Bone mineral density and bone metabolism in hemodialysis patients. Correlation with PTH, 25OHD3 and leptin
Densidad mineral y metabolismo óseo en pacientes en hemodiálisis. Correlación con la hormona paratifoidea, el 25(OH)D3 y la leptina
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Correlation with PTH, 25OHD3 and leptin" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "73" "paginaFinal" => "78" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "A. Polymeris, K. Doumouchtsis, E. Grapsa" "autores" => array:3 [ 0 => array:4 [ "Iniciales" => "A." "apellidos" => "Polymeris" "email" => array:1 [ 0 => "antonispolymeris@yahoo.gr" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 1 => array:3 [ "Iniciales" => "K." "apellidos" => "Doumouchtsis" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 2 => array:3 [ "Iniciales" => "E." 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Correlación con la hormona paratifoidea, el 25(OH)D3 y la leptina" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10916_16025_15578_en_t1_109163.jpg" "Alto" => 241 "Ancho" => 1060 "Tamanyo" => 118225 ] ] "descripcion" => array:1 [ "en" => "Demographic data in 18 female patients" ] ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION</span></p><p class="elsevierStylePara">Chronic renal failure is almost always associated with alterations in mineral and bone metabolism<span class="elsevierStyleSup">1,2</span>. With the starting of haemodialysis (HD), histological signs of secondary hyperparathyroidism can be seen in bones in over 50% of patients<span class="elsevierStyleSup">3</span>. In end stage renal disease (ESRD) patients, skeletal abnormalities known as Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD) (the so called renal osteodystrophy) include several types of bone tissue lesions, such as the most prevalent high bone turn over disease but also the adynamic bone disease<span class="elsevierStyleSup">4,5</span>.<span class="elsevierStyleSup"> </span>Other less frequent bone diseases such as osteomalacia, aluminum-related bone disease, fluorosis, strontium overload or mixed types have also been described<span class="elsevierStyleSup">3</span>.</p><p class="elsevierStylePara">It is well known that bone mineral density (BMD) is reduced in patients with chronic renal failure and they are at higher fracture risk<span class="elsevierStyleSup">6,7</span>. Uremic patients usually exhibit high plasma intact PTH and high serum concentration of biochemical markers of bone metabolism such as bone specific alkaline phosphatase (bSAP) and collagen breakdown products<span class="elsevierStyleSup">8</span>.<span class="elsevierStyleSup"> </span>Some studies showed low 25OHD3 levels in uremic patients, which is probably implicated in CKD-MBD<span class="elsevierStyleSup">9</span>.</p><p class="elsevierStylePara">Leptin, a hormone produced by fat tissue, decreases appetite and increases basal metabolic rate. Besides that, leptin induces <span class="elsevierStyleItalic">in vitro</span> stem cells differentiation to osteoblasts and reduces osteoclastogenesis, also having an <span class="elsevierStyleItalic">in vivo</span> positive effect on bone mass in mice<span class="elsevierStyleSup">10-13</span>.<span class="elsevierStyleSup"> </span>Intracerebroventricular administration of leptin in wild or ob/ob leptin deficient mice resulted in bone loss<span class="elsevierStyleSup">14</span>.<span class="elsevierStyleSup"> </span>In renal failure serum leptin levels are increased, as leptin is cleared by the kidneys<span class="elsevierStyleSup">15</span>.<span class="elsevierStyleSup"> </span>In ESRD patients, in particular, the blood purification modality appears to affect leptin concentrations<span class="elsevierStyleSup">16</span>.<span class="elsevierStyleSup"> </span>This fact might contribute to the development of CKD-MBD<span class="elsevierStyleSup">17-19</span>.</p><p class="elsevierStylePara">The aim of current study is to investigate, the bone mass density and the bone metabolism in hemodialysed patients as estimated by serum markers of bone metabolism (bSAP and NTx) and to correlate with serum Ca, P, PTH, 25OHD3 and leptin.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">SUBJECTS AND METHODS </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Patients</span></p><p class="elsevierStylePara">Thirty seven patients, 18 postmenopausal female and 19 male, on maintenance HD were included in the present study after their informed consent. The study was performed during the period April-May. Females were 43-73 years old, mean age 56.7 years and were on HD for 6-222 months with mean HD duration 68.1 months. Males were 41-79 years old, mean age 58 years and were on HD for 24-207 months with mean HD duration 67.1 months. All the patients were treated by conventional HD 4-5 hours, three times a week. None of the patients had a past history of parathyroidectomy or renal transplantation, of fracture or radiographic evidence of vertebral, rib or hip fracture. At the moment of the evaluation none of the patients, in particular the postmenopausal women, was receiving or had received previous to the study, oestrogen or raloxifene, calcitonin, bisphosphonates, PTH or corticosteroids. Thirteen patients received an active vitamin D derivative (one alpha) orally. None of the patients received vitamin K or aluminum hydroxide. There was no clinical or biological evidence for other bone disease such as osteomalacia or Paget’s disease. All patients were measured for BMD at lumbar spine and at femoral neck and for body weight and height and their body mass index (BMI) was calculated.              </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Biochemistry</span></p><p class="elsevierStylePara">Pre-midweek dialysis blood sampling was collected in the morning from the arteriovenus fistula after a 12h fast. The serum obtained after centrifugation was stored in aliquots at -20 <span class="elsevierStyleSup">o</span>C until assayed, with measurements made immediately after thawing. Serum calcium, phosphorus, total protein, albumin, urea, creatinine, magnesium and total alkaline phosphatase were determined routinely using an automatic analyzer. Serum bSAP was measured by ELISA (Metra BAP EIA, sensitivity 0.7 U/l, intra-assay variation 5.8%, inter-assay variation 5.2%) and serum NTx was also measured by ELISA (Wampole Laboratories, USA, intra-assay variation 4.6%, inter-assay variation 6.9%). Serum bioactive PTH and 25OHD3 were measured by chemiluminescence’s assay (Nichols advantage, functional sensitivity ≤4 ng/ml, CV 20% for bioactive PTH and functional sensitivity ≤7 ng/ml, CV 20% for 25OHD3). Serum leptin was measured by RIA (Linco Research, sensitivity 0.5 ng/ml, intra-assay variation 4.6%, inter-assay variation 5%).</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Bone mineral density</span></p><p class="elsevierStylePara">Bone mineral density (BMD) of the lumbar spine, total hip, femoral neck and trochanter were measured using Lunar DPX-L densitometer (Lunar, Madison, Wis, USA). All BMD measurements were performed by the same experienced operator. The densitometer was calibrated everyday with a standard phantom specimen. BMD results were obtained in absolute values (g/cm<span class="elsevierStyleSup">2</span>), in T score and in Z score. T score is the number of standard deviations from the mean of a healthy young adult population (20-40 years old) and is used to determine osteoporosis or osteopenia. Zscore is the number of standard deviations from the mean of a healthy age- and gender-matched normal population, which allows the comparison of BMD between patients of different age and gender. Osteoporosis was defined as a BMD T score at any site less than -2,5 and osteopenia as a BMD Tscore between -1 and –2,5. The reference values were obtained from an Italian normal population, similar to Greek normal population, provided by Lunar.        </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Statistical analysis</span></p><p class="elsevierStylePara">All results are shown as means ± SD, unless otherwise indicated. Correlations between variables were assessed using simple linear regression and p <0.05 was accepted as statistically significant. Comparison of categorical variables was performed using chi-square analyses.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTS</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Demographic and biochemical data</span></p><p class="elsevierStylePara">Table 1 depicts the demographic data for the 18 female patients and table 2 for the 19 male patients. Table 3 depicts the biochemical data for all 37 patients.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Bone densinometric data</span></p><p class="elsevierStylePara">The prevalence of osteoporosis (T score <-2.5) at lumbar spine and femoral neck was 14.3% and 21.4% respectively. The prevalence of osteopenia (T score between –1 and –2.5) at the same sites was 32.1% and 50% respectively. Lumbar spine Z score (m ± SD) was -0.09 ± 1.69 and femoral neck Z- score was –0.76 ± 1.14.          </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Bone markers, PTH, 25OHD3 and leptin</span></p><p class="elsevierStylePara">Serum levels of bone markers (NTx and bSAP) were very high (table 3). Serum PTH and phosphorus levels were also high as expected. Serum 25OHD3 levels were low and the prevalence of vitamin D deficiency was 89.2% among patients. Only 4 patients had normal 25OHD3 levels. Serum leptin was increased particularly in women (table 3).</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Correlation of BMD with PTH, leptin, duration of hemodialysis, body weight and BMI</span></p><p class="elsevierStylePara">Lumbar spine and femoral neck Z-score correlated significantly in a negative manner with serum PTH (p <0.025) (figure 1, figure 2). Lumbar spine and femoral neck Z-score was not related with serum leptin or with the duration of hemodialysis. We found that 10% of lumbar spine Z-score and 22.9% of femoral neck Z-score variability is due to serum PTH levels. No correlation was found between body weight or BMI and Z-score at any site.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Correlation of PTH with bone markers, 25OHD3 and leptin</span> </p><p class="elsevierStylePara">Serum PTH correlated significantly in a positive manner with serum NTx and bSAP (R = 0.715; p <0.001 and R = 0.690; p <0.001 respectively) (figure 3, figure 4). We found that 50% of serum NTx and bSAP variability is due to PTH levels. No correlation was found between serum PTH and 25OHD3 or leptin levels.   </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Correlation of 25OHD3 with bone markers and leptin</span></p><p class="elsevierStylePara">No correlation was found between 25OHD3, bone markers (NTx and bSAP) or leptin levels.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Correlation of leptin with bone markers, BMI, body weight, age and duration of hemodialysis</span></p><p class="elsevierStylePara">Serum leptin was not correlated with bone markers (NTx and bSAP). As expected, serum leptin levels were positively correlated with BMI (R = 0.697; p <0.001) and with body weight (R = 0.577; p <0.001) (figure 5, figure 6). We also found that 48.5% of serum leptin variability is due to BMI. Leptin levels had no correlation with age or hemodialysis duration. Serum leptin had a positive correlation with serum creatinine (R = 0.419; p = 0.012).</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION </span></p><p class="elsevierStylePara">The data on the effect of hemodialysis in end stage renal disease patients on bone density are limited. To date most of the work has been focused on predialysis, HD and kidney transplanted patients and scarce information is available for patients on peritoneal dialysis, haemofiltration and haemodialfiltration<span class="elsevierStyleSup">20-23</span>. The prevalence of osteoporosis in hemodialysed patients is quite variable and depends on several factors including the method used for BMD measurement, the skeletal site and patients’ characteristics. Nonetheless, most of the studies showed reduced BMD in HD patients, which appears to be more pronounced than in peritoneal dialysis patients<span class="elsevierStyleSup">24</span>. The prevalence of osteoporosis in HD patients has been estimated to be 13-29% at lumbar spine<span class="elsevierStyleSup">4,5,24</span> and 16-19% at femoral neck<span class="elsevierStyleSup">4</span>. Our findings are in accordance with these studies. Additionally, we found a high prevalence of osteopenia particularly at femoral neck. In CKD-MBD bone loss is site specific and in patients with uremic hyperparathyroidism, PTH has a preferential effect on cortical bone<span class="elsevierStyleSup">25,26</span>.<span class="elsevierStyleSup"> </span></p><p class="elsevierStylePara"> It has been reported that serum NTx is significantly higher in HD patients than in healthy individuals<span class="elsevierStyleSup">27</span> and appears to be the most reliable and useful bone resorption marker in renal osteodystrophy<span class="elsevierStyleSup">28</span>. In the present study we found extremely high levels of serum NTx and a significant positive correlation between serum NTx and PTH which is in line with previous published results<span class="elsevierStyleSup">27,28</span>.</p><p class="elsevierStylePara">The clearance of bSAP is not performed by the kidney and serum bSAP concentration is therefore not affected by renal function. In our study a number of patients exhibited slightly increased serum bSAP. The significant positive correlation between serum bSAP and NTx with PTH probably suggests that the increased bone turnover is due to secondary hyperparathyroidism.</p><p class="elsevierStylePara">Plasma 25OHD3 levels are often abnormally low in normal population, particularly in the elderly<span class="elsevierStyleSup">29</span> and in unselected medical inpatients<span class="elsevierStyleSup">30</span>, as well as in HD patients<span class="elsevierStyleSup">31</span>. In our cohort of patients there was also a high prevalence of vitamin D deficiency. Ghazali A et al in their study found that low plasma 25OHD3 appears to be a major risk factor for hyperparathyroidism and Looser’s zones independent of calcitriol levels<span class="elsevierStyleSup">9</span>. Interestingly, and in contrast, we found no correlation between 25OHD3 and PTH or bone markers.</p><p class="elsevierStylePara">Leptin, an adipocyte-derived hormone, is cleared by the kidney, and thus, plasma leptin levels are elevated in HD patients<span class="elsevierStyleSup">17</span>. We also found increased serum leptin levels in our HD patients, particularly in women, which is in accordance with previous studies. It has been reported that there is a link between leptin and bone metabolism in vitro and in vivo experiments<span class="elsevierStyleSup">10-12</span>. Furthermore some studies in humans have shown a positive relationship between leptin and bone parameters<span class="elsevierStyleSup">32-34</span>, while others have not<span class="elsevierStyleSup">35-37</span>.<span class="elsevierStyleSup"> </span>In our study simple regression analysis showed no correlation between serum leptin and Z-score at lumbar spine and femoral neck. Similarly, no correlation was found between leptin and bone markers (NTx and bSAP). Serum leptin showed a significant positive correlation only with BMI and body weight as expected.</p><p class="elsevierStylePara">In conclusion the prevalence of osteoporosis/osteopenia is increased in HD patients and bone mineral density appears to correlate with high serum levels of bioactive PTH but not with 25OH vitamin D or high serum leptin. Interestingly, the duration of hemodialysis does not appear to affect bone density. The impact of leptin on bone metabolism in HD patients remains to be elucidated with further studies.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflict of interest</span></p><p class="elsevierStylePara">The authors declare they have no potential conflicts of interest related to the contents of this article.</p><p class="elsevierStylePara"><a href="grande/10916_16025_15578_en_t1_109163.jpg" class="elsevierStyleCrossRefs"><img src="10916_16025_15578_en_t1_109163.jpg" alt="Demographic data in 18 female patients"></img></a></p><p class="elsevierStylePara">Table 1. Demographic data in 18 female patients</p><p class="elsevierStylePara"><a href="grande/10916_16025_15579_en_t2109163.jpg" class="elsevierStyleCrossRefs"><img src="10916_16025_15579_en_t2109163.jpg" alt="Demographic data in 19 male patients"></img></a></p><p class="elsevierStylePara">Table 2. Demographic data in 19 male patients</p><p class="elsevierStylePara"><a href="grande/10916_16025_15580_en_t310916.jpg" class="elsevierStyleCrossRefs"><img src="10916_16025_15580_en_t310916.jpg" alt="Biochemical data in all patients"></img></a></p><p class="elsevierStylePara">Table 3. Biochemical data in all patients</p><p class="elsevierStylePara"><a href="grande/10916_16025_15581_en_f110916.jpg" class="elsevierStyleCrossRefs"><img src="10916_16025_15581_en_f110916.jpg" alt="Lumbar spine Z score vs PTH."></img></a></p><p class="elsevierStylePara">Figure 1. Lumbar spine Z score vs PTH.</p><p class="elsevierStylePara"><a href="grande/10916_16025_15582_en_f210916.jpg" class="elsevierStyleCrossRefs"><img src="10916_16025_15582_en_f210916.jpg" alt="Femoral neck Z score vs PTH."></img></a></p><p class="elsevierStylePara">Figure 2. Femoral neck Z score vs PTH.</p><p class="elsevierStylePara"><a href="grande/10916_16025_15583_en_f310916.jpg" class="elsevierStyleCrossRefs"><img src="10916_16025_15583_en_f310916.jpg" alt="PTH vs NTx."></img></a></p><p class="elsevierStylePara">Figure 3. PTH vs NTx.</p><p class="elsevierStylePara"><a href="grande/10916_16025_15584_en_f410916.jpg" class="elsevierStyleCrossRefs"><img src="10916_16025_15584_en_f410916.jpg" alt="PTH vs bSAP."></img></a></p><p class="elsevierStylePara">Figure 4. PTH vs bSAP.</p><p class="elsevierStylePara"><a href="grande/10916_16025_15585_en_f510916.jpg" class="elsevierStyleCrossRefs"><img src="10916_16025_15585_en_f510916.jpg" alt="Leptin vs BMI."></img></a></p><p class="elsevierStylePara">Figure 5. Leptin vs BMI.</p><p class="elsevierStylePara"><a href="grande/10916_16025_15586_en_f610916.jpg" class="elsevierStyleCrossRefs"><img src="10916_16025_15586_en_f610916.jpg" alt="Leptin vs Body Weight."></img></a></p><p class="elsevierStylePara">Figure 6. Leptin vs Body Weight.</p>" "pdfFichero" => "P1-E532-S3377-A10916-EN.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "es" => array:6 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec439137" "palabras" => array:1 [ 0 => "Hormona paratiroidea" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec439139" "palabras" => array:1 [ 0 => "Leptina" ] ] 2 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec439141" "palabras" => array:1 [ 0 => "Hemodiálisis" ] ] 3 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec439143" "palabras" => array:1 [ 0 => "Metabolismo óseo" ] ] 4 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec439145" "palabras" => array:1 [ 0 => "Vitamina D3" ] ] 5 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec439147" "palabras" => array:1 [ 0 => "Densidad mineral ósea" ] ] ] "en" => array:6 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec439138" "palabras" => array:1 [ 0 => "PTH" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec439140" "palabras" => array:1 [ 0 => "Leptin" ] ] 2 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec439142" "palabras" => array:1 [ 0 => "Hemodialysis" ] ] 3 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec439144" "palabras" => array:1 [ 0 => "Bone metabolism" ] ] 4 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec439146" "palabras" => array:1 [ 0 => "Vitamin D3" ] ] 5 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec439148" "palabras" => array:1 [ 0 => "Bone mineral density" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "es" => array:1 [ "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Antecedentes: </span>Los trastornos del metabolismo óseo en pacientes en hemodiálisis (HD) implican varios factores humorales, de los cuales la función central recae sobre la hormona paratiroidea. Cuando hay insuficiencia renal normalmente se detectan niveles elevados de leptina y su relación con el metabolismo óseo está aún por esclarecer. Investigamos la densidad mineral ósea (DMO) y el metabolismo óseo en relación con la hormona paratiroidea sérica, el 25(OH)D3 y la leptina en pacientes en HD. <span class="elsevierStyleBold">Métodos: </span>Medimos la fosfatasa alcalina ósea (FAO), el telopéptido N, la hormona paratiroidea, el 25(OH)D3 y la leptina en 37 pacientes en HD. Asimismo, evaluamos el IMC y la DMO en la columna lumbar (CL) y en el cuello femoral (CF) mediante DXA. Las evaluaciones estadísticas se basaron en análisis de regresión simples. Entrecruzamiento del telopéptido N del colágeno óseo tipo I. <span class="elsevierStyleBold">Resultados:</span> 1) De nuestros pacientes, el 32,1% presentaba osteopenia en CL y 50% en CF y el 14,3% y el 21,4% osteoporosis, respectivamente. El puntaje Z en CL o CF no estaba relacionado con la duración de la HD. 2) Los marcadores óseos, la hormona paratiroidea, y los niveles de fósforo y leptina se vieron incrementados. 3) El 25(OH)D3 era bajo y no estaba relacionado con el telopéptido N, la FAO o la hormona paratiroidea. 4) La hormona paratiroidea estaba correlacionada con los marcadores óseos y con el puntaje Z en CL y CF. 5) La leptina no presentaba correlación con los marcadores óseos o con el puntaje Z (con excepción del IMC). <span class="elsevierStyleBold">Conclusiones: </span>En nuestros pacientes en hemodiálisis, los marcadores del metabolismo óseo se vieron incrementados en relación con los niveles elevados de hormona paratiroidea sérica. La elevada leptina sérica observada no estaba asociada al metabolismo óseo. Además, la duración de la hemodiálisis no pareció afectar a la densidad ósea.<br /><br /></p>" ] "en" => array:1 [ "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Background:</span> Bone metabolism disorders in hemodialysed patients (HD) involve several humoral factors, of which PTH plays the central role. Leptin is usually found increased in renal failure and its link with bone metabolism  has not been elucidated. We investigated the BMD and bone metabolism  in association with serum  PTH, 25OHD3 and leptin in HD patients. <span class="elsevierStyleBold">Methods: </span>We measured bone alkaline phosphatase (bSAP), cross linked N telopeptide of type 1 collagen (NTx), PTH, 25OHD3 and leptin in 37 HD patients. We also evaluated BMI and BMD in lumbar spine (LS) and in femoral neck (FN) by DXA. Statistical evaluations were based on simple regression analysis. <span class="elsevierStyleBold">Results: </span>1) Osteopenia was found in 32,1% in LS and 50% in FN and osteoporosis in 14.3% and 21.4% of our patients, respectively. LS or FN Z score was not related  to HD duration. 2) Bone markers, PTH, phosphorus and leptin levels were increased. 3) 25OHD3 was low and was not related to NTx, bSAP or PTH. 4) PTH correlated with bone markers and Z score in LS and FN. 5) Leptin had no correlation with bone markers or Z score (except BMI). <span class="elsevierStyleBold">Conclusions: </span>In our hemodialysed patients bone metabolism markers were increased in relation with high serum  PTH levels. The observed high serum leptin was not associated with bone metabolism. Additionally the duration of hemodialysis did not appear to affect bone density.<span class="elsevierStyleBold"></span></p>" ] ] "multimedia" => array:9 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10916_16025_15578_en_t1_109163.jpg" "Alto" => 241 "Ancho" => 1060 "Tamanyo" => 118225 ] ] "descripcion" => array:1 [ "en" => "Demographic data in 18 female patients" ] ] 1 => array:8 [ "identificador" => "fig2" "etiqueta" => "Tab. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10916_16025_15579_en_t2109163.jpg" "Alto" => 239 "Ancho" => 1041 "Tamanyo" => 117388 ] ] "descripcion" => array:1 [ "en" => "Demographic data in 19 male patients" ] ] 2 => array:8 [ "identificador" => "fig3" "etiqueta" => "Tab. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10916_16025_15580_en_t310916.jpg" "Alto" => 895 "Ancho" => 2171 "Tamanyo" => 620287 ] ] "descripcion" => array:1 [ "en" => "Biochemical data in all patients" ] ] 3 => array:8 [ "identificador" => "fig4" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10916_16025_15581_en_f110916.jpg" "Alto" => 600 "Ancho" => 1004 "Tamanyo" => 133794 ] ] "descripcion" => array:1 [ "en" => "Lumbar spine Z score vs PTH." ] ] 4 => array:8 [ "identificador" => "fig5" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10916_16025_15582_en_f210916.jpg" "Alto" => 587 "Ancho" => 994 "Tamanyo" => 133805 ] ] "descripcion" => array:1 [ "en" => "Femoral neck Z score vs PTH." ] ] 5 => array:8 [ "identificador" => "fig6" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10916_16025_15583_en_f310916.jpg" "Alto" => 608 "Ancho" => 1005 "Tamanyo" => 126245 ] ] "descripcion" => array:1 [ "en" => "PTH vs NTx." ] ] 6 => array:8 [ "identificador" => "fig7" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10916_16025_15584_en_f410916.jpg" "Alto" => 593 "Ancho" => 1002 "Tamanyo" => 123413 ] ] "descripcion" => array:1 [ "en" => "PTH vs bSAP." ] ] 7 => array:8 [ "identificador" => "fig8" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10916_16025_15585_en_f510916.jpg" "Alto" => 606 "Ancho" => 1010 "Tamanyo" => 123921 ] ] "descripcion" => array:1 [ "en" => "Leptin vs BMI." ] ] 8 => array:8 [ "identificador" => "fig9" "etiqueta" => "Fig. 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10916_16025_15586_en_f610916.jpg" "Alto" => 614 "Ancho" => 1010 "Tamanyo" => 135259 ] ] "descripcion" => array:1 [ "en" => "Leptin vs Body Weight." ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:37 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Hruska KA, Teitelbaum SL. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 9 | 11 | 20 |
| 2024 October | 93 | 39 | 132 |
| 2024 September | 64 | 40 | 104 |
| 2024 August | 63 | 57 | 120 |
| 2024 July | 60 | 38 | 98 |
| 2024 June | 77 | 38 | 115 |
| 2024 May | 71 | 43 | 114 |
| 2024 April | 49 | 43 | 92 |
| 2024 March | 52 | 30 | 82 |
| 2024 February | 42 | 38 | 80 |
| 2024 January | 50 | 24 | 74 |
| 2023 December | 80 | 28 | 108 |
| 2023 November | 43 | 32 | 75 |
| 2023 October | 37 | 36 | 73 |
| 2023 September | 60 | 34 | 94 |
| 2023 August | 47 | 27 | 74 |
| 2023 July | 44 | 34 | 78 |
| 2023 June | 79 | 19 | 98 |
| 2023 May | 65 | 30 | 95 |
| 2023 April | 63 | 33 | 96 |
| 2023 March | 102 | 24 | 126 |
| 2023 February | 97 | 20 | 117 |
| 2023 January | 45 | 29 | 74 |
| 2022 December | 76 | 42 | 118 |
| 2022 November | 64 | 35 | 99 |
| 2022 October | 62 | 54 | 116 |
| 2022 September | 56 | 28 | 84 |
| 2022 August | 55 | 50 | 105 |
| 2022 July | 45 | 48 | 93 |
| 2022 June | 61 | 39 | 100 |
| 2022 May | 57 | 30 | 87 |
| 2022 April | 82 | 53 | 135 |
| 2022 March | 62 | 70 | 132 |
| 2022 February | 43 | 43 | 86 |
| 2022 January | 44 | 25 | 69 |
| 2021 December | 60 | 44 | 104 |
| 2021 November | 66 | 37 | 103 |
| 2021 October | 136 | 43 | 179 |
| 2021 September | 113 | 36 | 149 |
| 2021 August | 72 | 51 | 123 |
| 2021 July | 48 | 23 | 71 |
| 2021 June | 30 | 31 | 61 |
| 2021 May | 39 | 26 | 65 |
| 2021 April | 95 | 67 | 162 |
| 2021 March | 101 | 45 | 146 |
| 2021 February | 78 | 16 | 94 |
| 2021 January | 82 | 26 | 108 |
| 2020 December | 67 | 21 | 88 |
| 2020 November | 49 | 11 | 60 |
| 2020 October | 41 | 18 | 59 |
| 2020 September | 55 | 8 | 63 |
| 2020 August | 66 | 11 | 77 |
| 2020 July | 54 | 19 | 73 |
| 2020 June | 57 | 21 | 78 |
| 2020 May | 81 | 17 | 98 |
| 2020 April | 81 | 16 | 97 |
| 2020 March | 67 | 18 | 85 |
| 2020 February | 58 | 19 | 77 |
| 2020 January | 66 | 31 | 97 |
| 2019 December | 70 | 27 | 97 |
| 2019 November | 49 | 20 | 69 |
| 2019 October | 140 | 21 | 161 |
| 2019 September | 59 | 25 | 84 |
| 2019 August | 52 | 10 | 62 |
| 2019 July | 37 | 25 | 62 |
| 2019 June | 39 | 24 | 63 |
| 2019 May | 34 | 17 | 51 |
| 2019 April | 72 | 42 | 114 |
| 2019 March | 57 | 27 | 84 |
| 2019 February | 43 | 19 | 62 |
| 2019 January | 45 | 26 | 71 |
| 2018 December | 115 | 44 | 159 |
| 2018 November | 127 | 30 | 157 |
| 2018 October | 140 | 28 | 168 |
| 2018 September | 117 | 21 | 138 |
| 2018 August | 78 | 16 | 94 |
| 2018 July | 85 | 17 | 102 |
| 2018 June | 77 | 12 | 89 |
| 2018 May | 84 | 16 | 100 |
| 2018 April | 95 | 13 | 108 |
| 2018 March | 91 | 9 | 100 |
| 2018 February | 53 | 13 | 66 |
| 2018 January | 79 | 7 | 86 |
| 2017 December | 88 | 13 | 101 |
| 2017 November | 84 | 18 | 102 |
| 2017 October | 65 | 20 | 85 |
| 2017 September | 61 | 14 | 75 |
| 2017 August | 53 | 8 | 61 |
| 2017 July | 56 | 19 | 75 |
| 2017 June | 65 | 9 | 74 |
| 2017 May | 77 | 14 | 91 |
| 2017 April | 67 | 12 | 79 |
| 2017 March | 63 | 21 | 84 |
| 2017 February | 89 | 34 | 123 |
| 2017 January | 65 | 15 | 80 |
| 2016 December | 83 | 6 | 89 |
| 2016 November | 105 | 12 | 117 |
| 2016 October | 152 | 14 | 166 |
| 2016 September | 230 | 10 | 240 |
| 2016 August | 278 | 10 | 288 |
| 2016 July | 262 | 10 | 272 |
| 2016 June | 145 | 0 | 145 |
| 2016 May | 161 | 0 | 161 |
| 2016 April | 133 | 0 | 133 |
| 2016 March | 106 | 0 | 106 |
| 2016 February | 140 | 0 | 140 |
| 2016 January | 122 | 0 | 122 |
| 2015 December | 156 | 0 | 156 |
| 2015 November | 116 | 0 | 116 |
| 2015 October | 89 | 0 | 89 |
| 2015 September | 100 | 0 | 100 |
| 2015 August | 77 | 0 | 77 |
| 2015 July | 81 | 0 | 81 |
| 2015 June | 49 | 0 | 49 |
| 2015 May | 67 | 0 | 67 |
| 2015 April | 7 | 0 | 7 |
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