Bone Osteomalacia Research Articles

Osteoidosis leads to altered differentiation and function of osteoclasts.

In patients with osteomalacia, a defect in bone mineralization leads to changed characteristics of the bone surface. Considering that the properties of the surrounding matrix influence function and differentiation of cells, we aimed to investigate the effect of osteoidosis on differentiation and function of osteoclasts. Based on osteomalacic bone biopsies, a model for osteoidosis in vitro (OIV) was established. Peripheral blood mononuclear cells were differentiated to osteoclasts on mineralized surfaces (MS) as internal control and on OIV. We observed a significantly reduced number of osteoclasts and surface resorption on OIV. Atomic force microscopy revealed a significant effect of the altered degree of mineralization on surface mechanics and an unmasking of collagen fibres on the surface. Indeed, coating of MS with RGD peptides mimicked the resorption phenotype observed in OIV, suggesting that the altered differentiation of osteoclasts on OIV might be associated with an interaction of the cells with amino acid sequences of unmasked extracellular matrix proteins containing RGD sequences. Transcriptome analysis uncovered a strong significant up‐regulation of transmembrane glycoprotein TROP2 in osteoclastic cultures on OIV. TROP2 expression on OIV was also confirmed on the protein level and found on the bone surface of patients with osteomalacia. Taken together, our results show a direct influence of the mineralization state of the extracellular matrix surface on differentiation and function of osteoclasts on this surface which may be important for the pathophysiology of osteomalacia and other bone disorders with changed ratio of osteoid to bone.

Uremia Induces Dental Pulp Ossification but Reciprocally Inhibits Adjacent Alveolar Bone Osteogenesis.

Uremic patients are predisposed to atrophy of the alveolar bone and narrowing of the dental pulp chamber. Such pulp chamber changes have only been diagnosed radiologically; however, this has not been supported by any pathological evidence. We used a uremic rat model with secondary hyperparathyroidism induced by 5/6 nephrectomy surgery and high-phosphate diet to examine the dental pulp and adjacent alveolar bone pathology. In addition, we collected pulp tissues for real-time PCR. We found an opposite histopathological presentation of the ossified dental pulp and the osteomalacic adjacent alveolar bone. Furthermore, pulp cells with positive staining for Thy-1, a surrogate stem cell marker, were significantly reduced in the pulp of uremic rats compared to the controls, indicating a paucity of stem cells. This was further evidenced by the reduced pulp expression of dickkopf-1 (Dkk-1), a Wnt/β-catenin signaling inhibitor produced by mesenchymal stem cells. In contrast, expressions of receptor activator of nuclear factor κB ligand (RANKL) and RANK in uremic pulp were up-regulated, probably to counteract the ossifying process of uremic pulp. In conclusion, uremic pulp ossifications were associated with a paucity of stem cells and dysregulated Dkk-1 and RANKL signaling systems, further shifting the imbalance toward osteogenesis. Strategies to counteract such an imbalance may offer a potential therapeutic target to improve dental health in uremic patients, which warrants further interventional studies.

BONE HISTOLOGY OF PATIENTS WITH ALENDRONATE-MEDIATED FRACTURED BONE — A NEW ENTITY OF ATYPICAL OSTEOMALACIA

Based on the pharmaco-physiology of the aminobisphosphonates, it could be speculated that bisphosphonates could induce not only the osteopetrotic bone disease because of their selective suppression of osteoclastic activity, but also could affect directly or indirectly the endocrine system, local factors, and also the bone metabolic turnover. Consequently, the bone fragility could be rather produced by long-term aminobisphosphonate therapy. Bisphosphonate-mediated bone disease was labeled by Odvina et al. in 2005 [Odvina CV, Zerwerth JE, Rao DS et al. Severely suppressed bone turnover; a potential complication of alendronate therapy. J Clin Endocrinol Metab 90: 1294–1301, 2005.] as the "severely suppressed bone turnover (SSBT)" on the metabolic turnover basis. However, such definition could contain various drug-induced bone diseases, and did not indicate any particular condition, induced by the bisphosphonate. The term "SSBT" is thought not solely to be based on its histology, and seems rather a clinical term applicable to the various drug-induced bone diseases. Therefore, the current authors attempted to characterize the bisphosphonate-mediated bone disease on the basis of the combined image and histological studies, and finally concluded that the prolonged bisphosphonate therapy could produce an atypical osteomalacic bone disease. (osteosclerosis of osteomalacia) which leads to fragility fracture. It is puzzling as to why malacia rather than petrosis develops in the skeleton.

Proteolytic processing of osteopontin by PHEX and accumulation of osteopontin fragments in Hyp mouse bone, the murine model of X-linked hypophosphatemia

X-linked hypophosphatemia (XLH/HYP)-with renal phosphate wasting, hypophosphatemia, osteomalacia, and tooth abscesses-is caused by mutations in the zinc-metallopeptidase PHEX gene (phosphate-regulating gene with homologies to endopeptidase on the X chromosome). PHEX is highly expressed by mineralized tissue cells. Inactivating mutations in PHEX lead to distal renal effects (implying accumulation of a secreted, circulating phosphaturic factor) and accumulation in bone and teeth of mineralization-inhibiting, acidic serine- and aspartate-rich motif (ASARM)-containing peptides, which are proteolytically derived from the mineral-binding matrix proteins of the SIBLING family (small, integrin-binding ligand N-linked glycoproteins). Although the latter observation suggests a local, direct matrix effect for PHEX, its physiologically relevant substrate protein(s) have not been identified. Here, we investigated two SIBLING proteins containing the ASARM motif-osteopontin (OPN) and bone sialoprotein (BSP)-as potential substrates for PHEX. Using cleavage assays, gel electrophoresis, and mass spectrometry, we report that OPN is a full-length protein substrate for PHEX. Degradation of OPN was essentially complete, including hydrolysis of the ASARM motif, resulting in only very small residual fragments. Western blotting of Hyp (the murine homolog of human XLH) mouse bone extracts having no PHEX activity clearly showed accumulation of an ∼35 kDa OPN fragment that was not present in wild-type mouse bone. Immunohistochemistry and immunogold labeling (electron microscopy) for OPN in Hyp bone likewise showed an accumulation of OPN and/or its fragments compared with normal wild-type bone. Incubation of Hyp mouse bone extracts with PHEX resulted in the complete degradation of these fragments. In conclusion, these results identify full-length OPN and its fragments as novel, physiologically relevant substrates for PHEX, suggesting that accumulation of mineralization-inhibiting OPN fragments may contribute to the mineralization defect seen in the osteomalacic bone characteristic of XLH/HYP.

A Challenging Case of Hypocalcemia Supporting the Concept That 25-Hydroxyvitamin D Status Is Important for Intestinal Calcium Absorption

Intestinal mucosa seems to be responsive not only to circulating calcitriol but also to serum 25-hydroxyvitamin D concentrations. We report a complex patient with chronic kidney disease who presented with symptomatic hypocalcemia (ionized calcium, 0.77 mmol/liter) despite regular calcitriol and calcium supplementation. Case history, laboratory evaluation, and bone biopsies are discussed. Only vigorous treatment with im cholecalciferol led to a significant improvement of serum calcium, a decrease in PTH levels, and histological improvement of osteomalacic bone disease. However, oral anticoagulation became necessary for advanced peripheral artery disease, which precluded further im injections. Therefore, UVB phototherapy was initiated to treat vitamin D deficiency. This case is clinically relevant because it demonstrates that efficient calcium absorption is markedly reduced in profound vitamin D deficiency, even with normal active vitamin D levels. An important consequence is to stay aware of vitamin D deficiency in patients with compromised kidney function irrespective of regular calcitriol replacement. Second, when both parenteral and oral vitamin D administration are contraindicated, ineffective, or unavailable, UVB phototherapy is an effective option to treat vitamin D deficiency. Third, this case underlines the importance of obtaining regular 25-hydroxyvitamin D levels in complex clinical cases when prediction of individual response is unreliable.

Three Novel Mutations of the PHEX Gene in Three Chinese Families with X-linked Dominant Hypophosphatemic Rickets

X-linked dominant hypophosphatemia (XLH, OMIM307800), the most prevalent form of inherited rickets in humans, is a dominant disorder of phosphate homeostasis characterized by growth retardation, rachitic and osteomalacic bone disease, hypophosphatemia, and renal phosphate wasting. The gene responsible for XLH was identified by positional cloning and designated PHEX (formerly PEX) to depict a phosphate-regulating gene homologous with endopeptidases on the X chromosome. Recently, extensive mutation analysis of the PHEX gene has revealed a wide variety of gene defects in XLH. The ethnic distribution of the mutations is very widespread but only a few mutations in Chinese have been reported. To analyze the molecular basis in three unrelated Chinese families with XLH, we determined the nucleotide sequence of the PHEX gene and fibroblast growth factor 23 (FGF23) gene of affected members. The serum FGF23 concentrations of these patients with XLH were also measured. Three different novel mutations were observed in these three families: one deletion mutation c.264delG causing p.W88 X; one missense mutation c.1673C>G causing p.P558A; one nonsense mutation c.1809G>A causing p.W603 X. Serum concentration of FGF23 in XLH patients of these three families was significantly higher than normal. The results suggest that PHEX gene mutations were responsible for XLH in these patients and these mutations may contribute to a higher serum FGF23 level.

Measurement of phosphorus content in normal and osteomalacic rabbit bone by solid‐state 3D radial imaging

In osteomalacia decreased mineralization reduces the stiffness and static strength of bone. We hypothesized that hypomineralization in osteomalacic bone could be quantified by solid-state (31)P magnetic resonance imaging (SS-MRI). Hypomineralization was measured with a 3D radial imaging technique at 162 MHz (9.4T) in rabbit cortical bone of hypophosphatemic (HY) and normophosphatemic (NO) animals. The results were compared with those obtained by quantitative micro-CT (micro-CT) and (31)P solution NMR. 3D images of 277 microm isotropic voxel size were obtained in 1.7 hr with SNR approximately 9. Mineral content was lower in the HY relative to the NO group (SS-MRI: 9.48 +/- 0.4 vs. 11.15 +/- 0.31 phosphorus wet wt %, P < 0.0001; micro-CT: 1114.6 +/- 28.3 vs. 1175.7 +/- 23.5 mg mineral/cm(3); P = 0.003). T(1) was shorter in the HY group (47.2 +/- 3.5 vs. 54.1 +/- 2.7 s, P = 0.004), which suggests that relaxation occurs via a dipole-dipole (DD) mechanism involving exchangeable water protons, which are more prevalent in bone from osteomalacic animals.

Infrared imaging of calcified tissue in bone biopsies from adults with osteomalacia

Osteomalacia is a pathological bone condition in which there is deficient primary mineralization of the matrix, leading to an accumulation of osteoid tissue and reduced bone mechanical strength. The hypothesis that there are no qualitative or quantitative differences in osteomalacic bone mineral or matrix compared to disease-free bones was tested by examining unstained sections of polymethyl methacrylate (PMMA) embedded iliac crest biopsies using Fourier transform infrared imaging (FTIRI) at approximately 6-μm spatial resolution. Controls were seven female subjects, aged 36–57, without apparent bone disease. The experimental group consisted of 11 patients aged 22–72, diagnosed with osteomalacia. The spectroscopic parameters analyzed in each data set were previously established as sensitive to bone quality: phosphate/amide I band area ratio (mineral content), 1660/1690 cm−1 peak ratio (collagen cross-links), and the 1030/1020 cm−1 peak ratio (mineral crystallinity). The correspondence between spectroscopic mineral content (phosphate/amide I ratio) and ash weight was validated for apatite crystals of different composition and crystallite size. The FTIRI results from the biopsies expressed as color-coded images and pixel population means were compared with the nonparametric Mann–Whitney U test. There were no significant differences in the cortical parameters. Significant difference was found in the mineral content of the trabecular regions with a lower mean value in osteomalacia (P = 0.01) than in controls. Mineral crystallinity tended to be decreased in the trabecular bone (P = 0.09). This study supports the hypothesis that, in osteomalacia, the quality of the organic matrix and of mineral in the center of bone does not change, while less-than-optimal mineralization occurs at the bone surface. This study provides the first spectroscopic evaluation of whole bone mineral and matrix properties in osteomalacia, demonstrating that there are few differences in collagen cross-links between biopsies from patients with osteomalacia and from individuals without histological evidence of bone disease.

Commonly recommended daily intake of vitamin D is not sufficient if sunlight exposure is limited.

Sunlight exposure of the skin is known to be the most important source of vitamin D. The aims of this study were: (i) to estimate vitamin D status amongst sunlight-deprived individuals (veiled Arab women, veiled ethnic Danish Moslem women and Danish controls); and (ii) through food intake analysis to estimate the oral intake of vitamin D necessary to keep a normal vitamin D status in sunlight-deprived individuals. Cross-sectional study amongst randomly selected Moslem women of Arab origin living in Denmark. Age-matched Danish women were included as controls. To control for racial differences, a group of veiled ethnic Danish Moslem women (all Caucasians) was included. Primary Health Care Centre, City Vest and Department of Endocrinology and Metabolism C, University Hospital of Aarhus, Aarhus Amtssygehus, Aarhus, Denmark. Sixty-nine Arab women (60 veiled, nine non-veiled) and 44 age-matched Danish controls were randomly selected amongst patients contacting the primary health care centre for reasons other than vitamin D deficiency. Ten ethnic Danish Moslem women were included through a direct contact with their community. Serum levels of 25-hydroxyvitamin D were used as estimates of vitamin D status. Intact parathyroid hormone (PTH) was used to control for secondary hyperparathyroidism. Alkaline phosphatase and bone-specific alkaline phosphatase were used as markers for osteomalacic bone involvement. Oral intake of vitamin D and calcium were estimated through a historical food intake interview performed by a trained clinical dietician. Veiled Arab women displayed extremely low values of 25-hydroxyvitamin D: 7.1 +/- 1.1 nmol L-1, compared with 17.5 +/- 2. 3 (P < 0.002) in ethnic Danish Moslems and 47.1 +/- 4.6 (P < 10-17) in Danish controls. PTH was increased amongst veiled Arab women: 15. 6 +/- 1.8 pmol L-1, compared with 5.7 +/- 1.4 in ethnic Danish Moslems and 2.7 +/- 0.3 (P < 10-6) in Danish controls. The vitamin D intake (including food supplementation) was very low amongst Arab women: 1.04 microg day-1, compared with 13.53 amongst ethnic Danish Moslems and 7.49 amongst Danish controls (P < 0.0005). Severe vitamin D deficiency is prevalent amongst sunlight-deprived individuals living in Denmark. In veiled Arab women, vitamin D deficiency is the result of a combination of limitations in sunlight exposure and a low oral intake of vitamin D. The oral intake of vitamin D amongst veiled ethnic Danish Moslems was, however, very high, at 13.53 microgram (approximately 600 IU), but they were still vitamin D-deficient. Our results suggest that the daily oral intake of vitamin D in sunlight-deprived individuals should exceed 600 IU; most probably it should be 1000 IU day-1 to secure a normal level of 25-hydroxyvitamin D. This finding is in contrast with the commonly used RDA (recommended daily allowance) for adults in Europe: 200 IU day-1.

PHEXdb, a locus-specific database for mutations causing X-linked hypophosphatemia.

X-linked hypophosphatemia (XLH) is a dominant disorder of phosphate (Pi) homeostasis characterized by growth retardation, rachitic and osteomalacic bone disease, hypophosphatemia, and renal defects in Pi reabsorption and vitamin D metabolism. The gene responsible for XLH was identified by positional cloning and designated PHEX (formerly PEX) to depict a Phosphate regulating gene with homology to Endopeptidases on the X chromosome. To date, 131 mutations in the PHEX gene have been reported. We undertook to centralize information on mutations in the PHEX gene by establishing a database search tool, PHEXdb (http://data.mch.mcgill.ca/phexdb). This site is dedicated to the collection and distribution of information on PHEX mutations, and is accessible to the scientific community. PHEXdb provides a submission form to allow the addition of newly identified mutations in the PHEX gene. Users can search the database by mutation, phenotype, and authors who have published or submitted mutations. The PHEXdb home page includes links to information pages, which refer to recent publications on PHEX, XLH, and murine Hyp and Gy homologues, and to other web pages relevant to XLH. This resource will facilitate the identification of PHEX structure-function relationships and phenotype-genotype correlations.

Calcified microspheres as biological entities and their isolation from bone.

Calcified microspheres, about 1 microm in diameter, appear at sites of bone formation where they invest the collagenous matrix, become confluent and disappear. Evidence that the particle boundaries are not lost with compaction but merely deformed is supported in section by the granular histochemical staining of the inorganic phase for bone salt, lipid, fibronectin and acid phosphatase in osteomalacic, acid-etched and normal human bone. Their persistence as discrete objects is confirmed by the application of methods for their isolation from the collagenous matrix of immature mouse calvarium and mature bovine femur. Five methods have been used to extract them and include (i) biochemical, (ii) chemical, (iii) mechanical, (iv) pyrogenous and (v) biological separation. Under the optical microscope, all isolates consisted of similar discrete objects and bridged assemblies, whose birefringence varied with treatment. After decalcification, their organic 'ghosts' remained. Each isolated microsphere had a complex substructure of clusters of non-collagenous calcified filaments surrounding a less dense centre. The filaments were 5 nm in diameter with a 5 nm periodicity and regular fine interfilamentous connections. It is concluded that the microspheres are independent, complex, pervasive and central to the containment (i.e. packaging) of calcium phosphate in bone. Their extraction will enable further analysis.

Pex mRNA is localized in developing mouse osteoblasts and odontoblasts.

Mutations in PEX, a phosphate-regulating gene with homology to endopeptidase on the X chromosome, were recently identified in patients with X-linked hypophosphatemia (XLH), an inherited disorder of phosphate homeostasis characterized by growth retardation and rachitic and osteomalacic bone disease. To understand the mechanism by which loss of PEX function elicits the mutant phenotype, a study of its mRNA localization and ontogenesis was undertaken. Using the reverse transcriptase-nested polymerase chain reaction (RT-nested PCR) with polyA+ RNA purified from mouse testis, a 337-bp Pex cDNA fragment was generated and cloned in the pCRII plasmid. The cDNA was used to generate sense and anti-sense Pex riboprobes for in situ hybridization (ISH) and Northern analysis. To survey a large number of different tissues, sagittal sections of embryos and newborn mice were examined. ISH showed the presence of Pex mRNA in osteoblasts and odontoblasts. Pex gene expression was detectable on Day 15 of embryonic development, which coincides with the beginning of intercellular matrix deposition in bones. Finally, Northern analysis of total RNA from calvariae and teeth of 3-day-old and adult mice showed that the abundance of the 7-kb Pex transcript is decreased in adult bones and in nongrowing teeth. The present study demonstrates that Pex mRNA is expressed in bones and teeth and suggests that this putative endopeptidase plays an important role in the development of these tissues.

X-linked hypophosphatemia: molecular biology and treatment controversies.

X-linked hypophosphatemia, currently one of the most prevalent varieties of familiar rickets, is attributed to renal phosphate wasting secondary to a gene defect localized to X p22 chromosomal region. The proximal tubular phosphate reabsorption defect is associated with blunted 1,25-dihydroxyvitamin D synthesis to hypophosphatemia or parathyroid hormone administration. It is characterized clinically by hypophosphatemia, growth retardation, and rickets especially in male patients. As the affected patients mature, pseudofractures, skeletal deformities, osteomalacic bone pain, progressive ankylosis, and dental caries occur, which may be alleviated and even prevented with adequate medical therapy. Long term treatment combines phosphate supplementation with calcitriol, augmented occasionally by diuretics. Hypercalcemia, hyperparathyroidism, and nephrocalcinosis are potential complications which require careful monitoring and continued investigations. The use of recombinant human growth hormone to augment renal tubular reabsorption of phosphate and to promote linear growth remains to be examined in well controlled, clinical trials.

The Aluminum Content of Parenteral Solutions: Current Status

Aluminum contaminates several chemical compounds that are administered intravenously to patients. The most highly contaminated are calcium and phosphate salts, followed by albumin and heparin. Parenteral administration of aluminum bypasses the gastrointestinal tract, which serves as a protective barrier to aluminum entry into the blood. In the past, parenteral administration of aluminum as a contaminant of water used in hemodialysis and of casein hydrolysate, the former source of protein in parenteral nutrition solutions, was associated with a low-turnover osteomalacic bone disease and, in the case of uremic patients, encephalopathy. Groups currently at risk for aluminum accumulation in tissue resulting from parenteral administration include premature infants receiving long-term parenteral nutrition and patients receiving plasmapheresis therapy with albumin. Both groups may develop metabolic bone disease; the pathogenesis may involve aluminum. The Food and Drug Administration is currently considering regulation of aluminum in fluids used for parenteral nutrition. No changes are presently proposed with regard to albumin.

Long-Term Parenteral Nutrition] and Metabolic Bone Disease

Home parenteral nutrition has prevented malnutrition in patients who cannot maintain adequate nutrition by enteral feedings alone. The risk of bone and mineral abnormalities in these patients is significant for several reasons. Pre-existing skeletal disease can occur from factors known to affect the population at large as well as from malnutrition, malabsorption, and corticosteroid use related to the underlying disease process. Long-term use of infused nutrients and potential toxins can further alter bone turnover. Hypercalciuria is frequently present during HPN, yet its etiology is poorly defined. Parenteral nutrition admixture concentrations of calcium, phosphorus, protein, sodium, and dextrose may all play a role. Any development of acidosis can certainly aggravate hypercalciuria, which may be an indirect marker of abnormal bone turnover. Although increased protein intake can promote the development of acidosis-induced calciuresis, infused phosphorus and acetate can help reduce calcium excretion. Parenteral nutrition contamination by aluminum can cause a spectrum of osteomalacic bone disease similar to aluminum-associated changes seen in renal failure patients. Even with recent attempts to remove aluminum from the parenteral admixture, low-turnover bone disease can still occur. At present, HPN-related bone disease is a poorly understood entity because of its multifaceted nature. Patients receiving long-term parenteral nutrition should be considered to have an increased risk for the development of metabolic bone disease. Early monitoring for and treatment of bone disease should be considered in all patients receiving HPN.

A Versatile New Mineralized Bone Stain for Simultaneous Assessment of Tetracycline and Osteoid Seams

A versatile mineralized bone stain (MIBS) for demonstrating osteoid seams and tetracycline fluorescence simultaneously in thin or thick undecalcified sections has been developed. Bone specimens are fixed in 70% ethanol, but 10% buffered formalin is permissible. Depending upon one's preference, these specimens can be left unstained or be prestained before plastic embedding. Osteoid seams are stained green to jade green, or light to dark purple. Mineralized bone matrix is unstained or green. Osteoblast and osteoclast nuclei are light to dark purple, cytoplasm varies from slightly gray to pink. The identification of osteoid seams by this method agrees closely with identification by in vivo tetracycline uptake using the same section from the same biopsy. The method demonstrates halo volumes, an abnormal, lacunar, low density bone around viable osteocytes in purple. This phenomenon is commonly seen in vitamin D-resistant rickets, fluorosis, renal osteodystrophy, hyperparathyroidism, and is sometimes seen in fluoride treated osteoporotic patients. In osteomalacic bone, most osteoid seams are irregularly stained as indicated by the presence of unmineralized osteoid between mineralized lamellae. The method has been used effectively in staining new bone formation in hydroxyapatite implants and bone grafts. Old, unstained, plastic embedded undecalcified sections are stained as well as fresh sections after removal of the coverslip. This stain also promises to be valuable in the study of different metabolic bone diseases from the point of view of remodeling, histomorphometry, and pathology.

Bone and Serum Concentrations of Osteocalcin as a Function of 1,25-Dihydroxyvitamin D3Circulating Levels in Bone Disorders in Rats*

Osteocalcin, the vitamin K-dependent protein in bone containing gamma-carboxyglutamic acid, has been found to be significantly decreased in the osteomalacic bone of chicks made vitamin D deficient for 6 weeks. To evaluate whether this decrease in bone osteocalcin was due directly to the decrease or absence of vitamin D and its metabolites or to the secondary hypocalcemia and osteomalacia or other changes accompanying the deficiency of vitamin D, three experimental groups of Holtzman rats were studied. One group was made rachitic by a diet deficient in vitamin D, and the other groups were made rachitic by diets deficient in inorganic orthophosphate or calcium. The changes in bone and serum osteocalcin, serum 1,25-dihydroxyvitamin D3 [1,25-(OH)2D3], and bone mineral content were evaluated, and morphological evaluation of bone was made. In the vitamin D-deficient animals, osteomalacia was evident histologically by 7 weeks, at which time serum 1,25-(OH)2D3 was not detectable, bone osteocalcin was decreased by 50%, and serum osteocalcin was decreased by 20%. In the animals fed a diet deficient in either calcium or inorganic orthophosphate but which were not depleted of vitamin D, the osteocalcin content of osteomalcic bone was normal, and an increase in the concentration of serum osteocalcin accompanied an increase in serum 1,25-(OH)2D3. These data are consistent with the conclusion that the metabolism of osteocalcin is affected by serum 1,25-(OH)2D3 and that the diminished level of osteocalcin in the bone of vitamin D-deficient animals is the result of a direct action of the metabolites and is not secondary to a decrease in the mineralization of bone tissue.

Aluminum and Phosphate: The Double Bind

THE recognition that aluminum contaminated dialyzate was responsible for dementia and osteomalacic bone disease led to the expectation that with suitable water treatment, aluminum storage, and, on occasion, intoxication, would be eliminated. I -5 Instead the epidemiology has changed so that sporadic cases are occurring rather than the clusters seen previously. 5-8 This represents an indication of the more gradual, insidious exposure to aluminum by the oral rather than by the dialyzate route. In areas such as our own where dialyzate has always been essentially aluminum free, 26 out of 47 patients or 55 % on dialysis for at least one year have stainable bone aluminum. All except three had taken oral aluminum compounds and these had negative staining. The prescription of oral aluminum salts, usually the hydroxide (AI(OHh), has been widely employed once it was shown that hyperphosphatemia was pivotal in the progression of the secondary hyperparathyroidism of end-stage renal disease (ESRD). It is necessary then to examine the major determinants of serum phosphorus in patients on renal replacement therapy. These would include residual renal function, bone resorption, dietary phosphorus, dialysis prescription, and, finally, dose of Al(OHh. Residual renal function, urine volume, and, hence, solute excretion are generally insignificant in patients on dialysis. The few with creatinine clearances of 4 to 6 mLimin will see these decline following the initiation of dialysis. The subjects own excretory function for phosphate (although not necessarily for water and other solutes) can therefore usually be ignored. Increased rates for bone resorption are characteristic of secondary hyperparathyroidism and would lead to increased flux of calcium and phosphate into extracellular fluid. Hypercalcemia, while it does occur, is uncommon and because calcium and phosphorus are found in a fixed ratio in apatite, hyperphosphatemia also would be infrequent. The reason for this anomaly is the coupling of formation to resorption so that although more bone is removed more is also formed at roughly equal rates. A further consideration is that if hyperphosphatemia is in fact responsible for secondary hyperparathyroidism then the finding of high serum phosphate levels are not necessarily the result of the parathyroid hyperactivity leading to augmented bone turnover but rather the cause. This is probably the reason for the previous report of higher serum phosphorus levels in patients with overt hyperparathyroidism when compared to those without, although several in the former group were hypercalcemic. 9 In our data, 39 patients were divided on the basis of their bone histology into either absent or minimal hyperparathyroidism (17 patients) or active disease (22 patients). Predialysis serum phosphorus was 6.2 ± 0.3 in both groups. Agreement with these propositions means that dietary phosphorus intake and the dialysis prescription for most patients are the only important parameters determining the predialysis serum phosphorus levels, in addition to oral AI(OHh intake. Any attempt to decrease AI(OH)3 intake will necessitate changes in either dietary phosphorus and/ or the amount of phosphorus removed by dialysis. Dietary phosphorus intake in the usual European and North American diet is quite high and the decreased incidence of renal osteodystrophy in Israel was reported to be associated with lower protein and phosphorus intakes and lower serum phosphorus values. lo In the National Cooperative Dialysis Study (NCDS) mean dietary phosphorus during the control phase for the 162 subjects was 879 mg/d with a standard deviation of 248 mg. II This indicates that a proportion of these selected compliant patients were ingesting more than 1,000

Aluminum deposition at the osteoid-bone interface. An epiphenomenon of the osteomalacic state in vitamin D-deficient dogs.

Although aluminum excess is an apparent pathogenetic factor underlying osteomalacia in dialysis-treated patients with chronic renal failure, the mechanism by which aluminum impairs bone mineralization is unclear. However, the observation that aluminum is present at osteoid-bone interfaces in bone biopsies of affected patients suggests that its presence at calcification fronts disturbs the cellular and/or physiochemical processes underlying normal mineralization. Alternatively, aluminum at osteoid-bone interfaces may reflect deposition in preexistent osteomalacic bone without direct effects on the mineralization process. We investigated whether aluminum accumulates preferentially in osteomalacic bone and, if so, whether deposition of aluminum occurs at calcification fronts and specifically inhibits mineralization. Aluminum chloride (1 mg/kg) was administered intravenously three times per week for 3 wk to five normal and five vitamin D-deficient osteomalacic dogs. Before administration of aluminum the vitamin D-deficient dogs had biochemical and bone biopsy evidence of osteomalacia. Bone aluminum content in the osteomalacic dogs (15.1 +/- 2.2 micrograms/g) and the plasma aluminum concentration (10.4 +/- 2.1 micrograms/liter) were no different than those of normal dogs (10.5 +/- 3.5 micrograms/g and 11.9 +/- 1.2 microgram/liter, respectively). After the 3 wk of aluminum administration the plasma phosphorus, parathyroid hormone, and 25-hydroxyvitamin D concentrations were unchanged in normal and vitamin D-deficient dogs. Similarly, no alteration in bone histology occurred in either group. In contrast, bone aluminum content increased to a greater extent in the vitamin D-deficient dogs (390.3 +/- 24.3 micrograms/g) than in the normal dogs (73.6 +/- 10.6 micrograms/g). Moreover, aluminum localized at the osteoid-bone interfaces of the osteomalacic bone in the vitamin D-deficient dogs, covering 42.9 +/- 9.2% of the osteoid-bone surface. Further, in spite of continued aluminum chloride administration (1 mg/kg two times per week), vitamin D repletion of the vitamin D-deficient dogs for 11 wk resulted in normalization of their biochemistries. In addition, while normal dogs maintained normal bone histology during the period of continued aluminum administration, vitamin D repletion of the vitamin D-deficient dogs induced healing of their bones. Indeed, the appearance of aluminum in the cement lines of the healed bones indicated that mineralization had occurred at sites of prior aluminum deposition. These observations illustrate that aluminum deposition in osteomalacic bone may be a secondary event that does not influence bone mineralization. Thus, although aluminum may cause osteomalacia in chronic renal failure, its presence at mineralization fronts may not be the mechanism underlying this derangement.

A microcomputer based digital imaging system for ion microanalysis

SUMMARYA microcomputer based digital imaging system was developed for a Cameca IMS‐3f ion microscope permitting real‐time digital acquisition of secondary ion images. Image signal‐to‐noise enhancement results from random noise reduction by real‐time ensemble averaging and from a reduction of pattern noise in the charge injection device (CID) array by subtraction of blank frames. Acquired images comprise 244times248 pixel arrays with 8‐bit intensity resolution. Images are displayed on a colour monitor in a grey scale or pseudo‐colour using one of four programmable lookup tables. Image processing software permits off‐line ion image enhancement and manipulation as well as multitechnique digital image correlations. System capability is illustrated by a biological example involving digital imaging studies of Al distribution in osteomalacic bone tissue, including correlative light microscopy and ion microanalysis.