Warum verirrt sich Kalzium in die Gefässeund fehlt im Knochen?
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1 Osteoporose Zentrum Zimmerberg (OZZ) NierensteinZentrum Zürich Warum verirrt sich Kalzium in die Gefässeund fehlt im Knochen? PD Dr. Bernhard Hess Innere Medizin & Nephrologie Kliniken Im Park & Hirslanden, Zürich &Paracelsus-Spital Richterswil Konsiliararzt Nephrolithiasis, Nephrologie, Kantonsspital Baden Leiter NierensteinZentrum Zürich & OsteoporoseZentrum Zimmerberg B. Hess 11/2016
2 Aortic calcifications & osteoporosis - why does calcium go astray? B. Hess 9/2016 (from Schousboe JT et al., J Bone Miner Res 23: , 2008)
3 Vascular calcifications & osteoporosis - Epidemiology Meta-analysis, 7 case control or cohort studies, 5850 subjects Odds ratio of atherosclerotic vascular abnormalities in individuals with low BMD vs. normal BMD, adjusted for age, gender, BMI, hypertension, and other vascular risk factors Conclusions Risk for atherosclerosis increases as BMD decreases Patients with decreased BMD scores should be screened for CV risks B. Hess 11/2016 (from YeChet al., PLOS ONE doi: /journal.pone , May 5, 2016)
4 Vascularcalcification& osteogenesis - Pathogeneticpathways (VSMCs) «Vascular-bone axis» B. Hess 9/2016 (adapted from Meregalli M et al., J Stem Cell Res Ther 1: 105-, 2011)
5 Vascularcalcifications& lowbonemass - clinicallyrelevant pathways Mechanismsinvolvedin bothlossof bone mass and cardiovasculardisease Increase in inflammatory cytokines Lack of endogenous sex hormones Oxidized lipids Diabetes mellitus Calcium intake Effectsof vitaminsd and K Drug effects& Lifestyle B. Hess 9/2016 (modified from Sprini D et al., Clin Cases Min Bone Metabol 11: , 2014; and Moe SM & Chen NX, JASN 19: , 2008)
6 Welches Kalzium ist am gesündesten? B. Hess 11/2016
7 Vascularcalcifications- relevant pathways: Calcium intake from diet vs. supplements 2742 adults, nocvd, age45-84 yrs., 52% women, excluded128 (missing data), analysisbasedon CT scans: 1489withoutCAC/ 1125 withcac score > WITH baseline CAC (1125) NO CAC (1489) RR incident CAC (10 years) p = Total calcium intake (mg/day) < B. Hess 11/2016 (adapted fromanderson JJB et al. J Am Heart Assoc, DOI: /JAHA , 2016)
8 Vascularcalcifications- relevant pathways: Calcium intake from diet vs. supplements(2) BUT : subjects without CAC Multivariate model additionally adjusted for total calcium intake: Intake of calcium supplements RR for incidentcac 1.22 ( ) Calcium supplement users with lowest total calcium intake (average 306 mg/day) RR for incidentcac 1.41 ( ) (from Anderson JJB et al. J Am Heart Assoc, DOI: /JAHA , 2016) EPIC-Heidelberg Study participants, years, free of CVD at baseline, average follow-up 11 years HR for MIwithmoderate intake of dietarycalcium(820 mg/d) 0.69(95% CI ) HR for MI in usersof calcium supplements2.39(95% CI ) vs. non-users (fromli K et al, Heart 98: , 2012) B. Hess 11/2016
9 Vascularcalcifications& lowbonemass - clinicallyrelevant pathways Mechanismsinvolvedin bothboneand cardiovasculardisease Increase in inflammatory cytokines Lack of endogenous sex hormones Oxidized lipids Diabetes mellitus Low calcium intake EEffects of Vitamin D Drug effects& Lifestyle B. Hess 9/2016 (modified from Sprini D et al., Clin Cases Min Bone Metabol 11: , 2014; and Moe SM & Chen NX, JASN 19: , 2008)
10 Non-classical extrarenal biological functions of vitamin D Vitamin D deficiency local calcitriol activation of non-renal VDR non-classical, extrarenalbiologicalfunctionsof vitamind B. Hess 9/2016 (modified from Rojas-Rivera J et al., Nephrol Dial Transplant 25: , 2010)
11 Vascular-bone axis - role of Vitamin D Vitamin D deficiency (25-OH-D < 30 ng/ml or < 75 nmol/l) risk of vascular (incl. coronary arteries) calcifications and cardiovascular diseases (epidemiologic data) prevalence of low bone mass and fractures Vitamin D receptors present in cardiovascular cells Vascular smooth muscle cells also express 1-hydroxylase 1,25 (OH) 2 -D production of MGP (strong calcification inhibitor) Low 1,25(OH) 2 -D MGP vascular calcification Low vitamin D-diet (50 IU/kg/day) in mice more pronounced calcification of aortic valve / adjacent aorta Phenotypic switch: vascular cells osteoblast-like cells bone matrix protein production B. Hess 11/2016 (various sources)
12 Vascularcalcifications& lowbonemass - clinicallyrelevant pathways Mechanismsinvolvedin bothboneand cardiovasculardisease Increase in inflammatory cytokines Lack of endogenous sex hormones Oxidized lipids Diabetes mellitus Low calcium intake EEffects of Vitamin K Drug effects& Lifestyle Phylloquinones(Vit. K1) Menaquinones(Vit. K2) B. Hess 11/2016 (modified from Sprini D et al., Clin Cases Min Bone Metabol 11: , 2014; and Moe SM & Chen NX, JASN 19: , 2008)
13 Vitamin K2 = menaquinones (in meat, cheese, curd) Protein carboxylation Coagulation factors B. Hess 11/2016
14 Vitamin K and vascularcalcification Rotterdam Study: population-based, assessment of disease occurrence, 7983 subjects>55 yrs., 4807 withdietarydata& withoutmi, F/U 7-10 years Phylloquinone (K1) intake NOT associated with CV endpoints/mortality Multivariate RR coronary events and all-cause mortality with menaquinone intake < > 32.7 ug/d Nonfatal MI CHD mortality Menaquinone (K2) intake Incident CHD All-cause mortality B. Hess 9/2016 (fromgeleijnsejm et al., J Nutr134: , 2004)
15 Vitamin K and decreasedboneloss 244 healthy post-menopausal women, 3 years placebo vs. menaquinone-7 (capsules), DXA measurements Placebo Menaquinone-7 B. Hess 11/2016 (fromknapen MHJ et al., OsteoporosInt24: , 2013)
16 Vascularcalcifications& lowbonemass - clinicallyrelevant pathways Mechanismsinvolvedin bothboneand cardiovasculardisease Increase in inflammatory cytokines Lack of endogenous sex hormones Oxidized lipids Diabetes mellitus Low calcium intake Effectsof vitaminsd and K Drug effects& Lifestyle B. Hess 11/2016 (modified from Sprini D et al., Clin Cases Min Bone Metabol 11: , 2014; and Moe SM & Chen NX, JASN 19: , 2008)
17 Vascular calcifications & osteoporosis - Drug effects Medications effective in osteoporosis and CV disease animal studies Statins B. Hess 11/2016 (adapted from Sprini D et al., Clin Cases Min Bone Metabol 11: , 2014) Bisphosphonates Raloxifene(selective modulator of estrogen receptors) Insulin Osteoclast activation (Transfer of fatty acid chains)
18 Vascularcalcifications& osteoporosis - potential therapeuticapproaches Benefits of bisphosphonate use on vascular disease - Meta-analysis: HR for all-cause mortality(48 trials with pts.) 0.90( , p = 0.01) HR for CV mortality(10 trialswith pts.) 0.81( , p = 0.07) (Kranenburg G et al, Atherosclerosis 252: , 2016) The otherwayround: benefitsof statinson bonedisease - Simvastatin: significant increases in BMD/bone formation markers and reductions in bone resorption markers (106 pts.) vs. no statin(106 pts.) (Chuengsamarn S et al., Bone 46: , 2010) B. Hess 11/2016
19 «Lifestyle» & vascular-bone axis B. Hess 9/2016
20 Lifestyle Freshfruitconsumption& cardiovasculardisease China Kadoorie Biobank Study: prospective cohort study in 10 regions, participants without CV disease or antihypertensive treatment «the most commonly consumed fruits in China are apples (flavonoids!), citrus fruit, and pears.» B. Hess 11/2016 (from Du H et al, N Engl J Med 374: , 2016)
21 Osteoporose Zentrum Zimmerberg (OZZ) NierensteinZentrum Zürich Gefäss-Knochen-Achse wie lenkt man Calcium ins «richtige» Organ? 1. Genügend Calcium and Vitamin D mg Calcium/d (NATÜRLICHEQuellen!) Serum 25-OH-Vitamin D > 75 nmol/l (> 30 ng/ml) 2. Genügend Vitamin K2 (Menaquinone) Fleisch Käse und Quark 3. Lifestyle: Früchte/Alkali: «An applea day.» 4. Wenn medikamentöse Primärprävention: STATIN - Risiko vs.aspirin: CV 25% vs.10%, Mortalität 14% vs.6% (Karmali KN et al. JAMA Cardiol 1: , 2016) -potentiellpositive Knocheneffekte B. Hess 11/2016
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