Bronwyn A. Crawford

Zoledronic Acid Prevents Bone Loss after Liver Transplantation: A Randomized, Double-Blind, Placebo-Controlled Trial

Context Rapid bone loss occurs in the first few months after liver transplantation and may be associated with fractures. Contribution This randomized, double-blind trial found that infusing zoledronic acid within 1 week of liver transplantation and again 1, 3, 6, and 9 months after transplantation prevented bone loss more effectively than did placebo infusions. Differences between groups lessened over time as some patients receiving placebo regained bone after several months. Zoledronic acid sometimes caused postinfusion hypocalcemia and temporary secondary hyperparathyroidism. Cautions The trial was not powered to assess differences in fracture outcomes. Implications Zoledronic acid infusions can prevent bone loss after liver transplantation. The Editors Osteoporosis is a frequent complication of end-stage liver disease of various causes. Initially described in patients with cholestatic liver disease (1-4), it also occurs in association with cirrhosis secondary to hepatitis B and C virus infection and alcohol abuse (5-8). Although contributing factors that are common to postmenopausal osteoporosis have been identified, such as age, gonadal status, and vitamin D deficiency, cirrhosis is an independent risk factor for osteoporosis (8, 9). Some patients with cirrhosis eventually need liver transplantation, a procedure that is associated with accelerated bone loss, particularly within the first 3 to 6 months (10-13). Investigators report fractures rates of 16% to 40% during this period, predominantly of the vertebrae and ribs (12-16). Pain and restricted mobility after a fracture delay rehabilitation of patients and are severe enough at times to require hospitalization. It is not clear whether bisphosphonate drugs, which inhibit osteoclast-mediated bone resorption, reverse bone loss after transplantation. One uncontrolled study reported variable results (17). A recent controlled study, however, did not find any benefit of intravenous pamidronate in liver transplant recipients who had unusually little acute post-transplantation bone loss and few fractures in both the treatment and control groups (18). In our experience, bone disease and fractures after transplantation are major problems. Thus, we performed a randomized, double-blind, placebo-controlled trial of a potent intravenous bisphosphonate, zoledronic acid, in patients undergoing liver transplantation. The primary end point was bone density change at 3 months after transplantation; secondary end points were bone density change at 12 months and biochemical variables of bone turnover. Methods Setting and Patients From July 2000 to July 2003, we recruited adults undergoing transplantation for chronic liver disease from 2 large transplantation centers within the Australian and New Zealand Liver Transplant program. We based recruitment primarily on convenience for individuals, including whether they resided close to the transplantation center and were not already taking part in other research studies. We excluded patients if they had a serum creatinine level greater than 1.5 times the upper limit of normal (for example, >165 mol/L [>1.86 mg/dL]), had had treatment within the previous 12 months with agents known to affect bone metabolism (bisphosphonates, calcitriol, or sex hormones), or had hypocalcemia (corrected serum calcium level <2.2 mmol/L [<8.8 mg/dL]). We discussed the study and obtained written informed consent from patients at their pretransplantation assessment. After transplantation, just before the first infusion, we asked the patients to verbally re-consent. Recruited patients were similar to adult patients in the Australian Liver Transplant Database (www.cs.nsw.gov.au/gastro/livertransplant) with respect to age, sex, ChildPugh score, and cause of cirrhosis. The ethics review committees at both institutions approved the study protocol. Randomization and Interventions As soon as was feasible after liver transplantation, patients were randomly assigned centrally to receive zoledronic acid or placebo. Random assignment was done by using the method of stratified minimization (19) on the basis of the following variables: age, sex, baseline bone mineral density (BMD), and primary immunosuppressive therapy (cyclosporine or tacrolimus). Of note, all but 4 patients were recruited from 1 center; these 14 patients were randomly allocated to 2 per treatment group. Hospital pharmacists prepared infusions and coded them to maintain blinding. Five infusions of zoledronic acid (4 mg in 100 mL of normal saline, administered over 15 minutes) or saline were given over a 12-month period. The first infusion was administered within 7 days of liver transplantation and then again at months 1, 3, 6, and 9 after transplantation. All patients received calcium carbonate, 600 mg/d, and vitamin D supplementation (ergocalciferol, 1000 U/d) from the time of transplantation listing and throughout the study. The standard immunosuppression regimen after transplantation at both centers consisted of tacrolimus or cyclosporine, azathioprine, and methylprednisolone at 500 mg on day 1, decreasing to 20 mg by day 12. Alternative immunosuppressive therapy included the use of mycophenolate instead of azathioprine in some patients. Biopsy-proven cellular rejection was treated with pulses of methylprednisolone, 1000 mg/d for 3 days, followed by reduced doses of prednisone similar to those used after transplantation, aiming to reach a prednisone dosage of 20 mg/d by day 14. Assessments and Follow-up Before transplantation, baseline data, including the ChildPugh score, were re-collected every 6 months (designated as time 0 months). Bone mineral density at L2 to L4 of the lumbar spine, femoral neck, and total hip was measured by using dual x-ray absorptiometry on a Prodigy densitometer (Lunar, Madison, Wisconsin) in both centers at baseline and at months 3, 6, and 12 after transplantation. In vitro and in vivo coefficients of variation for BMD at the lumbar spine, hip, spine, and total body were less than 1.0 and less than 2.0%, respectively. The BMD data were expressed as T-scores (that is, SDs removed from the average BMD of young healthy controls) using the North American reference ranges provided by the densitometer manufacturer. Radiographs of the thoracolumbar spine were taken at the baseline assessment and at 12 months after transplantation. New vertebral fractures were identified by radiology report. Blood and urine samples were collected in the morning at the pretransplantation assessment and were subsequently taken every 6 months until liver transplantation and at months 1, 3, 6, 9, and 12 months after transplantation. Serum testosterone levels (in men), parathyroid hormone (PTH) levels, and urinary free deoxypyridinoline levels, corrected for creatinine, were measured on the Immulite 2000 autoanalyzer (Diagnostic Products Corp., Los Angeles, California). Both 25- and 1,25-hydroxyvitamin D levels were measured by radioimmunoassay (Diasorin, Stillwater, Minnesota) after an initial extraction from serum with acetonitrile and a second solvent column extraction step for 1,25-hydroxyvitamin D. Serum levels of insulin-like growth factor I were measured by using a double antibody radioimmunoassay after acidethanol extraction (Bioclone, New South Wales, Australia). The coefficients of variation, measured at 2 levels, were less than 8% for total testosterone, intact PTH, and 25- and 1,25-hydroxyvitamin D; less than 11.0% for insulin-like growth factor I; and 17.7% and 6.9% for urinary deoxypyridinoline at 27 nmol/L and 107 nmol/L, respectively. Bone-specific alkaline phosphatase (ALP) was measured by using competitive immunocapture assay on an Access analyzer (Beckman Coulter, Inc., Fullerton, California). Adverse events were assessed at each follow-up point by open-ended questions asked by the treating physician and by review of charts by the research nurse. Physicians and nurses were blinded to treatment group. Physicians rated events as expected or unexpected and assessed potential attribution to therapy. Fractures or renal impairment and serum creatinine levels greater than 165 mol/L (>1.86 mg/dL) resulted in discontinuation of therapy. Hypocalcemia (corrected serum calcium) was graded according to the following criteria: grade 1, 1.90 to 2.14 mmol/L (7.6 to 8.6 mg/dL); grade 2, 1.70 to 1.89 mmol/L (6.8 to 7.6 mg/dL); grade 3, 1.50 to 1.69 mmol/L (6.0 to 6.8 mg/dL); and grade 4, less than 1.50 mmol/L (<6.0 mg/dL). Statistical Analysis The primary end points of change in BMD at 3 months for the hip and the lumbar spine were used as the basis for a priori sample size calculations. On the basis of a 10% difference in BMD change, a 2-tailed P value of 0.05, and 80% power, 34 patients per group were required. Anticipating a 10% noncompletion rate, we estimated that 75 patients would need to be recruited. Linear mixed-effects models were fitted to BMD at the lumbar spine, femoral neck, and total hip and to biochemical data. Treatment (zoledronic acid or placebo), time, and their 2-way interaction were considered as fixed effects, as were the baseline body weight, serum PTH level, and testosterone level (in men). These baseline variables showed some imbalance between treatment groups. Differences between treatments were estimated as both unadjusted and adjusted for potential confounding variables, baseline weight, and serum PTH level. Because estimates of treatment differences in men further adjusted for testosterone changed by less than 10%, this covariate was not included in any final models. All tabulated results refer to men and women combined. The unadjusted treatment differences are based on intention-to-treat analyses of all 62 patients. Because 10 patients had missing baseline weight or serum PTH measurements, the adjusted analyses represent modified intention-to-treat analyses of the remaining 52 patients. Unadjusted and adjusted treatment differences for the percentage change in BMD fro

Vitamin D replacement for cirrhosis-related bone disease

The osteoporotic fracture rate in patients with chronic liver disease is approximately twice that of age-matched, control individuals. About 66% of patients with moderately severe cirrhosis and 96% of patients awaiting liver transplantation have vitamin D deficiency. Studies have shown a strong correlation between vitamin D deficiency and bone density, particularly in the hip. Previous studies of vitamin D therapy in cirrhosis-related bone disease have had major design flaws. Most reports and guidelines on the treatment of hepatic bone disease have concluded that vitamin D deficiency does not have a significant pathogenetic role in the development of osteoporosis in cirrhosis, and that there is no evidence for a therapeutic effect of vitamin D supplementation. Conversely, it is generally recommended that patients with cirrhosis and low bone density should receive calcium and vitamin D supplementation; yet there is a paucity of reliable data on the optimal doses to use, as well as a lack of clearly demonstrated benefit. We believe that clinical trials of vitamin D therapy in these patients with liver disease are warranted. As low-dose oral supplementation often will not normalize vitamin D levels or suppress parathyroid hormone activity in cirrhotic patients, high-dose, parenteral vitamin D might be preferable, but further long-term studies are required to assess the benefits and safety of this approach.

The heterogeneity of bone disease in cirrhosis: a multivariate analysis

This study aimed to assess the clinical, biochemical and hormonal factors contributing to low bone density in a large ambulatory group of patients with cirrhosis of diverse aetiology. Bone density of the lumbar spine, neck of femur, total hip, total body, as well as total body fat, was measured by dual X-ray (DEXA) absorptiometry in 81 men and 32 women (average age 50.3 years). Morning blood and urine samples were taken for hormonal and biochemical analysis. Viral hepatitis was the most common cause of cirrhosis (54%) and the severity of cirrhosis ranged from Child-Pugh A5–C14. Osteoporosis was most common in the lumbar spine but was present at any site in 31% of women and 22% of men, with osteopenia present in another 40% of both genders. Urinary deoxypyridinoline, a marker of bone resorption, was elevated in 56% of patients and was associated with increasing severity of cirrhosis and a higher prevalence of osteoporosis, particularly of the lumbar spine. Hip-bone density was primarily affected by low 25-hydroxyvitamin D levels and was associated with secondary hyperparathyroidism in one third of these patients. Additional important predictors for low bone density at all sites were age in women and testosterone in men. These findings indicate that, although the pathophysiology of osteoporosis in chronic liver disease is heterogeneous, high bone turnover may be the underlying pathophysiological mechanism in a significant subgroup of cirrhotic patients and may reflect metabolic effects of hypogonadism or secondary hyperparathyroidism on bone.

Growth and hormone characteristics of pubertal development in the hamadryas baboon

Abstract: The semi‐longitudinal collection of growth measurements in male and female hamadryas baboons has enabled documentation of the timing of puberty and the development of sexually dimorphic growth patterns in body weight, crown‐rump length (CRL), limb lengths, and muscle mass. In addition, another sexually dimorphic characteristic appears to be the presence of a pubertal growth spurt in body weight, and possibly CRL, in male but not female baboons. Serum testosterone levels rose during male development; however, there was a progressive decrease in dehydroepiandrosterone sulfate levels indicating the absence of adrenarche. Insulin‐like growth factor‐I (IGF‐I) and its major binding protein, IGFBP‐3, both rose during pubertal development; however, a simultaneous rise in the IGF‐I:IGFBP‐3 molar ratio suggests other factors may enhance the bioactivity of IGF‐I during puberty. A distinct rise in serum osteocalcin levels was also associated with puberty in male baboons. These growth and hormonal changes during puberty in the hamadryas baboon indicate that this species provides a close primate model for human puberty.

A randomized, double-blind, placebo-controlled trial of intravenous zoledronic acid in the treatment of thalassemia-associated osteopenia.

Beta-thalassaemia major is associated with low bone mass and fractures. We conducted a 2 year randomized controlled trial of zoledronic acid 4 mg administered intravenously every 3 months or placebo in the treatment of β-thalassaemia-associated osteopenla. We recruited 23 subjects from 2 university hospitals with a T score of less than −1.0 at either the lumbar spine or hip, and 23 subjects completed the study (17 M, 6 F). Treatment groups did not differ significantly with respect to bone mineral density (BMD), age, height, weight and body mass index (BMI) at baseline. BMD was assessed at baseline, 12 months and 24 months by dual-energy X-ray absorptiometry (DXA) at the lumbar spine, femoral reek, total hip and total body. After two years average lumbar spine BMD was 8.9% greater (95%CI 2.3–15.5%, P = 0.011), average femoral neck BMD was 9.1% greater (95%CI 5.5–12.7%, P < 0.0001), average total hip BMD was 9.6% greater (95%CI 6.5–12.6%, P < 0.0001) and average total body BMD was 4.7% greater (95%CI 2.7–6.8%, P < 0.0001) in the treated group compared to placebo. The absolute change in BMD from baseline to 2 years and the annualized rate of change of BMD was significantly greater in treated patients at all four sites. Age, gender, height, weight and BMI did not interact with the effect of treatment and so unadjusted data was used. The serum total ALP decreased 45% by 12 months (P = 0.004) and urinary deoxypyridinoline/creatinine ratio decreased 47% by 3 months (NS). We conclude that zoledronic acid (4 mg i.v. 3 monthly) suppresses bone turnover and increases BMD in β-thalassaemia-associated osteopenia.

A Leydig Cell Tumor of the Ovary Resulting in Extreme Hyperandrogenism, Erythrocytosis, and Recurrent Pulmonary Embolism

CONTEXT Secondary erythrocytosis due to androgens is most commonly seen in the context of T replacement therapy in men. Leydig cell ovarian tumors are a rare cause of virilization, erythrocytosis, and thromboembolism. PATIENT CASE We describe the case of a 55-year-old postmenopausal woman who presented with a 3-year history of frontal balding and virilization and a 5-year history of obstructive sleep apnea. She had not experienced significant alteration in libido or mood. Menstruation had ceased at age 46. She had a history of recurrent pulmonary embolism and unexplained secondary erythrocytosis. Past hematological investigations had not revealed any evidence of malignancy or thrombophilia, and the JAK2 mutation was negative. The serum erythropoietin was mildly elevated at 20.3 mIU/mL (normal range, 3.6-16.6 mIU/mL). The serum T was initially reported (by immunoassays) as >1600 ng/dL (>55 nmol/L). Similarly, serum androstenedione (>1000 ng/dL; >35 nmol/L), estradiol (169 pg/mL; 621 pmol/L), and dehydroepiandrosterone sulfate (348 μg/dL; 9.4 μmol/L) were all elevated for a postmenopausal woman. Repeat analysis of the serum T by mass spectrometry showed an extremely elevated level of 4270 ng/dL (148 nmol/L). Computed tomography scan revealed a 5.0-cm right ovarian tumor. After surgical removal of an ovarian Leydig cell tumor, her virilization, erythrocytosis, and sleep apnea resolved. CONCLUSION Hyperandrogenism in women should be considered as a rare but important cause of erythrocytosis, recurrent thromboembolism, and sleep apnea. The diagnosis of hyperandrogenism requires a careful history and physical examination because in postmenopausal women, menstrual disturbance does not occur and cosmetic measures may mask overt clinical features.

Minimally invasive radio-guided surgery for recurrent thyroid cancer using iodine-123.

Minimally invasive radio-guided surgery is widely used in the setting of sentinel node biopsy for breast, melanoma, and other malignancies, as well as in minimally invasive parathyroid surgery. A 20-year-old woman with recurrent papillary carcinoma of the thyroid underwent minimally invasive radio-guided surgery after localization of recurrent disease using 1-123.

Bisphosphonate-induced hypocalcemia associated with vitamin D deficiency in a patient with advanced cancer

A case is presented of symptomatic hypocalcemia following treatment with bisphosphonates. This patient also had deficiency of 25 hydroxyvitamin D that was unrecognized. The use of bisphosphonates in cancer is increasing, not only in the treatment of hypercalcemia, but also for bone pain and to decrease the risk of skeletal morbidity in metastatic breast cancer, multiple myeloma, and Paget’s disease in normocalcemic patients. The patient was probably vitamin D deficient because of a combination of poor oral intake, inadequate sunlight exposure, and the development of renal failure. However, despite receiving both parenteral and oral calcium therapy, the serum calcium remained low until the replacement of vitamin D. With increasing use of bisphosphonate therapy in malignant disease, we believe that an assessment of vitamin D status, calcium intake, renal function, phosphate, magnesium, and albumin should be undertaken prior to initiating therapy in most palliative care patients.

Is there a case for the early use of bisphosphonates in smouldering myeloma and MGUS? (Bisphosphonates in SMM & MGUS).

Sir, there is now good evidence that in patients with multiple myeloma who are receiving chemotherapy, the use of bisphosphonates reduces the incidence of subsequent skeletal events (Berenson et al., 1998; McCloskey et al., 1998). This reduction is seen even in patients in whom no bony abnormalities were detected radiologically prior to therapy (McCloskey et al., 1998). LETTER TO THE EDITOR INTERNATIONAL JOURNAL OF LABORATORY HEMATOLOGY

Parasitic thyroid nodules: cancer or not?

Summary In 2006, a 58-year-old woman presented with thyrotoxicosis. She had undergone left hemithyroidectomy 14 years before for a benign follicular adenoma. Ultrasound imaging demonstrated bilateral cervical lymphadenopathy with enhanced tracer uptake in the left lateral neck on a Technetium-99m uptake scan. Fine-needle aspiration biopsy of a left lateral neck node was insufficient for a cytological diagnosis; however, thyroglobulin (Tg) washings were strongly positive. The clinical suspicion was of functionally active metastatic thyroid cancer in cervical lymph nodes. A completion thyroidectomy and bilateral cervical lymph node dissection were performed. Histology demonstrated benign multinodularity in the right hemithyroid, with bilateral reactive lymphadenopathy and 24 benign hyperplastic thyroid nodules in the left lateral neck that were classified as parasitic thyroid nodules. As there had been a clinical suspicion of thyroid cancer, and the hyperplastic/parasitic thyroid tissue in the neck was extensive, the patient was given ablative radioactive iodine (3.7 GBq). After 2 years, a diagnostic radioactive iodine scan was clear and the serum Tg was undetectable. The patient has now been followed for 7 years with no evidence of recurrence. Archived tissue from a left lateral neck thyroid nodule has recently been analysed for BRAF V600E mutation, which was negative. Learning points Thyrotoxicosis due to functional thyroid tissue in the lateral neck is very rare and may be due to metastatic thyroid cancer or benign parasitic thyroid tissue. Parasitic thyroid nodules should be considered as a differential diagnosis of lateral neck thyroid deposits, particularly where there is a history of prior thyroid surgery. Parasitic thyroid nodules may occur as a result of traumatic rupture or implantation from a follicular adenoma at the time of surgery. The use of ablative radioactive iodine may be appropriate, as resection of all parasitic thyroid tissue can prove difficult. BRAF mutational analysis of parasitic thyroid tissue may provide extra reassurance in the exclusion of papillary thyroid carcinoma.