aarhus, Denmark; Geneva University Hospitals and Faculty of Medicine (R.R.), 1205 Geneva, Switzerland; Eunice Kennedy Shriver National Institute of Child Health and Human Development (K.K.W.), National Institutes of Health, Bethesda, Maryland 20892; and Sackler School of Medicine (U.A.L.), Tel Aviv University, Tel Aviv 6997801, Israel
| | - Karen K Winer
- Columbia University College of Physicians & Surgeons (J.P.B., N.E.C., M.R.R.), New York, New York 10032; Department of Surgery and Translational Medicine (M.L.B.), University of Florence, 50121 Florence, Italy; Massachusetts General Hospital (M.M., J.T.P.), Boston, Massachusetts 02114; Aarhus University Hospital (L.R.), 8000 Aarhus, Denmark; Geneva University Hospitals and Faculty of Medicine (R.R.), 1205 Geneva, Switzerland; Eunice Kennedy Shriver National Institute of Child Health and Human Development (K.K.W.), National Institutes of Health, Bethesda, Maryland 20892; and Sackler School of Medicine (U.A.L.), Tel Aviv University, Tel Aviv 6997801, Israel
| | - Uri A Liberman
- Columbia University College of Physicians & Surgeons (J.P.B., N.E.C., M.R.R.), New York, New York 10032; Department of Surgery and Translational Medicine (M.L.B.), University of Florence, 50121 Florence, Italy; Massachusetts General Hospital (M.M., J.T.P.), Boston, Massachusetts 02114; Aarhus University Hospital (L.R.), 8000 Aarhus, Denmark; Geneva University Hospitals and Faculty of Medicine (R.R.), 1205 Geneva, Switzerland; Eunice Kennedy Shriver National Institute of Child Health and Human Development (K.K.W.), National Institutes of Health, Bethesda, Maryland 20892; and Sackler School of Medicine (U.A.L.), Tel Aviv University, Tel Aviv 6997801, Israel
| | - John T Potts
- Columbia University College of Physicians & Surgeons (J.P.B., N.E.C., M.R.R.), New York, New York 10032; Department of Surgery and Translational Medicine (M.L.B.), University of Florence, 50121 Florence, Italy; Massachusetts General Hospital (M.M., J.T.P.), Boston, Massachusetts 02114; Aarhus University Hospital (L.R.), 8000 Aarhus, Denmark; Geneva University Hospitals and Faculty of Medicine (R.R.), 1205 Geneva, Switzerland; Eunice Kennedy Shriver National Institute of Child Health and Human Development (K.K.W.), National Institutes of Health, Bethesda, Maryland 20892; and Sackler School of Medicine (U.A.L.), Tel Aviv University, Tel Aviv 6997801, Israel
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Winer KK. Perspectives on the Search for a True Physiologic Replacement Therapy for Hypoparathyroidism. Eur Endocrinol 2016; 12:47-48. [PMID: 29632590 PMCID: PMC5813461 DOI: 10.17925/ee.2016.12.01.47] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 03/10/2016] [Indexed: 01/11/2023]
Abstract
Over the past two decades, we have studied various parathyroid hormone (PTH) 1-34 regimens, including once-daily and twice-daily injections without the concurrent conventional therapy. We recently studied PTH delivery by insulin pump, which produced normal, steady-state serum and urine calcium levels. The recent approval of PTH 1-84 represents an important milestone in the treatment of hypoparathyroidism. As PTH 1-84 and PTH 1-34 have similar pharmacokinetic (PK) and pharmacodynamic profiles, one can assume that many of the principles learned from studies of PTH 1-34 also apply to PTH 1-84 in the management of this rare disease.
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Affiliation(s)
- Karen K Winer
- NICHD, National Institutes of Health, Bethesda, Maryland, US
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24
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Mauras N, Mazaika P, Buckingham B, Weinzimer S, White NH, Tsalikian E, Hershey T, Cato A, Cheng P, Kollman C, Beck RW, Ruedy K, Aye T, Fox L, Arbelaez AM, Wilson D, Tansey M, Tamborlane W, Peng D, Marzelli M, Winer KK, Reiss AL. Longitudinal assessment of neuroanatomical and cognitive differences in young children with type 1 diabetes: association with hyperglycemia. Diabetes 2015; 64:1770-9. [PMID: 25488901 PMCID: PMC4407847 DOI: 10.2337/db14-1445] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 12/05/2014] [Indexed: 12/11/2022]
Abstract
Significant regional differences in gray and white matter volume and subtle cognitive differences between young diabetic and nondiabetic children have been observed. Here, we assessed whether these differences change over time and the relation with dysglycemia. Children ages 4 to <10 years with (n = 144) and without (n = 72) type 1 diabetes (T1D) had high-resolution structural MRI and comprehensive neurocognitive tests at baseline and 18 months and continuous glucose monitoring and HbA1c performed quarterly for 18 months. There were no differences in cognitive and executive function scores between groups at 18 months. However, children with diabetes had slower total gray and white matter growth than control subjects. Gray matter regions (left precuneus, right temporal, frontal, and parietal lobes and right medial-frontal cortex) showed lesser growth in diabetes, as did white matter areas (splenium of the corpus callosum, bilateral superior-parietal lobe, bilateral anterior forceps, and inferior-frontal fasciculus). These changes were associated with higher cumulative hyperglycemia and glucose variability but not with hypoglycemia. Young children with T1D have significant differences in total and regional gray and white matter growth in brain regions involved in complex sensorimotor processing and cognition compared with age-matched control subjects over 18 months, suggesting that chronic hyperglycemia may be detrimental to the developing brain.
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Affiliation(s)
- Nelly Mauras
- Division of Endocrinology, Diabetes & Metabolism, Nemours Children's Clinic, Jacksonville, FL
| | - Paul Mazaika
- Center for Interdisciplinary Brain Sciences Research, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA
| | - Bruce Buckingham
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Stuart Weinzimer
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Neil H White
- Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Eva Tsalikian
- Pediatric Endocrinology, University of Iowa, Iowa City, IA
| | - Tamara Hershey
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, MO Department of Radiology, Washington University School of Medicine in St. Louis, St. Louis, MO Department of Neurology, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Allison Cato
- Division of Neurology, Nemours Children's Clinic, Jacksonville, FL
| | | | | | - Roy W Beck
- Jaeb Center for Health Research, Tampa, FL
| | | | - Tandy Aye
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Larry Fox
- Division of Endocrinology, Diabetes & Metabolism, Nemours Children's Clinic, Jacksonville, FL
| | - Ana Maria Arbelaez
- Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Darrell Wilson
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Michael Tansey
- Pediatric Endocrinology, University of Iowa, Iowa City, IA
| | - William Tamborlane
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Daniel Peng
- Center for Interdisciplinary Brain Sciences Research, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA
| | - Matthew Marzelli
- Center for Interdisciplinary Brain Sciences Research, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA Department of Bioengineering, Stanford University School of Medicine, Stanford, CA
| | - Karen K Winer
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
| | - Allan L Reiss
- Center for Interdisciplinary Brain Sciences Research, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA Department of Pediatrics, Stanford University School of Medicine, Stanford, CA Department of Radiology, Stanford University School of Medicine, Stanford, CA
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25
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Short DF, Gilsanz V, Kalkwarf HJ, Lappe JM, Oberfield S, Shepherd JA, Winer KK, Zemel BS, Hangartner TN. Anthropometric models of bone mineral content and areal bone mineral density based on the bone mineral density in childhood study. Osteoporos Int 2015; 26:1099-108. [PMID: 25311106 PMCID: PMC4768717 DOI: 10.1007/s00198-014-2916-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 09/24/2014] [Indexed: 10/24/2022]
Abstract
UNLABELLED New models describing anthropometrically adjusted normal values of bone mineral density and content in children have been created for the various measurement sites. The inclusion of multiple explanatory variables in the models provides the opportunity to calculate Z-scores that are adjusted with respect to the relevant anthropometric parameters. INTRODUCTION Previous descriptions of children's bone mineral measurements by age have focused on segmenting diverse populations by race and sex without adjusting for anthropometric variables or have included the effects of a single anthropometric variable. METHODS We applied multivariate semi-metric smoothing to the various pediatric bone-measurement sites using data from the Bone Mineral Density in Childhood Study to evaluate which of sex, race, age, height, weight, percent body fat, and sexual maturity explain variations in the population's bone mineral values. By balancing high adjusted R(2) values with clinical needs, two models are examined. RESULTS At the spine, whole body, whole body sub head, total hip, hip neck, and forearm sites, models were created using sex, race, age, height, and weight as well as an additional set of models containing these anthropometric variables and percent body fat. For bone mineral density, weight is more important than percent body fat, which is more important than height. For bone mineral content, the order varied by site with body fat being the weakest component. Including more anthropometrics in the model reduces the overlap of the critical groups, identified as those individuals with a Z-score below -2, from the standard sex, race, and age model. CONCLUSIONS If body fat is not available, the simpler model including height and weight should be used. The inclusion of multiple explanatory variables in the models provides the opportunity to calculate Z-scores that are adjusted with respect to the relevant anthropometric parameters.
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Affiliation(s)
- D F Short
- Wright State University, Dayton, OH, USA,
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Lappe JM, Watson P, Gilsanz V, Hangartner T, Kalkwarf HJ, Oberfield S, Shepherd J, Winer KK, Zemel B. The longitudinal effects of physical activity and dietary calcium on bone mass accrual across stages of pubertal development. J Bone Miner Res 2015; 30:156-64. [PMID: 25130421 PMCID: PMC4280289 DOI: 10.1002/jbmr.2319] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Revised: 07/18/2014] [Accepted: 07/21/2014] [Indexed: 11/07/2022]
Abstract
Childhood and adolescence are critical periods of bone mineral content (BMC) accrual that may have long-term consequences for osteoporosis in adulthood. Adequate dietary calcium intake and weight-bearing physical activity are important for maximizing BMC accrual. However, the relative effects of physical activity and dietary calcium on BMC accrual throughout the continuum of pubertal development in childhood remains unclear. The purpose of this study was to determine the effects of self-reported dietary calcium intake and weight-bearing physical activity on bone mass accrual across the five stages of pubertal development in a large, diverse cohort of US children and adolescents. The Bone Mineral Density in Childhood study was a mixed longitudinal study with 7393 observations on 1743 subjects. Annually, we measured BMC by dual-energy X-ray absorptiometry (DXA), physical activity and calcium intake by questionnaire, and pubertal development (Tanner stage) by examination for up to 7 years. Mixed-effects regression models were used to assess physical activity and calcium intake effects on BMC accrual at each Tanner stage. We found that self-reported weight-bearing physical activity contributed to significantly greater BMC accrual in both sexes and racial subgroups (black and nonblack). In nonblack males, the magnitude of the activity effect on total body BMC accrual varied among Tanner stages after adjustment for calcium intake; the greatest difference between high- and low-activity boys was in Tanner stage 3. Calcium intake had a significant effect on bone accrual only in nonblack girls. This effect was not significantly different among Tanner stages. Our findings do not support differential effects of physical activity or calcium intake on bone mass accrual according to maturational stage. The study demonstrated significant longitudinal effects of weight-bearing physical activity on bone mass accrual through all stages of pubertal development.
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Huibregtse KE, Wolfgram P, Winer KK, Connor EL. Polyglandular autoimmune syndrome type I - a novel AIRE mutation in a North American patient. J Pediatr Endocrinol Metab 2014; 27:1257-60. [PMID: 24945421 PMCID: PMC4407642 DOI: 10.1515/jpem-2013-0328] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Accepted: 05/08/2014] [Indexed: 11/15/2022]
Abstract
Autoimmune polyglandular syndrome type 1 (APS-1), also referred to as autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED), is a rare autoimmune disease that results from autosomal recessive mutations of the human autoimmune regulatory (AIRE) gene. We present the case of a 17-year-old North American girl of primarily Norwegian descent with a novel AIRE gene mutation causing APS-1. In addition to the classic triad of chronic candidiasis, hypoparathyoidism and autoimmune adrenocortical insufficiency, she also has vitiligo, intestinal malabsorption, autoimmune hepatitis, autoimmune hypothyroidism, myositis, myalgias, chronic fatigue, and failure to thrive. Genetic testing revealed heterozygosity for c.20_115de196 and c.967_979del13 mutations in the AIRE gene. The AIRE gene c.20_115de196 mutation has not been previously reported.
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Affiliation(s)
| | - Peter Wolfgram
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Karen K. Winer
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Ellen L. Connor
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Wren TAL, Kalkwarf HJ, Zemel BS, Lappe JM, Oberfield S, Shepherd JA, Winer KK, Gilsanz V. Longitudinal tracking of dual-energy X-ray absorptiometry bone measures over 6 years in children and adolescents: persistence of low bone mass to maturity. J Pediatr 2014; 164:1280-5.e2. [PMID: 24485819 PMCID: PMC4035430 DOI: 10.1016/j.jpeds.2013.12.040] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Revised: 11/08/2013] [Accepted: 12/18/2013] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Early assessment of bone mass may be useful for predicting future osteoporosis risk if bone measures "track" during growth. This prospective longitudinal multicenter study examined tracking of bone measures in children and adolescents over 6 years to sexual and skeletal maturity. STUDY DESIGN A total of 240 healthy male and 293 healthy female patients, ages 6-17 years, underwent yearly evaluations of height, weight, body mass index, skeletal age, Tanner stage, and dual-energy x-ray absorptiometry (DXA) bone measurements of the whole body, spine, hip, and forearm for 6 years. All subjects were sexually and skeletally mature at final follow-up. Correlation was performed between baseline and 6-year follow-up measures, and change in DXA Z-scores was examined for subjects who had baseline Z < -1.5. RESULTS DXA Z-scores (r = 0.66-0.87) had similar tracking to anthropometric measures (r = 0.64-0.74). Tracking was stronger for bone mineral density compared with bone mineral content and for girls compared with boys. Tracking was weakest during mid- to late puberty but improved when Z-scores were adjusted for height. Almost all subjects with baseline Z < -1.5 had final Z-scores below average, with the majority remaining less than -1.0. CONCLUSIONS Bone status during childhood is a strong predictor of bone status in young adulthood, when peak bone mass is achieved. This suggests that bone mass measurements in children and adolescents may be useful for early identification of individuals at risk for osteoporosis later in life.
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Affiliation(s)
| | | | | | | | | | | | - Karen K Winer
- National Institute of Child Health and Human Development, Bethesda, MD
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Kelly A, Winer KK, Kalkwarf H, Oberfield SE, Lappe J, Gilsanz V, Zemel BS. Age-based reference ranges for annual height velocity in US children. J Clin Endocrinol Metab 2014; 99:2104-12. [PMID: 24601728 PMCID: PMC4037731 DOI: 10.1210/jc.2013-4455] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 02/07/2014] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Clinicians caring for children rely on measures of linear growth as a biomarker of development and overall health. Current reference ranges for height velocity (HV) for US children are unable to provide HV percentiles or Z-scores for early maturing and late maturing children at ages other than age at peak velocity. We present empirically acquired, age-specific reference ranges for HV from a contemporary sample of US youth. STUDY DESIGN Subjects were enrolled in the Bone Mineral Density in Childhood Study, a large, multicenter, multiethnic, contemporary cohort of children (aged 5-19 y at enrollment) from the United States followed for up to 7 years. More than 4000 annual (12 ± 1 mo) HV measurements from approximately 1500 children were available. Pubertal status was determined by breast stage or testicular volume assessed by experienced health providers. Age-specific reference ranges were determined using the LMS method. RESULTS Reference ranges (third to 97th percentiles) were generated for the entire cohort and for subgroups whose pubertal timing was defined as "earlier," "average," or "later." African American girls experienced earlier pubertal onset and had greater HV at younger ages and lower HV at older ages, compared to non-African American girls; differences did not persist after adjustment for pubertal timing. These differences were not observed for males. CONCLUSIONS These reference ranges for annual HV can be used to assess growth relative to peers of the same age and sex, with consideration of pubertal timing. Z-scores and exact percentiles for HV can also be determined for population studies.
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Affiliation(s)
- Andrea Kelly
- Department of Pediatrics (A.K., B.S.Z.), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104; Eunice Kennedy Shriver National Institute of Child Health and Human Development (K.K.W.), Bethesda, Maryland 20892; Department of Pediatrics (H.K.), Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio 45229; Department of Pediatrics (S.E.O.), Columbia University Medical Center, New York, New York 10032; Department of Medicine (J.L.), Creighton University, Omaha, Nebraska 68102; and Departments of Orthopaedic Surgery and Radiology (V.G.), Children's Hospital Los Angeles, Los Angeles, California 90027
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Winer KK, Rothenberg ME, Guimond J, Handwerger S, Boxer LA, Grave G, Devaskar SU, Castle VP. The Child Health Research Centers: twenty-one years of promoting the development of pediatrician scientists from 1990-2011. J Pediatr 2012; 161:975-6. [PMID: 23171484 DOI: 10.1016/j.jpeds.2012.09.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Karen K Winer
- Endocrinology, Nutrition, and Growth Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892-7510, USA.
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Wren TAL, Shepherd JA, Kalkwarf HJ, Zemel BS, Lappe JM, Oberfield S, Dorey FJ, Winer KK, Gilsanz V. Racial disparity in fracture risk between white and nonwhite children in the United States. J Pediatr 2012; 161:1035-40. [PMID: 22974572 PMCID: PMC3504618 DOI: 10.1016/j.jpeds.2012.07.054] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Revised: 06/26/2012] [Accepted: 07/27/2012] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To examine risk factors for fracture in a racially diverse cohort of healthy children in the US. STUDY DESIGN A total of 1470 healthy children, aged 6-17 years, underwent yearly evaluations of height, weight, body mass index, skeletal age, sexual maturation, calcium intake, physical activity levels, and dual-energy x-ray absorptiometry (DXA) bone and fat measurements for up to 6 years. Fracture information was obtained at each annual visit, and risk factors for fracture were examined using the time-dependent Cox proportional hazards model. RESULTS The overall fracture incidence was 0.034 fracture per person-year with 212 children reporting a total of 257 fractures. Being white (hazard ratio [HR] = 2.1), being male (HR = 1.8), and having skeletal age of 10-14 years (HR = 2.2) were the strongest risk factors for fracture (all P ≤ .001). Increased sports participation (HR = 1.4), lower body fat percentage (HR = 0.97), and previous fracture in white girls (HR = 2.1) were also significant risk factors (all P ≤ .04). Overall, fracture risk decreased with higher DXA z scores, except in white boys, who had increased fracture risk with higher DXA z scores (HR = 1.7, P < .001). CONCLUSIONS Boys and girls of European descent had double the fracture risk of children from other backgrounds, suggesting that the genetic predisposition to fractures seen in elderly adults also manifests in children.
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Affiliation(s)
- Tishya A L Wren
- Departments of Orthopaedic Surgery and Radiology, Children's Hospital Los Angeles, Los Angeles, CA 90027, USA.
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Winer KK, Zhang B, Shrader JA, Peterson D, Smith M, Albert PS, Cutler GB. Synthetic human parathyroid hormone 1-34 replacement therapy: a randomized crossover trial comparing pump versus injections in the treatment of chronic hypoparathyroidism. J Clin Endocrinol Metab 2012; 97:391-9. [PMID: 22090268 PMCID: PMC3275355 DOI: 10.1210/jc.2011-1908] [Citation(s) in RCA: 114] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
CONTEXT Vitamin D therapy for hypoparathyroidism does not restore PTH-dependent renal calcium reabsorption, which can lead to renal damage. An alternative approach, PTH 1-34 administered twice daily, provides acceptable long-term treatment but is associated with nonphysiological serum calcium fluctuation. OBJECTIVE Our objective was to compare continuous PTH 1-34 delivery, by insulin pump, with twice-daily delivery. RESEARCH DESIGN AND METHODS In a 6-month, open-label, randomized, crossover trial, PTH 1-34 was delivered by pump or twice-daily sc injection. After each 3-month study period, serum and 24-h urine mineral levels and bone turnover markers were measured daily for 3 d, and 24-h biochemical profiles were determined for serum minerals and 1,25-dihydroxyvitamin D(3) and for urine minerals and cAMP. STUDY PARTICIPANTS AND SETTING: Eight patients with postsurgical hypoparathyroidism (mean ± sd age 46 ± 5.6 yr) participated at a tertiary care referral center. RESULTS Pump vs. twice-daily delivery of PTH 1-34 produced less fluctuation in serum calcium, a more than 50% reduction in urine calcium (P = 0.002), and a 65% reduction in the PTH dose to maintain eucalcemia (P < 0.001). Pump delivery also produced higher serum magnesium level (P = 0.02), normal urine magnesium, and reduced need for magnesium supplements. Finally, pump delivery normalized bone turnover markers and significantly lowered urinary cross-linked N-telopeptide of type 1 collagen and pyridinium crosslinks compared with twice-daily injections (P < 0.05). CONCLUSION Pump delivery of PTH 1-34 provides the closest approach to date to physiological replacement therapy for hypoparathyroidism.
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Affiliation(s)
- Karen K Winer
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland 20892-7510, USA.
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Khosla S, Bellido TM, Drezner MK, Gordon CM, Harris TB, Kiel DP, Kream BE, LeBoff MS, Lian JB, Peterson CA, Rosen CJ, Williams JP, Winer KK, Sherman SS. Forum on aging and skeletal health: summary of the proceedings of an ASBMR workshop. J Bone Miner Res 2011; 26:2565-78. [PMID: 21915901 PMCID: PMC3625440 DOI: 10.1002/jbmr.488] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2011] [Accepted: 07/14/2011] [Indexed: 11/06/2022]
Abstract
With the aging of the population, the scope of the problem of age-related bone loss and osteoporosis will continue to increase. As such, it is critical to obtain a better understanding of the factors determining the acquisition and loss of bone mass from childhood to senescence. While there have been significant advances in recent years in our understanding of both the basic biology of aging and a clinical definition of age-related frailty, few of these concepts in aging research have been evaluated adequately for their relevance and application to skeletal aging or fracture prevention. The March 2011 Forum on Aging and Skeletal Health, sponsored by the NIH and ASBMR, sought to bring together leaders in aging and bone research to enhance communications among diverse fields of study so as to accelerate the pace of scientific advances needed to reduce the burden of osteoporotic fractures. This report summarizes the major concepts presented at that meeting and in each area identifies key questions to help set the agenda for future research in skeletal aging.
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Affiliation(s)
- Sundeep Khosla
- College of Medicine, Mayo Clinic, Rochester, MN 55905, USA.
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Shepherd JA, Wang L, Fan B, Gilsanz V, Kalkwarf HJ, Lappe J, Lu Y, Hangartner T, Zemel BS, Fredrick M, Oberfield S, Winer KK. Optimal monitoring time interval between DXA measures in children. J Bone Miner Res 2011; 26:2745-52. [PMID: 21773995 PMCID: PMC3200454 DOI: 10.1002/jbmr.473] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The monitoring time interval (MTI) is the expected time in years necessary to identify a change between two measures that exceeds the measurement error. Our purpose was to determine MTI values for dual-energy X-ray absorptiometry (DXA) scans in normal healthy children, according to age, sex, and skeletal site. 2014 children were enrolled in the Bone Mineral Density in Childhood Study and had DXA scans of the lumbar spine, total hip, nondominant forearm, and whole body. Measurements were obtained annually for seven visits from 2002 to 2010. Annualized rates of change were calculated by age and sex for all bone regions. A subgroup of 155 children ages 6 to 16 years (85 boys) had duplicate scans for calculation of scan precision. The bone mineral density (BMD) regions of interest included the spine, total body less head (TBLH), total hip, femoral neck, and one-third radius. Bone mineral content (BMC) was also evaluated for the spine and TBLH. The percent coefficient of variation (%CV) and MTI were calculated for each measure as a function of age and sex. The MTI values were substantially less than 1 year for the TBLH and spine BMD and BMC for boys ≤ 17 years and girls ≤ 15 years. The hip and one-third radius MTIs were generally 1 year in the same group. MTI values as low as 3 months were found during the peak growth years. However, the MTI values in late adolescence for all regions were substantially longer and became nonsensical as each region neared the age for peak bone density. All four DXA measurement sites had reasonable (< 1 year) MTI values for boys ≤ 17 years and girls ≤ 15 years. MTI was neither useful nor stable in late adolescence and young adulthood. Alternative criteria to determine scan intervals must be used in this age range.
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Affiliation(s)
- John A Shepherd
- Department of Radiology, Bone and Breast Density Research Group, University of California, San Francisco, San Francisco, CA, USA.
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Zemel BS, Kalkwarf HJ, Gilsanz V, Lappe JM, Oberfield S, Shepherd JA, Frederick MM, Huang X, Lu M, Mahboubi S, Hangartner T, Winer KK. Revised reference curves for bone mineral content and areal bone mineral density according to age and sex for black and non-black children: results of the bone mineral density in childhood study. J Clin Endocrinol Metab 2011; 96:3160-9. [PMID: 21917867 PMCID: PMC3200252 DOI: 10.1210/jc.2011-1111] [Citation(s) in RCA: 331] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
CONTEXT Deficits in bone acquisition during growth may increase fracture risk. Assessment of bone health during childhood requires appropriate reference values relative to age, sex, and population ancestry to identify bone deficits. OBJECTIVE The objective of this study was to provide revised and extended reference curves for bone mineral content (BMC) and areal bone mineral density (aBMD) in children. DESIGN The Bone Mineral Density in Childhood Study was a multicenter longitudinal study with annual assessments for up to 7 yr. SETTING The study was conducted at five clinical centers in the United States. PARTICIPANTS Two thousand fourteen healthy children (992 males, 22% African-Americans) aged 5-23 yr participated in the study. INTERVENTION There were no interventions. MAIN OUTCOME MEASURES Reference percentiles for BMC and aBMD of the total body, lumbar spine, hip, and forearm were obtained using dual-energy x-ray absorptiometry for Black and non-Black children. Adjustment factors for height status were also calculated. RESULTS Extended reference curves for BMC and aBMD of the total body, total body less head, lumbar spine, total hip, femoral neck, and forearm for ages 5-20 yr were constructed relative to sex and age for Black and non-Black children. Curves are similar to those previously published for 7-17 year olds. BMC and aBMD values were greater for Black vs. non-Black children at all measurement sites. CONCLUSIONS We provide here dual-energy x-ray absorptiometry reference data on a well-characterized cohort of 2012 children and adolescents. These reference curves provide the most robust reference values for the assessment and monitoring of bone health in children and adolescents in the literature to date.
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Affiliation(s)
- Babette S Zemel
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.
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Winer KK, Sinaii N, Reynolds J, Peterson D, Dowdy K, Cutler GB. Long-term treatment of 12 children with chronic hypoparathyroidism: a randomized trial comparing synthetic human parathyroid hormone 1-34 versus calcitriol and calcium. J Clin Endocrinol Metab 2010; 95:2680-8. [PMID: 20392870 PMCID: PMC2902068 DOI: 10.1210/jc.2009-2464] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
CONTEXT Hypoparathyroidism is among the few hormonal insufficiency states not treated with replacement of the missing hormone. This is the first randomized controlled study in children comparing treatment with synthetic human PTH 1-34 and calcitriol. OBJECTIVE The primary objective was to assess the efficacy and safety of long-term PTH 1-34 vs. calcitriol treatment in the maintenance of normal serum calcium values and renal calcium excretion in children with hypoparathyroidism. SETTING The study was conducted at a clinical research center. SUBJECTS Subjects included 12 children aged 5-14 yr with chronic hypoparathyroidism and without severe renal or hepatic insufficiency. STUDY DESIGN The study was a 3-yr randomized parallel trial comparing twice-daily calcitriol (plus calcium and cholecalciferol in four daily doses) vs. s.c. PTH 1-34 treatment, with weekly or biweekly monitoring of serum and urine calcium. RESULTS Mean predose serum calcium levels were maintained at, or just below, the normal range, and urine calcium levels remained in the normal range throughout the 3-yr study, with no significant differences between treatment groups. Creatinine clearance, corrected for body surface area, did not differ between groups and remained normal throughout the study. Markers of bone turnover were mildly elevated during PTH 1-34 therapy and remained within the normal range during calcitriol therapy. Mean bone mineral density Z-scores at the anterior-posterior lumbar spine, femoral neck, distal radius, and whole body remained within the normal range and did not differ between groups throughout the study. Similarly, height and weight percentiles did not differ between treatment groups and remained normal throughout the 3-yr follow-up. CONCLUSION We conclude that PTH 1-34 therapy is safe and effective in maintaining stable calcium homeostasis in children with hypoparathyroidism. Additionally, PTH 1-34 treatment allowed normal skeletal development because there were no differences in bone mineral accrual, linear growth, or weight gain between the two treatment arms over the 3-yr study period.
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Affiliation(s)
- Karen K Winer
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892-7510, USA.
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Kalkwarf HJ, Gilsanz V, Lappe JM, Oberfield S, Shepherd JA, Hangartner TN, Huang X, Frederick MM, Winer KK, Zemel BS. Tracking of bone mass and density during childhood and adolescence. J Clin Endocrinol Metab 2010; 95:1690-8. [PMID: 20194709 PMCID: PMC2853985 DOI: 10.1210/jc.2009-2319] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2009] [Accepted: 01/25/2010] [Indexed: 01/26/2023]
Abstract
CONTEXT Whether a child with low bone mineral density (BMD) at one point in time will continue to have low BMD, despite continued growth and maturation, is important clinically. The stability of a characteristic during growth is referred to as "tracking." OBJECTIVE We examined the degree of tracking in bone mineral content (BMC) and BMD during childhood and adolescence and investigated whether tracking varied according to age, sexual maturation, and changes in growth status. DESIGN We conducted a longitudinal study with measurements at baseline and annually for 3 yr. SETTING The Bone Mineral Density in Childhood Study was conducted at five clinical centers in the United States. STUDY PARTICIPANTS A total of 1554 girls and boys, ages 6-16 yr at baseline, participated in the study. MAIN OUTCOME MEASURES Whole body, spine, hip, and forearm BMC and BMD were measured by dual-energy x-ray absorptiometry, and age-, sex-, and race-specific Z-scores were calculated. Deviation from tracking was calculated as the Z-score at yr 3 minus baseline. RESULTS Correlations between Z-scores at baseline and yr 3 ranged from 0.76-0.88. Among children with a Z-score below -1.5 at baseline, 72-87% still had a Z-score below -1 after 3 yr. Age, sexual maturation, and deviations in growth status (P < 0.01) were associated with deviation from tracking; however, tracking was strongly evident even after adjusting for the effects of age, maturation, and growth. CONCLUSIONS Bone density showed a high degree of tracking over 3 yr in children and adolescents. Healthy children with low bone density will likely continue to have low bone density unless effective interventions are instituted.
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Affiliation(s)
- Heidi J Kalkwarf
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio 45229, USA.
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Zemel BS, Leonard MB, Kelly A, Lappe JM, Gilsanz V, Oberfield S, Mahboubi S, Shepherd JA, Hangartner TN, Frederick MM, Winer KK, Kalkwarf HJ. Height adjustment in assessing dual energy x-ray absorptiometry measurements of bone mass and density in children. J Clin Endocrinol Metab 2010; 95:1265-73. [PMID: 20103654 PMCID: PMC2841534 DOI: 10.1210/jc.2009-2057] [Citation(s) in RCA: 292] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2009] [Accepted: 12/31/2009] [Indexed: 11/19/2022]
Abstract
CONTEXT In children, bone mineral content (BMC) and bone mineral density (BMD) measurements by dual-energy x-ray absorptiometry (DXA) are affected by height status. No consensus exists on how to adjust BMC or BMD (BMC/BMD) measurements for short or tall stature. OBJECTIVE The aim of this study was to compare various methods to adjust BMC/BMD for height in healthy children. DESIGN Data from the Bone Mineral Density in Childhood Study (BMDCS) were used to develop adjustment methods that were validated using an independent cross-sectional sample of healthy children from the Reference Data Project (RDP). SETTING We conducted the study in five clinical centers in the United States. PARTICIPANTS We included 1546 BMDCS and 650 RDP participants (7 to 17 yr of age, 50% female). INTERVENTION No interventions were used. MAIN OUTCOME MEASURES We measured spine and whole body (WB) BMC and BMD Z-scores for age (BMC/BMD(age)), height age (BMC/BMD(height age)), height (BMC(height)), bone mineral apparent density (BMAD(age)), and height-for-age Z-score (HAZ) (BMC/BMD(haz)). RESULTS Spine and WB BMC/BMD(age)Z and BMAD(age)Z were positively (P < 0.005; r = 0.11 to 0.64) associated with HAZ. Spine BMD(haz) and BMC(haz)Z were not associated with HAZ; WB BMC(haz)Z was modestly associated with HAZ (r = 0.14; P = 0.0003). All other adjustment methods were negatively associated with HAZ (P < 0.005; r = -0.20 to -0.34). The deviation between adjusted and BMC/BMD(age) Z-scores was associated with age for most measures (P < 0.005) except for BMC/BMD(haz). CONCLUSIONS Most methods to adjust BMC/BMD Z-scores for height were biased by age and/or HAZ. Adjustments using HAZ were least biased relative to HAZ and age and can be used to evaluate the effect of short or tall stature on BMC/BMD Z-scores.
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Affiliation(s)
- Babette S Zemel
- The Children's Hospital of Philadelphia, 3535 Market Street, Room 1560, Philadelphia, Pennsylvania 19104, USA.
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Winer KK, Sinaii N, Peterson D, Sainz B, Cutler GB. Effects of once versus twice-daily parathyroid hormone 1-34 therapy in children with hypoparathyroidism. J Clin Endocrinol Metab 2008; 93:3389-95. [PMID: 18492754 PMCID: PMC2567852 DOI: 10.1210/jc.2007-2552] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Hypoparathyroidism is among the few hormonal insufficiency states not treated with replacement of the missing hormone. Long-term conventional therapy with vitamin D and analogs may lead to nephrocalcinosis and renal insufficiency. OBJECTIVE Our objective was to compare the response of once-daily vs. twice-daily PTH 1-34 treatment in children with hypoparathyroidism. SETTING The study was conducted at a clinical research center. SUBJECTS Fourteen children ages 4-17 yr with chronic hypoparathyroidism were studied. STUDY DESIGN This was a randomized cross-over trial, lasting 28 wk, which compared two dose regimens, once-daily vs. twice-daily PTH1-34. Each 14-wk study arm was divided into a 2-wk inpatient dose-adjustment phase and a 12-wk outpatient phase. RESULTS Mean predose serum calcium was maintained at levels just below the normal range. Repeated serum measures over a 24-h period showed that twice-daily PTH 1-34 increased serum calcium and magnesium levels more effectively than a once-daily dose. This was especially evident during the second half of the day (12-24 h). PTH 1-34 normalized mean 24-h urine calcium excretion on both treatment schedules. This was achieved with half the PTH 1-34 dose during the twice-daily regimen compared with the once-daily regimen (twice-daily, 25 +/-15 microg/d vs. once-daily, 58 +/- 28 microg/d; P < 0.001). CONCLUSIONS We conclude that a twice-daily PTH 1-34 regimen provides a more effective treatment of hypoparathyroidism compared with once-daily treatment because it reduces the variation in serum calcium levels and accomplishes this at a lower total daily PTH 1-34 dose. The results showed, as in the previous study of adult patients with hypoparathyroidism, that a twice-daily regimen produced significantly improved metabolic control compared with once-daily PTH 1-34.
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Affiliation(s)
- Karen K Winer
- National Institute of Child Health and Human Development, National Institutes of Health, Building 6100, Room 4B11, Bethesda, Maryland 20892-7510, USA.
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Collins MT, Lindsay JR, Jain A, Kelly MH, Cutler CM, Weinstein LS, Liu J, Fedarko NS, Winer KK. Fibroblast growth factor-23 is regulated by 1alpha,25-dihydroxyvitamin D. J Bone Miner Res 2005; 20:1944-50. [PMID: 16234967 DOI: 10.1359/jbmr.050718] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2005] [Revised: 06/08/2005] [Accepted: 07/13/2005] [Indexed: 12/20/2022]
Abstract
UNLABELLED Serum FGF-23 regulation was studied in patients with hypoparathyroidism or pseudohypoparathyroidism treated with calcitriol. Serum FGF-23 levels changed in parallel in response to changes in serum 1,25-D, suggesting that FGF-23 may be regulated by 1,25-D. In addition, the phosphaturic effect of FGF-23 may be diminished in the absence of PTH action on the kidney. INTRODUCTION Fibroblast growth factor (FGF)-23 is a recently described hormone that has been shown to be involved in the regulation of phosphate and vitamin D metabolism. The physiologic role of FGF-23 in mineral metabolism and how serum FGF-23 levels are regulated have yet to be elucidated. Three patients with mineral metabolism defects that allowed for the investigation of the regulation of FGF-23 were studied. MATERIALS AND METHODS Patient 1 had postsurgical hypoparathyroidism and Munchausen's syndrome and consumed a pharmacologic dose of calcitriol. Patient 2 had postsurgical hypoparathyroidism and fibrous dysplasia of bone. She was treated with increasing doses of calcitriol followed by synthetic PTH(1-34). Patient 3 had pseudohypoparathyroidism type 1B and tertiary hyperparathyroidism. She underwent parathyroidectomy, which was followed by the development of hungry bone syndrome and hypocalcemia, requiring treatment with calcitriol. Serum FGF-23 and serum and urine levels of mineral metabolites were measured in all three patients. RESULTS Patient 1 had an acute and marked increase in serum FGF-23 (70 to 670 RU/ml; normal range, 18-108 RU/ml) within 24 h in response to high-dose calcitriol administration. Patient 2 showed stepwise increases in serum FGF-23 from 117 to 824 RU/ml in response to increasing serum levels of 1alpha,25-dihydroxyvitamin D (1,25-D). Finally, before parathyroidectomy, while hypercalcemic, euphosphatemic, with low levels of 1,25-D (10 pg/ml; normal range, 22-67 pg/ml), and with very high serum PTH (863.7 pg/ml; normal range, 6.0-40.0 pg/ml), patient 3 had high serum FGF-23 levels (217 RU/ml). After surgery, while hypocalcemic, euphosphatemic, and with high serum levels of serum 1,25-D (140 pg/ml), FGF-23 levels were higher than preoperative levels (305 RU/ml). It seemed that the phosphaturic effect of FGF-23 was diminished in the absence of PTH or a PTH effect. CONCLUSIONS Serum FGF-23 may be regulated by serum 1,25-D, and its phosphaturic effect may be less in the absence of PTH.
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Affiliation(s)
- Michael T Collins
- Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland 20892-4320, USA.
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Winer KK, Ko CW, Reynolds JC, Dowdy K, Keil M, Peterson D, Gerber LH, McGarvey C, Cutler GB. Long-term treatment of hypoparathyroidism: a randomized controlled study comparing parathyroid hormone-(1-34) versus calcitriol and calcium. J Clin Endocrinol Metab 2003; 88:4214-20. [PMID: 12970289 DOI: 10.1210/jc.2002-021736] [Citation(s) in RCA: 169] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Hypoparathyroidism is one of the few remaining hormonal insufficiency states for which replacement therapy is unavailable. Previous short-term controlled trials have shown PTH to be a safe and effective treatment of hypoparathyroidism. In this randomized, parallel group, open-label trial, we compared synthetic human PTH-(1-34) (PTH) with conventional therapy, calcitriol and calcium, over a 3-yr period. Twenty-seven patients with confirmed hypoparathyroidism, aged 18-70 yr, were randomized to either twice daily sc PTH or oral calcitriol and calcium. The primary end points were calcium levels in serum and urine. Secondary end points were creatinine clearance, markers of bone turnover, and bone mineral density. Throughout the 3-yr study period, serum calcium levels were similar in both treatment groups within or just below the normal range. Mean urinary calcium excretion was within the normal range from 1-3 yr in PTH-treated patients, but remained above normal in the calcitriol group. Bone mineral content and bone mineral density showed no significant between-group differences over the 3-yr study period. We conclude that treatment with twice daily sc PTH provides a safe and effective alternative to calcitriol therapy and is able to maintain normal serum calcium levels without hypercalciuria for at least 3 yr in patients with hypoparathyroidism.
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Affiliation(s)
- Karen K Winer
- Pediatric and Reproductive Endocrinology Branch, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892, USA.
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Abstract
BACKGROUND Iron deficiency anemia in adults is most frequently due to chronic blood loss. When the clinical course is complicated by sudden, severe declines in Hb concentration, the cause, nature, and lo- cation of bleeding may require an extensive clinical evaluation. CASE REPORT A 39-year-old woman was admitted for management of refractory hypoparathyroidism related to total thyroidectomy for Graves' disease. Two weeks before admission, her Hb level was 7.0 g per dL. Despite transfusion with four units of RBCs during this interval, her admission Hb level was 5.7 g per dL. There was no evidence of blood loss or hemolysis. Laboratory values were consistent with an iron-deficient state. The patient's hospital course included repeated instances of sharp Hb drop and appropriate but unsustained response to RBC transfusion. Extensive work-up identified no occult source of bleeding. Clinical suspicion raised the possibility of self-inflicted blood loss. The patient subsequently admitted to repeatedly drawing blood from her indwelling catheter and discarding it in the lavatory. CONCLUSION Munchausen syndrome should be considered in cases of unexplained anemia, especially in the target demographic group: young, female, healthcare professionals. Early diagnosis may prevent morbidity, multiple hospitalizations, and the risk of invasive diagnostic procedures.
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Affiliation(s)
- Salim A Haddad
- Department of Transfusion Medicine, National Institutes of Health, Warren G. Magnusson Clinical Center, Bethesda, Maryland 20892, USA.
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Affiliation(s)
- K K Winer
- Developmental Endocrinology Branch, National Institute of Child Health and Human Development, Bethesda, MD 20892-1862, USA
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Winer KK, Yanovski JA, Sarani B, Cutler GB. A randomized, cross-over trial of once-daily versus twice-daily parathyroid hormone 1-34 in treatment of hypoparathyroidism. J Clin Endocrinol Metab 1998; 83:3480-6. [PMID: 9768650 DOI: 10.1210/jcem.83.10.5185] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Once-daily sc injection of PTH 1-34 can normalize mean serum and urine calcium levels in patients with hypoparathyroidism; however, once-daily PTH has diminishing effects on serum calcium after 12 h, such that serum calcium levels fall below the normal range in some patients. Once-daily PTH also causes a marked increase in bone turnover, with persistent increases in markers of bone formation and resorption. To test the hypothesis that a twice-daily PTH regimen can produce more physiological control than a once-daily regimen, we performed a randomized cross-over trial, lasting 28 weeks, in 17 adult subjects with hypoparathyroidism. Each 14-week study arm was divided into a 2-week inpatient dose-adjustment phase and a 12-week outpatient phase. The PTH dose (given sc once daily at 0900 h or twice daily with one dose at 0900 h and the other at 2100 h) was adjusted to maintain both serum and urine calcium within, or close to, the normal range. During the second half of the day (12-24 h), twice-daily PTH increased serum calcium and magnesium levels more effectively than once-daily PTH. In patients with calcium receptor mutations (CaR), once-daily PTH normalized urine calcium, provided that serum calcium was maintained at levels below normal range. However, twice-daily PTH treatment produced higher mean serum calcium in patients with CaR with no significant rise in urine calcium excretion, and with no significant differences in either serum or urine calcium levels between CaR and patients with acquired or idiopathic hypoparathyroidism. Thus, treatment with twice-daily PTH is the better regimen for patients with CaR to overcome their tendency to hypercalciuria while producing near-normal levels of serum calcium. The total daily PTH dose was markedly reduced with the twice-daily regimen (twice daily 46+/-52 vs. once daily 97+/-60 microg/day, P < 0.001). We conclude that a twice-daily PTH regimen provides effective treatment of hypoparathyroidism and reduces the variation in serum calcium levels at a lower total daily PTH dose.
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Affiliation(s)
- K K Winer
- Developmental Endocrinology Branch, National Institutes of Health, Bethesda, Maryland 20892-1862, USA
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Mancilla EE, De Luca F, Ray K, Winer KK, Fan GF, Baron J. A Ca(2+)-sensing receptor mutation causes hypoparathyroidism by increasing receptor sensitivity to Ca2+ and maximal signal transduction. Pediatr Res 1997; 42:443-7. [PMID: 9380434 DOI: 10.1203/00006450-199710000-00004] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Activating mutations of the Ca(2+)-sensing receptor (CaR) gene cause autosomal dominant hypoparathyroidism. Functional expression studies have been reported for several mutations, but have produced conflicting results. Thus, the mechanism by which these mutations activate the receptor is unclear. We describe here a new family with autosomal dominant hypoparathyroidism. The mother and three daughters experienced muscle spasms and/or seizures from early childhood. They were treated with oral calcium and vitamin D analogs, and all four patients developed hypercalciuria, nephrocalcinosis, and renal insufficiency. In this family, we identified a heterozygous missense mutation (F612S) involving the extracellular region of the CaR. The mutation cosegregated with disease. It was not present in 50 normal control individuals. We used site-directed mutagenesis to introduce this mutation into the CaR cDNA, and then expressed the mutant receptor in human embryonic kidney (HEK)-293 cells. In these cells, the accumulation of inositol phosphates was measured as a function of extracellular Ca2+ concentration. Compared with the wild-type receptor, the mutant receptor showed a left-shift in the concentration-response curve and an increase in the maximal response to high Ca2+ concentration. These effects did not appear to be mediated by changes in levels of receptor expression, as judged by ELISA, or by changes in receptor glycosylation, as judged by Western analysis. We conclude that this CaR mutation causes hypoparathyroidism by a dual increase in receptor sensitivity to extracellular Ca2+ and maximal signal transduction capacity.
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Affiliation(s)
- E E Mancilla
- Developmental Endocrinology Branch, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892, USA
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De Luca F, Ray K, Mancilla EE, Fan GF, Winer KK, Gore P, Spiegel AM, Baron J. Sporadic hypoparathyroidism caused by de Novo gain-of-function mutations of the Ca(2+)-sensing receptor. J Clin Endocrinol Metab 1997; 82:2710-5. [PMID: 9253358 DOI: 10.1210/jcem.82.8.4166] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Activating mutations of the Ca(2+)-sensing receptor (CaR) gene have been identified in families with autosomal dominant hypoparathyroidism and in one patient with sporadic hypoparathyroidism. Here, we describe two additional patients with sporadic hypoparathyroidism. One patient presented with mild symptoms at age 18 yr; the other was severely symptomatic from infancy. A heterozygous missense mutation was identified in each patient. One mutation (L773R) involved the fifth transmembrane domain of the CaR, the other (N118K) affected the amino-terminal, extracellular domain. In both cases, the probands' parents lacked the mutation, indicating that the mutations arose de novo. In expression studies the mutations shifted the concentration-response curve to the left and increased maximal activity. We conclude that 1) sporadic hypoparathyroidism can be caused by de novo gain-of-function mutations of the CaR; 2) the phenotype can vary from mild to life-threatening hypocalcemia; 3) gain-of-function mutations can involve not only extracellular regions, as previously reported, but also transmembrane domains of the CaR; and 4) the mechanism of activation can involve both increased receptor sensitivity to Ca2+ and increased maximal signal transduction.
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Affiliation(s)
- F De Luca
- Developmental Endocrinology Branch, National Institute of Child Health and Human Development Bethesda, Maryland 20892, USA.
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Affiliation(s)
- K K Winer
- Developmental Endocrinology Branch of the National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892-1862, USA
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Baron J, Winer KK, Yanovski JA, Cunningham AW, Laue L, Zimmerman D, Cutler GB. Mutations in the Ca(2+)-sensing receptor gene cause autosomal dominant and sporadic hypoparathyroidism. Hum Mol Genet 1996; 5:601-6. [PMID: 8733126 DOI: 10.1093/hmg/5.5.601] [Citation(s) in RCA: 154] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Parathyroid hormone secretion is negatively regulated by a 7-transmembrane domain, G-protein coupled Ca(2+)-sensing receptor. We hypothesized that activating mutations in this receptor might cause autosomal dominant hypoparathyroidism (ADHP). Consistent with this hypothesis, we identified, in two families with ADHP, heterozygous missense mutations in the Ca(2+)-sensing receptor gene that cosegregated with the disorder. None of 50 normal controls had either mutation. We also identified a de novo, missense Ca(2+)-sensing receptor mutation in a child with severe sporadic hypoparathyroidism. The amino acid substitution in one ADHP family affected the N-terminal, extracellular domain of the receptor. The other mutations involved the transmembrane region. Unlike patients with acquired hypoparathyroidism, patients with these mutations had hypercalciuria even at low serum calcium concentrations. Their greater hypercalciuria presumably reflected activation of Ca(2+)-sensing receptors in kidney cells, where the receptor negatively regulates calcium reabsorption. This augmented hypercalciuria increases the risk of renal complications and thus has implications for the choice of therapy.
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Affiliation(s)
- J Baron
- Developmental Endocrinology Branch, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892-1862, USA
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