The role of sclerostin/dickkopf-1 and receptor activator of nuclear factor kB ligand/osteoprotegerin signalling pathways in the development of osteoporosis in patients with haemophilia A and B: A cross-sectional study

AIM

Haemophilia A and B are associated with reduced bone mineral density (BMD). The aim of this study was to assess circulating sclerostin and dickkopf-1 (Dkk-1), (inhibitors of osteoblastic differentiation), as well as the receptor activator of nuclear factor kB ligand (RANKL)/osteoprotegerin (OPG) system (the major regulator of osteoclastogenesis), in patients with haemophilia (PWH), their possible correlations with clinical risk factors and the effect of ibandronate on these markers.

METHODS

Eighty-nine male PWH (mean age 45.9 ± 15.3 years) and 30 age-matched healthy male controls participated. BMD was assessed by DXA. Sclerostin, Dkk-1, RANKL and OPG were measured in serum of patients, controls, as well as in ten patients receiving oral ibandronate (150 mg/mo), at baseline and after 12 months.

RESULTS

Patients with haemophilia had lower circulating sclerostin (median ± IQR: 47.4 ± 26.93 vs 250 ± 250 pmol/L, P < .001), Dkk-1 (21.24 ± 17.18 vs 26.16 ± 15.32pg/mL, P = .04) and higher levels of RANKL (0.23 ± 0.03 vs 0.04 ± 0.03 pmol/L, P = .001), RANKL/OPG ratio (0.063 ± 0.25 vs 0.005 ± 0.11, P = .001) compared with controls. Patients with low BMD had higher OPG concentrations compared to those with normal BMD. Sclerostin and RANKL/OPG correlated positively with BMD. Patients with severe haemophilia had lower sclerostin concentrations compared with those with mild or moderate disease. The degree of arthropathy negatively correlated with sclerostin and Dkk-1 levels. PWH who received ibandronate showed a decrease in serum Dkk-1 without any significant effect on sclerostin and RANKL/OPG.

CONCLUSIONS

Patients with haemophilia present increased osteoclastic activity coupled with compensatory increased osteoblastic activity. Ibandronate did not affect RANKL/OPG ratio, but it decreased Dkk-1.

Acute Leukemia and Pregnancy

The combination of acute leukemia and pregnancy is infrequent. It is estimated to occur in less than 1 in 75,000 pregnancies. Maternal and fetal outcomes have improved substantially in recent years. In general, multi-agent chemotherapy is given as soon as the diagnosis of leukemia is established, even if it is in the first trimester. There are two important considerations in the management of a patient with leukemia during pregnancy, the mother who needs optimal cancer therapy and the developing fetus who could potentially be affected by the disease and/or the teratogenicity of antineoplactic agents. Vaginal delivery is preferable, and caesarian section is reserved for obstetrical indications only.

Bone mineral density in men and children with haemophilia A and B: a systematic review and meta-analysis

SUMMARY

Although haemophilia is not considered among the classic causes of secondary osteoporosis, the present meta-analysis provides strong evidence that men with haemophilia have a significant reduction in both lumbar spine and femoral bone mineral density, which appears to begin in childhood.

INTRODUCTION

Haemophilia is not considered among the classic causes of secondary osteoporosis. The aim of this study was to systematically review the literature for case-control trials that have studied bone mass in males with haemophilia and to meta-analyze the best evidence available.

METHODS

Electronic databases MEDLINE, EMBASE and CENTRAL were systematically searched for case-control trials that have studied bone mass in men or boys with haemophilia. Standardized mean difference (SMD) for bone mineral density (BMD) in the lumbar spine was the main study outcome and SMD in femoral neck and total hip BMD the secondary ones. Patient and control characteristics, such as age, body mass index (BMI), level of physical activity and blood-borne infections were recorded as possible predictors of the main outcome.

RESULTS

Thirteen studies were included in the systematic review and ten in the main outcome meta-analysis. Men with haemophilia demonstrated reduced lumbar spine [random effects SMD [95 % confidence interval (CI)] = -0.56 (-0.84, -0.28), between-study heterogeneity (I (2)) = 51 %] and femoral neck BMD [random effects SMD (95 % CI) = -0.82 (-1.21, -0.44), I (2) = 63 %] compared with controls, which indicated a large and clinically significant association. Similar results were obtained for children [random effects SMD (95 % CI) = -0.92 (-1.77, -0.07), I (2) = 92 %]. No evidence of publication bias was detected. There was no evidence that age, BMI, level of physical activity or presence of blood-borne infections predicted lumbar spine BMD.

CONCLUSIONS

This meta-analysis shows that men with haemophilia present a significant reduction in both lumbar spine and hip BMD, which appears to begin in childhood.

The clinical utility of bone turnover markers in the evaluation of bone disease in patients with haemophilia A and B

Haemophilia A and B have been associated with increased prevalence of low bone mineral density (BMD). However, the utility of bone turnover markers (BTM) remains unknown. The aim of this study was to evaluate bone metabolism in men with haemophilia and to investigate associations between BTM and bone disease. Serum N- (NTX-I), C-terminal telopeptide of type I collagen (CTX-I) and tartrate-resistant acid phosphatase band-5b (TRAP-5b), as bone resorption markers, and osteocalcin (OC) and bone-specific alkaline phosphatase (b-ALP), as bone formation markers, were assessed. Seventy men with haemophilia A (n = 59) or B (n = 11) were studied. Patients with low BMD had significantly higher b-ALP concentrations compared with those with normal BMD (12.8 ± 1.60 vs. 9.72 ± 0.58 μg/L, P = 0.009), without any differences in the other BTM. NTX-I and CTX-I concentrations were negatively associated with oestradiol levels and hip BMD and positively with human immunodeficiency virus infection, number of affected joints and arthropathy scores. B-ALP and OC concentrations were negatively associated with hip BMD, severity of haemophilia and fracture history, and positively with the number of affected joints and testosterone concentrations. After multivariate analysis, NTX-I levels remained negatively associated with oestradiol levels, whereas b-ALP concentrations negatively correlated with the level of physical activity and positively with the number of affected joints. Increased bone metabolism exists in men with haemophilia and low BMD. Increased b-ALP levels may identify patients at high risk for fracture. Increased number of target joints, low physical activity and low oestradiol concentrations are independently associated with increased bone metabolism.

Multiple myeloma and bone disease: pathogenesis and current therapeutic approaches

Multiple myeloma is a haematologic malignancy caused by clonal expansion of malignant plasma cells and associated with bone disease and hypercalcaemia. Myeloma cells are in close proximity to sites of active bone resorption and the interactions between those cells, osteoblasts and osteoclasts, are crucial not only for the bone distraction but for the proliferation of bone marrow cells as well. Recent studies have revealed that numerous regulating factors of osteoblast and osteoclast activity interfere with the pathogenesis of multiple myeloma's bone disease and that the understanding of the pathophysiological pathways involved is the first step towards discovering novel potential therapeutic approaches.

Increased levels of proinflammatory cytokines in children with family history of coronary artery disease

BACKGROUND

Parental history of coronary artery disease (CAD) is considered an important risk factor for early atherosclerosis

HYPOTHESIS

The onset of the inflammatory process of atherosclerosis initiates early during childhood in children with positive family history (PFH) of CAD.

METHODS

We studied 55 healthy children (5-15 years), 30 (16 male) with PFH and 25 age and sex matched control subjects. Blood samples were taken to measure white blood count (WBC), glucose, total cholesterol, triglycerides (TG), high-density lipoprotein (HDL), low-density lipoprotein (LDL), erythrocyte sedimentation rate (SDE), C-reactive protein (CRP), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-a). We performed cultures on monocytes (from peripheral blood) measuring in the cell culture supernatants the proinflammatory cytokines IL-6 and TNF-a, by using the immunoassay ELISA method.

RESULTS

: Higher values of body mass index (BMI), total cholesterol, LDL, cholesterol, TG, SDE, leucocytes, and CRP were calculated in children with PFH. Significantly higher values of cytokines in monocell cultures were measured in the PFH group compared to the control group (IL-6 = 139.32 +/- 80.84 pg/ml versus 14.30 +/- 12.97 pg/ml, p < 0.001 and TNF-a = 39.91 +/- 11.80 pg/ml versus 8.65 +/- 4.35 pg/ml, p < 0.001). IL-6 values in plasma and cultures were found independently associated with PFH of premature CAD (p < 0.001, p = 0.005, respectively). A similar relation was found for TNF-a values measured in cultures (p = 0.005) and CRP values in plasma (p < 0.001). The values of IL-6 were found proportionally related to TG.

CONCLUSION

In individuals with PFH of CAD the inflammatory process of atheromatosis appears to begin early in childhood. Except for triglycerides, this inflammatory process appears to occur independently of several traditional cardiovascular risk factors.

Management of acute bleeding in a patient with congenital afibrinogenaemia

Congenital afibrinogenaemia is a rare bleeding disorder characterized by absence of fibrinogen and varying bleeding tendency. Treatment with fibrinogen concentrates is considered to be the best choice for afibrinogenaemic patients who experience bleeding. We report the case of a 22-year-old Greek patient who presented with large muscular haematomas and was treated with fibrinogen concentrates. The efficacy of this treatment and the problems that arose during his hospitalization are being discussed.

Hemophagocytic syndrome associated with multiple myeloma

Hemophagocytic syndrome (HPS) is an uncommon reactive disorder characterized by proliferation of histiocytes that actively engulf other hematopoietic cells causing cytopenia. It complicates several diseases including hematological neoplasias. We report the case of a 54-year-old woman who was admitted to our hospital with fever of unknown origin. Her clinical picture was characterized by renal failure, splenomegaly and pancytopenia. Findings on bone marrow examination showed HPS associated with multiple myeloma. A review of the literature revealed that only one case has previously been published.

Severe neutropenia in a patient with large granular lymphocytosis: prolonged successful control with cyclosporin A

A case of severe neutropenia associated with large granular lymphocytosis in a 40-year-old female is described. The patient, with no findings of an underlying systemic disorder, had suffered from recurrent life threatening, mainly pseudomonal, infections for about two years, despite the various regimes tried. During the last twelve months cyclosporin A treatment resulted in a significant increase in absolute neutrophil counts, concomitant with a remarkable decrease in bone marrow infiltration by GLs and almost normal counts of GLs in the peripheral blood. During this time she has remained completely free from infectious episodes. The mechanisms involved remain to be determined.

The use of fluorodeoxyuridine synchronization for cytogenetic investigation of acute lymphoblastic leukemia

The role of fluorodeoxyuridine (FUdR) synchronization in cytogenetic analysis of acute lymphoblastic leukemia (ALL) was investigated using samples of bone marrow (BM) (10 patients) and peripheral blood (PB) (2 patients), prepared for chromosome analysis using both 24-hour unstimulated cultures (24-hr) and cultures synchronized with FUdR. The mitotic index (MI) in FUdR was lower than in 24-hr in 8 of 10 BM and 2 of 2 PB cultures. The quality of the metaphases was the same in both cultures. The FUdR had a lower percentage of abnormal cells than the 24-hr in the 7 BM samples with a normal/abnormal population and sufficient analyzable cells in each culture for comparison (p less than 0.05). PB FUdR cultures yielded only normal cells. We conclude that FUdR cultures are inferior to 24-hr cultures for chromosome analysis in ALL.

Trisomy 8 in acute lymphoblastic leukemia (ALL): a case report and update of the literature

A case of acute lymphoblastic leukemia (ALL) cytogenetically characterized by trisomy 8 as a sole aberration is described. The patient, one of 116 adults with ALL investigated cytogenetically, was a 36-year-old male with leukocyte count 12.3 x 10(9)/liter with 90% blasts of FAB type L1 and common ALL immunological phenotype. Remission was achieved with the current U.K. treatment trial. The patient recovered from an autologous bone marrow transplant (BMT) in first remission but relapsed 15 months later. BMT, in second remission, from an unrelated donor, was rejected. Autologous reinfusion failed and he died 26 months after diagnosis. Molecular investigation of immunoglobulin gene rearrangement identified the same B cell clone at diagnosis and in relapse. The clinical and cytogenetic findings of six published cases of ALL with trisomy 8 have been reviewed with updates supplied by the authors. These reveal an heterogeneous group of patients ranging in age from 9 months to 39 years with no apparent association with a particular immunophenotype. Four patients were alive after 10-108 months follow-up. Two patients died, in relapse, 7 and 17 months after diagnosis. Thus trisomy 8 occurs in ALL with an incidence of 1-2%. The prognostic significance of this remains to be determined.