Pathogenesis Of Bone Disease Research Articles

Immunoglobulin M Myeloma: Evaluation of Molecular Features and Cytokine Expression

Immunoglobulin (Ig) M myeloma is a distinct entity with features of multiple myeloma (MM) and Waldenström's macroglobulinemia (WM). The malignant cells in IgM myeloma have a distinctive chromosomal translocation that differentiates them from WM. These cells are postgerminal–center in origin with isotype-switch transcripts. They appear to be arrested at a point of maturation between that of WM and MM. Preliminary data indicate that a pattern of osteoclast-activating factor and osteoprotegerin expression similar to that observed in classic MM is present in IgM myeloma. Additional studies on patients with this rare tumor may provide further insight into the pathogenesis of bone disease in plasma cell dyscrasias.

Autologous stem cell transplantation normalizes abnormal bone remodeling and sRANKL/osteoprotegerin ratio in patients with multiple myeloma.

The osteoprotegerin (OPG)/receptor activator of NF-kappa B ligand (RANKL) system has a major role in the pathogenesis of bone disease in myeloma (MM). The effect of autologous stem cell transplantation (ASCT) on bone turnover in MM was evaluated in 51 patients (35M/16F). Markers of bone resorption (NTX, TRACP-5b), bone formation (bone-alkaline phosphatase (bALP), osteocalcin), OPG and sRANKL were measured pre- and every month post-ASCT. The median follow-up period was 12 months. Four patients were transplanted in CR, 44 were transplanted in PR and three patients had progressive/resistant disease. All patients received bisphosphonates both pre- and post-ASCT. At baseline the majority of patients had increased NTX, TRACP-5b levels, and sRANKL/OPG ratio, while markers of bone formation were strongly suppressed. ASCT produced a significant reduction of sRANKL/OPG ratio, with a concomitant decrease of NTX, and TRACP-5b levels, starting the second month post-ASCT. Bone formation markers, osteocalcin and bALP, started to increase after the 9th and 11th month post-ASCT, respectively, while the increase of OPG preceded this. These results provide biochemical evidence that ASCT normalizes the abnormal bone resorption in MM patients possibly through the decrease of RANKL/OPG ratio, while bone formation requires a longer period to return to normal.

Osteoclast-like Cell Formation by Circulating Myeloma B Lymphocytes: Role of RANK-L

Excessive bone resorption in multiple myeloma (MM), a malignancy of B lymphoid origin, is mediated through osteoclasts, which respond to local osteoclast-activating factors produced by tumor cells within the bone marrow microenvironment. Direct bone resorption by myeloma cells is investigated in the present study, since a connection between B lymphocytes and osteoclast differentiation pathways has been recently postulated in mice. Peripheral CD19 + B lymphocytes isolated from 10 myeloma patients with multiple osteolytic lesions and 10 healthy donors were cultured in the presence of M-CSF and RANK-L, two major osteoclast-activating factors. The TRAP expression and resorption of bone substrates were employed to evaluate osteoclast differentiation. MM patients were characterized by the presence of circulating B lymphocytes endowed with both phenotypical and functional properties of osteoclast-like cells in vitro when stimulated with RANK-L. The absence of these characteristics in B lymphocytes from healthy donors indicates that the transformation can be ascribed to the presence of clonogenic B cells in patients with MM. Clonotypic B lymphocytes may contribute to the pathogenesis of bone disease in MM by acting as RANK-L-dependent osteoclast progenitors.

Circulating Forms of Parathyroid Hormone: Peeling Back the Onion

Circulating parathyroid hormone (PTH) regulates normal bone and mineral ion homeostasis and is central in the pathogenesis of bone disease in primary and secondary hyperparathyroidism, especially in advanced renal insufficiency (1). The major biological effects of PTH, a linear polypeptide 84 amino acids in length, reflect activation of the G-protein-coupled PTH/PTHrP receptor (PTHR) expressed on target cells in the renal tubules and the osteoblastic lineage of bone (2). Activation of PTHRs requires only the most N-terminal portion of PTH [PTH(1–34) is a full agonist] and is mostly eliminated if the N-terminal serine residue of the human hormone is removed. PTH, secreted by the parathyroid glands primarily in response to changes in blood ionized calcium, undergoes rapid endopeptidic cleavage, mainly by Kupffer cells in the liver (3). This event generates a series of N-truncated “CPTH” fragments (the corresponding N-terminal segments are destroyed in situ) that reenter the circulation and are cleared mainly by glomerular filtration, an important route for PTH clearance as well (4). Chemical analysis of PTH fragments isolated from rat blood after administration of radiolabeled bovine PTH established that hepatic metabolism yields a family of CPTH fragments with NH2 termini ranging between residues 34 and 43, although the methods used likely would not have detected substantially larger CPTH fragments (5). Interestingly, chemically similar CPTH fragments are secreted directly from the parathyroid glands as well, and the ratio of secreted CPTH fragments to intact PTH increases as blood calcium increases (6)(7). CPTH fragments typically circulate at a three- to fivefold molar excess over intact PTH, but this ratio may increase dramatically in end-stage renal disease (ESRD), depending on the severity and chronicity of renal insufficiency and the blood concentrations of calcium, phosphate, and 1,25-dihydroxyvitamin D, all of which regulate PTH secretion (1)(8). Measurement of …

Bone histomorphometry in children and adolescents with beta-thalassemia disease: iron-associated focal osteomalacia.

Thalassemia/hemoglobinopathy is a hereditary disease that causes chronic anemia and increased erythropoiesis. Consequently, an expansion of bone marrow spaces may contribute to osteopenia/osteoporosis. However, the pathogenesis of bone changes is not yet known. We, therefore, carried out the study on bone histomorphometry and biochemical and hormonal profiles in children and adolescents with suboptimally treated beta-thalassemia disease with the hope of gaining some new insight into the cellular and structural alterations of thalassemic bone. Seventeen patients underwent iliac crest bone biopsy for histomorphometric analyses. Bone mineral density (BMD) measurements were performed by dual energy x-ray absorptiometry. Most patients had growth retardation and delayed bone age. BMD was low especially at the lumbar spine. Serum IGF-I levels were almost always low. Bone histomorphometry revealed increased osteoid thickness, osteoid maturation time, and mineralization lag time, which indicate impaired bone matrix maturation and defective mineralization. In addition, iron deposits appeared along mineralization fronts and osteoid surfaces. Moreover, focal thickened osteoid seams were found together with focal iron deposits. Dynamic bone formation study revealed reduced bone formation rate. These findings indicate that delayed bone maturation and focal osteomalacia are the pathogenesis of bone disease in suboptimally blood-transfused thalassemics with iron overload. Iron deposits in bone and low circulating IGF-I levels may partly contribute to the above findings.

Postmenopausal osteoporosis in the dialysis patient.

Osteoporosis is the most prevalent bone disorder in the general population, particularly in the middle and older age groups. Although more than half of the prevalent dialysis population is within these age groups, little concern has been given to the possible role of estrogen deficiency in the pathogenesis of bone disease in end-stage renal disease. The purpose of this review is to summarize the recent published evidence that supports a potential role of the postmenopausal state in the pathogenesis of bone disease in end-stage renal disease and their implications for treatment. Recent studies have shown that although the risk factors for fracture in end-stage renal disease are similar to the general population, the incidence is three to fourfold higher. The high prevalence of older population, the frequently observed premature amenorrhea and early menopause in dialysis patients may play a role. Similarly, the proportion of end-stage renal disease women receiving hormone replacement therapy is at least three times lower than the general population. Recent evidence on the risk of hormone replacement therapy should caution about its use in end-stage renal disease patients. New evidence suggests that selective estrogen receptor modulators may increase bone mass without significant secondary effects. Other alternatives, such as the use of bisphosphonates, should be considered with caution due to the risk of excessive suppression of bone turnover, worsening or favoring the development of adynamic bone disease. Osteoporosis should be recognized as an important entity that may modify the current conception of renal osteodystrophy in postmenopausal patients with end-stage renal disease. Further clinical studies are needed in order to propose strategies that may reduce the impact of postmenopausal osteoporosis in the dialysis population.

Vitamin K Status in Relation to Bone Metabolism in Patients with Renal Failure

Vitamin K abnormalities may be involved in the pathogenesis of bone disease in patients with advanced renal failure since vitamin K plays a role in the synthesis of osteocalcin, a marker of bone formation. Vitamin K may also indirectly suppress parathyroid function. The aim of this study was to evaluate vitamin K status in patients with renal failure and in healthy volunteers in relation to some biochemical markers of bone turnover. The studies were performed on: patients with chronic renal failure (CRF) on conservative treatment; hemodialyzed patients treated with continuous ambulatory peritoneal dialysis (CAPD); kidney transplant patients, and a control group. Intact PTH, osteocalcin, vitamin 1,25-(OH)₂D₃, 25-OH-D₃, bone-specific alkaline phosphatase, procollagen type-I cross-linked carboxyterminal telopeptide, deoxypyridinoline, and osteonectin were assayed using commercially available kits, and the vitamin K concentration by HPLC. We found that vitamin K concentrations did not differ significantly between all the groups studied. Only in CRF patients was the vitamin K concentation low, almost reaching statistical significance when compared to the healthy volunteers (p = 0.05) and correlated positively with age, serum calcium and osteonectin. No statistically significant correlations were found between vitamin K and osteocalcin, PTH or other biochemical parameters of bone metabolism studied in patients with CRF and renal replacement therapy. In patients after renal replacement therapy, the only significant positive correlation was found between phylloquinone and osteonectin (r = 0.027, p = 0.004). The same applied when we also included healthy volunteers. The correlations of osteonectin and vitamin K are of unknown clinical relevance. Our study does not support the hypotheses of a possible role of vitamin K deficiency in patients with CRF and the influence of vitamin K on bone metabolism.

Development of a synthetic peptide-based tartrate-resistant acid phosphatase radioimmunoassay for the measurement of bone resorption in rat serum.

Selective markers of bone turnover provide a convenient and reproducible alternative to the complex and expensive histochemical techniques used commonly to study the effect of pharmacological agents and the pathogenesis of bone disease in the ovariectomized (OVX) rat model. One marker, which has been specifically linked to terminally differentiated osteoclasts and, thus, provides useful insight at cellular levels, is type-5 tartrate-resistant acid phosphatase (TRACP). We describe the development of a TRACP radioimmunoassay (RIA), which requires synthetic peptide for antibody development. To develop the RIA, polyclonal antibodies were generated in goats against a synthetic peptide, DPSVRHQRKCY, corresponding to amino acid residues 267-275 of the rat type-5 TRACP sequence. In the RIA, 50 microl of rat serum, 100 microl of goat anti-TRACP antibodies, and 100 microl of tracer were incubated overnight. The antibody-bound fraction was separated, counted, and unknown values were calculated by comparison with the peptide calibrator. Rat serum shows parallelism with the synthetic peptide calibrator used in the RIA. The sensitivity of the RIA was 24.7 microg/l, and the measuring range was 19-2476 microg/l. The average intra-assay coefficients of variation for (CV) two controls were less than 7%. The average dilution and spike recoveries were 107% and 87%, respectively. We applied our peptide-based RIA to study bone resorption in an OVX rat model. TRACP concentrations in serum in 12-week-old OVX Sprague Dawley rats were 14%-22% (P < 0.05) higher than those in the sham-operated rats, and TRACP concentrations in OVX rats treated with estradiol were 24%-32% lower (P < 0.01) than those in the vehicle-treated OVX group. Similarly, as compared with those in OVX rats, TRACP concentrations decreased to those of sham levels in OVX rats receiving 10 microg/kg per day of alendronate for 10 days. In addition, the TRACP levels determined by RIA showed a significant correlation with serum C-telopeptide (type-I collagen) concentrations (r = 0.56; P < 0.001) measured by an enzyme-linked immunosorbent assay (ELISA) developed earlier for the rat model. In conclusion, we have developed a TRACP RIA that could be used to monitor the rate of bone resorption in the rat model.

Serum Magnesium Concentration is An Independent Predictor of Parathyroid Hormone Levels in Peritoneal Dialysis Patients

Parathyroid hormone (PTH) is a cardinal factor in the pathogenesis of bone disease in the dialysis population. The spectrum of renal osteodystrophy has been reported to have changed during the past years, and adynamic bone disease has emerged as the most common bone disorder in these patients. Continuous ambulatory peritoneal dialysis (CAPD) is considered a risk factor for the development of this condition, and furthermore, the adynamic bone lesion is associated with a state of relative hypoparathyroidism (hypo-PTH). Calcium, vitamin D, and phosphorus play a key role in the control of parathyroid gland function in uremic patients. However, magnesium may also be able to modulate PTH secretion in a way similar to calcium. The aims of this study were (1) to analyze the serum Mg concentration in a large group of CAPD patients, (2) to study the relationship between serum Mg and PTH levels, and (3) to investigate whether this relationship is independent of other factors, such as calcium, phosphorus, and calcitriol, that regulate parathyroid function. We studied 51 stable patients, aged 23-77 years, under maintenance CAPD for more than 6 months (range 8-48 months). Calcium carbonate was used as a phosphate binder in all patients, and 9 subjects also received aluminum hydroxide. No patient had been previously treated with vitamin D. Biochemical parameters were prospectively evaluated over 6 months, and the mean values were computed. The mean serum Mg was 1.08 +/- 0.19 mmol/L, and hypermagnesemia, defined as a Mg level higher than 1.01 mmol/L, was found in 30 patients (59%). Thirty-one subjects (60%) had an intact PTH (iPTH) level lower than 120 pg/mL and were diagnosed as having relative hypo-PTH. Except for the values of iPTH and alkaline phosphatase, the only difference between the two groups was the serum Mg concentration, which was significantly higher in patients with hypo-PTH (1.16 +/- 0.15 mmol/L vs 0.91 +/- 0.14 mmol/L; p< 0.001). Furthermore, iPTH levels were lower in patients with hypermagnesemia than in subjects with normal serum Mg (69 +/- 49 pg/mL vs 190 +/- 89 pg/mL, p < 0.001). There was a significant correlation between serum Mg and PTH levels (r= -0.70, p< 0.01). After controlling for the effect of other variables by partial correlation analysis, a significant positive association between P and PTH (r= 0.25, p < 0.05), and a negative relationship between Mg and PTH (r= -0.57, p < 0.001) were evident. A forward stepwise multiple regression analysis showed that only P and Mg predicted PTH values (multiple r = 0.59, p < 0.001). Hypermagnesemia and hypoparathyroidism are frequent in CAPD patients. There is a significant inverse relationship between serum Mg concentration and iPTH levels. Furthermore, this association is independent of the most important factors regulating parathyroid gland function (calcium, phosphorus, and calcitriol). These results suggest that hypermagnesemia may have a suppressive effect on PTH synthesis and/or secretion. Therefore, elevated serum Mg levels may play a role in the pathogenesis of adynamic bone disease.

EFFECTS OF HUMAN LYMPHOCYTE-CONDITIONED MEDIUM ON MG-63 HUMAN OSTEOSARCOMA CELL FUNCTION

Lymphocytes are implicated in the pathogenesis of bone disease in chronic inflammation, osteoporosis, transplantation and osteopetrosis. The effects of lymphocytes and lymphocyte-conditioned medium on bone-resorbing activity and osteoclast function have been well studied, but there are few studies of the effects of LCM on bone formation and osteoblast function. The effects of LCM on the function of the MG-63 human osteosarcoma cell line were studied, which, when stimulated with 1,25-(OH)2D3, demonstrates many of the properties of the mature human osteoblast. Lymphocytes contain oestrogen receptors and the model was also used to test the hypothesis that the effects of oestrogen on bone cells may be mediated indirectly via lymphokines. Lymphokines were measured by ELISA in human lymphocyte conditioned medium (LCM) collected following incubation of mixed lymphocytes with or without stimulation for 72 h. Unstimulated LCM increased proliferation of MG-63 cells and this increase was not affected by neutralization of interleukin 1 (IL-1), IL-3, IL-6, granulocyte-macrophage colony-stimulating factor (GM-CSF), tumour necrosis factor (TNF), lymphotoxin α, or interferon γ (IFN-γ). Phytohaemagglutinin-stimulated LCM decreased proliferation of MG-63 cells, as well as induced expression of IL-6 mRNA, increased alkaline phosphatase production, and inhibited osteocalcin production. The decrease in proliferation was abolished by neutralization of IFN-γ but was unaffected by neutralization of IL-1, IL-2, IL-3, IL-4, IL-6, GM-CSF, TNF, or lymphotoxin α. Neutralization of IFN-γ in stimulated LCM also partially inhibited the increase in alkaline phosphatase production but had no effects on the decrease in osteocalcin production. Although oestrogen inhibited lymphocyte proliferation, the effects of LCM collected from lymphocytes in the presence of oestrogen on MG-63 cell proliferation and function was no different than the effects of LCM collected in the absence of oestrogen.LCM has multiple effects on MG-63 cell function and gene expression. Lymphocyte stimulation during the preparation of LCM further modulates these effects. Although partially mediated by IFN-γ, the effects of LCM on these cells cannot be completely explained by individual component lymphokines. This may have implications for understanding the pathophysiology of bone loss in inflammatory disorders as well as possible feedback loops of locally generated cytokines in bone.

The role of magnesium in the pathogenesis of bone disease in childhood cholestatic liver disease: a preliminary report.

Magnesium deficiency may contribute to the metabolic bone disease that complicates chronic cholestatic liver disease. We hypothesized that magnesium deficiency alters vitamin D metabolism by decreasing parathyroid hormone (PTH) response, resulting in decreased serum osteocalcin and decreased bone accretion. Nine subjects, age 3-22 years, with cholestatic liver disease were evaluated with the magnesium retention test. The response of PTH, 1,25(OH)2 vitamin D, and osteocalcin to provocative stimuli and dual x-ray absorptiometry measurement of bone mineral density (BMD) of the lumbar spine were assessed. Thereafter, subjects were treated with oral magnesium supplements. All nine subjects were magnesium depleted. Repletion with magnesium was successful in seven subjects, and required 4 to 31 (median 14) months with doses of 6 to 34 (median 11) mg/kg/day. Baseline serum PTH was significantly reduced in the cholestatic subjects compared to 15 age-matched controls. Comparison of baseline to repleted provocative testing was performed in six Mg-repleted subjects. Osteocalcin response increased significantly (p = 0.048) with repletion, while PTH response increased (p = 0.061). Lumbar spine BMD increased modestly with repletion (p = 0.093). This preliminary report suggests that magnesium depletion is extremely common in children with chronic cholestasis. We speculate that magnesium supplementation may be warranted to forestall the progression of metabolic bone disease in chronic cholestasis.

The Michael Mason Prize Essay 1997. Nitric oxide and bone: what a gas!

Nitric oxide (NO) is an important signalling molecule in bone which is produced in response to diverse stimuli such as pro-inflammatory cytokines, mechanical strain and sex hormones. Recent work suggests that NO exerts biphasic effects on bone cell activity: high concentrations of NO inhibit bone resorption by inhibiting osteoclast formation and by inhibiting the resorptive function of mature osteoclasts, whereas lower NO concentrations potentiate cytokine-induced bone resorption and may be essential for normal osteoclast function. Similarly, growth and differentiation of osteoblasts are inhibited by high concentrations of NO which may partly be responsible for the inhibitory effects of pro-inflammatory cytokines on bone formation. In contrast, lower amounts of NO produced by constitutive nitric oxide synthase (NOS) enzymes may play a role in regulating normal osteoblast growth and in mediating the effects of oestrogens on bone formation. Evidence of inducible nitric oxide synthase (iNOS) expression has been found in the rheumatoid joint and patients with active rheumatoid arthritis (RA) have raised levels of NO breakdown products in blood and urine. This indicates that NO may be involved in the pathogenesis of bone disease and tissue damage associated with inflammatory conditions such as RA, and raises the possibility that iNOS inhibitors may be of therapeutic value in this situation. The observation that both oestrogen and mechanical strain increase NO production by activating constitutive NOS further suggests that bone loss associated with oestrogen deficiency and immobilization may be related to production of NO and may hence be amenable to treatment with pharmacological NO donors.

Intestinal calcium absorption and vitamin D status in chronic cholestatic liver disease.

Metabolic bone disease is common in patients with cholestatic liver disease. The importance of vitamin D status and calcium malabsorption in the pathogenesis of bone disease in these patients remains undefined. We have measured intestinal calcium absorption in relation to vitamin D status in 14 patients with chronic cholestatic liver disease including 11 with primary biliary cirrhosis. Fractional calcium absorption was determined from radioactive counts in the right forearm after separate oral and intravenous doses of 47CaCl2 in the fasting state. Eight of 14 patients (57%) had a decreased calcium absorption compared to controls. A significant correlation was observed between serum 25-hydroxyvitamin D levels and fractional calcium absorption (r = 0.623, p less than 0.02). Treatment with oral 25-hydroxyvitamin D3 in three patients with low serum 25-hydroxyvitamin D levels resulted in correction of serum 25-hydroxyvitamin D levels and improvement in fractional calcium absorption. No correlation was found between serum 1,25-dihydroxyvitamin D levels and fractional calcium absorption (r = 0.221). Calcium malabsorption was common in this series of patients, and serum 25-hydroxyvitamin D levels were useful in predicting fractional calcium absorption. Treatment with oral 25-hydroxyvitamin D3 was accompanied by improved calcium absorption.

Reduced serum levels of 1 alpha,25-dihydroxyvitamin D during long-term total parenteral nutrition.

Painful bone disease, characterized by patchy osteomalacia and inactive bone, can develop in patients treated with total parenteral nutrition for more than 3 months. Serum levels of 1 alpha,25-dihydroxyvitamin D (1 alpha, 25(OH)2D), 24,25-dihydroxyvitamin D and 25-hydroxyvitamin D were measured in seven adults and five children treated with parenteral nutrition for 9 to 60 months. Serum levels of 1 alpha, 25(OH)2D were markedly reduced, while levels of 25-hydroxyvitamin D and 24,25-dihydroxyvitamin D were normal. Serum calcium and phosphorus levels were normal or slightly increased, and immunoreactive parathyroid hormone levels were normal or low. Renal function was normal or minimally reduced. Skeletal symptoms disappeared and serum 1 alpha, 25(OH)2D levels rose to normal in one patient when nutrient infusions were discontinued for 6 weeks. Removal of calcium from the nutrient solution for 2 to 4 days was associated with no change in serum 1 alpha, 25(OH)2D in two patients. The cause of the reduction in serum levels of 1 alpha, 25(OH)2D and its role in the pathogenesis of bone disease in these patients remain uncertain.

Evidence for a relationship between plasma immunoreactive calcitonin and bone disease in chronic renal failure.

In experimental animals a major effect of the administration of calcitonin (CT) is to inhibit bone resorption and this property has led to its use in man to suppress excessive bone turnover in Paget’s disease and other disorders (1–4). On the other hand, the role of endogenous CT in the pathogenesis of bone disease has remained unresolved. The present studies were designed to examine the relationships between plasma immunoreactive CT (iCT), parathyroid hormone (iPTH) and bone disease in chronic renal failure.