Inflammation And Autoimmune Responses Are Independent Of Peripheral Mhc Class Ii Expression Driven By Ciita Piv In Collagen Induced Arthritis

Background In rheumatoid arthritis (RA), non-professional antigen presenting cells (APCs) such as fi broblast-like synoviocytes (FLS) can express MHC class II (MHCII) molecules and function as non-professional APCs in vitro.Objective To examine the regulation of MHCII expression in FLS and to investigate the role of FLS as non-professional APCs in collagen-induced arthritis (CIA). Methods Expression of MHCII, CIITA and Ciita isoforms pI, pIII and pIV was examined by RT-qPCR, immunohistochemistry and fl ow cytometry in human synovial tissues, arthritic mouse joints and human as well as mouse FLS. CIA was induced in mice knockout for the isoform IV of Ciita (pIV-/-), in pIV-/- mice transgenic for CIITA in the thymus (pIV-/- K14 CIITA) and in control littermates in the DBA/1 background by immunising with bovine collagen type II (CII) in complete Freund's adjuvant.Results HLA-DRA, total CIITA and CIITA pIII mRNA levels were signifi cantly increased in the synovial tissues from RA compared to osteoarthritis patients. Human FLS expressed surface MHCII via CIITA pIII and pIV, while MHCII expression in murine FLS was entirely mediated by pIV. pIV-/- mice lacked both inducible MHCII expression on non-professional APCs including FLS, and in the thymic cortex. The thymic defect in pIV-/- mice impaired CD4+ positive selection, thus protecting pIV-/- mice from CIA by preventing CD4+ T cells immune responses against CII and blocking the release of IFN-γ and IL-17 in ex vivo stimulated lymph node cells. The production of T dependent, arthritogenic anti-CII antibodies was also impaired in pIV-/- mice. A normal thymic expression of MHCII and CD4+ T cell repertoire was obtained in pIV-/- K14 CIITA Tg mice. Immune responses against CII were restored in pIV-/- K14 CIITA Tg mice, as well as the arthritis incidence and clinical severity despite the lack of MHCII expression by mouse FLS. At histology, infl ammation andneutrophils infi ltration scores were not reduced in pIV-/- K14 CIITA Tg mice, while the bone erosion score was signifi cantly lower than in controls.Conclusion Over expression of MHCII is tightly correlated with CIITA pIII in the arthritic human synovium. MHCII is induced via CIITA pIII and pIV in human FLS. In the mouse, MHCII expression in the thymic cortex and in FLS is strictly dependent upon Ciita pIV. The lack of Ciita pIV in the periphery of pIV-/- K14 CIITA Tg mice lowered the bone erosion score but did not signifi cantly protect from infl ammation and autoimmune responses in CIA.

Success of a general school-based physical activity intervention on bone mineral content depends on pubertal stage but not on gender

Aims: We performed a randomised controlled trial in children of both gender and different pubertal stages to determine whether a school-based physical activity (PA) program during a full schoolyear influences bone mineral content (BMC) and whether there are differences in response for boys and girls before and during puberty. Methods: Twenty-eight 1st and 5th grade classes were cluster randomised to an intervention (INT, 16 classes, n=297) and control (CON; 12 classes, n=205) group. The intervention consisted of a multi-component PA intervention including daily physical education during a full school year. Each lesson was predetermined, included about ten minutes of jumping or strength training exercises of various intensity and was the same for all children. Measurements included anthropometry (height and weight), tanner stages (by self-assessment), PA (by accelerometry) and BMC for total body, femoral neck, total hip and lumbar spine using dualenergy X-ray absorptiometry (DXA). Bone parameters were normalized for gender and tanner stage (pre- vs. puberty). Analyses were performed by a regression model adjusted for gender, baseline height, baseline weight, baseline PA, post-intervention tanner stage, baseline BMC, and cluster. Researchers were blinded to group allocation. Children in the control group did not know about the intervention arm. Results: 217 (57%) of 380 children who initially agreed to have DXA measurements had also post-intervention DXA and PA data. Mean age of prepubertal and pubertal children at baseline was 9.0±2.1 and 11.2±0.6 years, respectively. 47/114 girls and 68/103 boys were prepubertal at the end of the intervention. Compared to CON, children in INT showed statistically significant increases in BMC of total body (adjusted z-score differences: 0.123; 95%>CI 0.035 to 0.212), femoral neck (0.155; 95%>CI 0.007 to 0.302), and lumbar spine (0.127; 95%>CI 0.026 to 0.228). Importantly, there was no gender*group, but a tanner*group interaction consistently favoring prepubertal children. Conclusions: Our findings show that a general, but stringent school-based PA intervention can improve BMC in elementary school children. Pubertal stage, but not gender seems to determine bone sensitivity to physical activity loading.

In vitro evaluation of staphylococcus aureus biofilm formation on bone grafts and bone substitues

Background: Bacteria form a biofilm on the surface of orthopaedic devices, causing persistent and infection. Little is known about biofilms formation on bone grafts and bone substitutes. We analyzed various representative materials regarding their propensity for biofilm formation caused by Staphylococcus aureus.Methods: As bone graft beta-tricalciumphosphate (b-TCP, CyclOsTM) and as bone substitute a tantalum metal mesh (trabecular metalTM) and PMMA (Pala-cosTM) were investigated. As test organism S. aureus (strain ATCC 29213) was used. Test materials were incubated with bacterial solution of 105 colony-forming units (cfu)/ml at 37°C for 24 h without shaking. After 24 h, the test materials were removed and washed 3 times in normal saline, followed by sonication in 50 ml Ringer solution at 40 kHz for 5 minutes. The resulting sonication fluid was plated in aliquots of 0.1 ml onto aerobe blood agar with 5% sheep blood and incubated at 37°C with 5% CO2 for 24 h. Then, bacterial counts were enumerated and expressed as cfu/ml. All experiments were performed in triplicate to calculate the mean ± standard deviation. The Wilcoxon test was used for statistical calculations.Results: The three investigated materials show a differing specific surface with b-TCB>trabecular metal>PMMA per mm2. S. aureus formed biofilm on all test materials as confirmed by quantitative culture after washing and sonication. The bacterial counts in sonication fluid (in cfu/ml) were higher in b-TCP (5.1 x 106 ± 0.6 x 106) and trabecular metal (3.7 x 106 ± 0.6 x 106) than in PMMA (3.9 x 104 ± 1.8 x 104), p<0.05.Conclusion: Our results demonstrate that about 100-times more bacteria adhere on b-TCP and trabecular metal than on PMMA, reflecting the larger surface of b-TCP and trabecuar metal compared to the one of PMMA. This in-vitro data indicates that bone grafts are susceptible to infection. Further studies are needed to evaluate efficient approaches to prevent and treat infections associated with bone grafts and substitutes, including modification of the surface or antibacterial coating.

Effects of Exemestane and Tamoxifen Treatment on Bone Texture Analysis Assessed by TBS in Comparison With Bone Mineral Density Assessed by DXA in Women With Breast Cancer.

We performed an analysis of a substudy of the randomized Tamoxifen Exemestane Adjuvant Multinational trial to determine the effects of exemestane (EXE) and tamoxifen (TAM) adjuvant treatment on bone mineral density (BMD) measured by dual-energy X-ray absorptiometry compared with the trabecular bone score, a novel grey-level texture measurement that correlates with 3-dimensional parameters of bone texture in postmenopausal women with hormone receptor-positive breast cancer for the first time. In total, 36 women were randomized to receive TAM (n = 17) or EXE (n = 19). Patients receiving TAM showed a mean increase of BMD in lumbar spine from baseline of 1.0%, 1.5%, and 1.9% and in trabecular bone score of 2.2%, 3.5%, and 3.3% at 6-, 12-, and 24-mo treatment, respectively. Conversely, patients receiving EXE showed a mean decrease from baseline in lumbar spine BMD of -2.3%, -3.6%, and -5.3% and in trabecular bone score of -0.9%, -1.7%, and -2.3% at 6-, 12-, and 24-mo treatment, respectively. Changes in trabecular bone score from baseline at spine were also significantly different between EXE and TAM: p = 0.05, 0.007, and 0.006 at 6, 12, and 24mo, respectively. TAM induced an increase in BMD and bone texture analysis, whereas EXE resulted in decreases. The results were independent from each other.

Role of the inflammasome in murine experimental models of arthritis

Summary : The purpose of this study was to investigate the role of the inflammasome in human and experimental murine models (such as ΑΙΑ and K/BxN) of rheumatoid arthritis (RA)RA, affecting 1% of the population is the most frequent inflammatory disease characterized by synovial hyperplasia and cartilage and bone erosion, leading to joint destruction. In general, women are 3 times more affected by RA suggesting a role of estrogen in this disease. The inflammasome is a multiproteic complex triggering the activation of caspase-1 leading to the activation of IL-1 β, an important pro-inflammatory cytokine implicated in arthritis. The inflammasome has been implicated in several inflammatory diseases and particularly in gout. To highlight a possible role of the inflammasome in murine arthritis, we obtained ASC, caspase-1 and NALP3 +/+ and -/- littermate mice to perform ΑΙΑ and K/BxN arthritis. NALP3 -/- and caspase-1 -/- mice were as arthritic as wild type littermate mice in both ΑΙΑ and K/BxN models implicating that the NALP3 inflammasome is not involved in experimental arthritis. By contrast, ΑΙΑ severity was significantly diminished in ASC- deficient male and female mice, and in the K/BxN model, in ASC-deficient female mice. These results were supported by histological scoring and acute phase protein serum amyloid A (SAA) levels that were equivalent between NALP+/+ and NALP3-/- mice and diminished in ASC -/- mice. In ΑΙΑ and K/BxN murine experimental models, we observed a sexdependent phenotype. We studied the role of estradiol in both the ALA and the K/BxN models. Castrated female or male ASC -/- mice that received estradiol had a decreased arthritis severity. This implies a protective role of estrogen in the absence of ASC. In the ΑΙΑ model, proliferation assay were performed using splenocytes from mBSA- immunized ASC +/+ and -/- mice. The mBSA-induced proliferation was significantly lower in ASC-/- splenocytes. Moreover the CD3-specific proliferation of purified splenic Τ cells was significantly lower in ASC-/- cells. Finally, Τ cells from ASC-/- mice produced significantly decreased levels of IFN-gamma associated with increased levels of IL-10. These results imply a possible role of ASC in the TCR-signaling pathway and Τ cell cytokine production. In parallel the expression of the different inflammasome components were analyzed in biopsies from rheumatoid arthritis (RA) and osteoarthritis (OA) patiens. The expression of the 14 different NALPs, their effector protein ASC, and caspase-1 and -5 was readily measurable by RT-PCR in a similar proportion in RA and OA synovial samples, with the exception of NALP-5 and NALP-13, which weren't found in samples from either disease. The corresponding NALP1, -3, -12 and ASC proteins were expressed at similar levels in both OA and RA biopsies, as determined by immunohistochemistry and Western-blot analysis. By contrast, caspase-1 levels were significantly enhanced in RA synovial tissues compared to those from OA patients. NALP-1, -2, -3, -10, -12 and -14, as well as ASC, caspase-1, and -5 were detected in RNA from unstimulated and stimulated RA synoviocytes. In FLS, only ASC and caspase-1 were expressed at the protein level. NALP1, 3 and 12 were not detected. However, upon stimulation, no secreted IL-Ιβ was detectable in either RA or in OA synoviocytes culture medium. Résumé : Le but de ce projet était d'étudier le rôle de l'inflammasome dans des modèles expérimentaux d'arthrite tels que les modèles ΑΙΑ et K/BxN ainsi que dans la polyarthrite humaine (RA). La polyarthrite est une maladie inflammatoire très fréquente avec 1 % de la population affectée et touche 3 fois plus les femmes que les hommes, suggérant un rôle des hormones sexuelles dans cette pathologie. L'inflammasome est un complexe multiprotéique qui permet l'activation de la caspase-1, une cystéine protéase qui va ensuite cliver et activer rinterleukine-ΐβ (IL-Ιβ). L'inflammasome a été impliqué ces dernières années dans de nombreuses maladies inflammatoires notamment dans la goutte. Pour mettre en évidence un éventuel rôle de l'inflammasome dans l'arthrite expérimentale nous avons obtenu des souris déficientes pour certains des composants de l'inflammasome tels que ASC, NALP3 et caspase-1. Les souris NALP3 déficientes et caspase-1 déficientes sont aussi arthritiques que les souris wild type correspondantes que ce soit dans le modèle ΑΙΑ ou K/BxN. Par contre les souris mâles et femelles ASC-déficientes sont moins arthritiques que les souris +/+ correspondantes dans le modèle ΑΙΑ. Dans le modèle KRN, le même phénotype (diminution de la sévérité de l'arthrite) est observé uniquement chez les femelles ASC-/- Ce phénotype est corrélé avec l'histologie ainsi qu'avec le dosage du serum amyloid A (SAA) qui reflète l'inflammation systémique et qui est diminué chez les souris ASC-déficientes. Nous avons ensuite étudié le rôle de Γ estradiol (une des formes active des estrogènes) dans les modèles K/BxN et ΑΙΑ. Les souris castrées maies ou femelles déficientes pour ASC ayant reçu de l'estradiol ont une arthrite moins sévère ce qui implique que les estradiol ont un effet protecteur en l'absence de ASC. Dans le modèle ΑΙΑ, nous nous sommes aussi intéressés à la réponse immune. Des tests de prolifération ont été effectués sur des splénocytes en présence de mBSA (qui est l'antigène utilisé dans le modèle ΑΙΑ). Les splénocytes ASC -/- ont une proliferation qui est diminuée en présence de l'antigène. De plus la proliferation de cellules Τ spléniques purifiées en présence d'anti-CD3 est diminuée chez les cellules Τ ASC-/-. Ces résultats nous indiquent une éventuelle implication de ASC dans la signalisation par le récépteur des cellules T. En parallèle l'expression des différents composants de l'inflammasome a été analysée dans des biopsies de patients atteints de polyarthrite rhumatoide (RA) et d'arthrose (OA). L'expression des 14 différents NALPs, de l'adaptateur ASC, ainsi que des caspase-1 et -5 était similaires dans les échantillons RA et OA, à l'exception de NALP5 et 13 qui n'étaient pas détéctables. L'expression protéique de NALP1, 3, 12 et ASC effectuée par Western blot et immunohistochimie était similaire dans les biopsies RA et OA. Par contre la quantité de la caspase-1 mesurée par ELISA était augmentée de façon significative dans les extraits protéiques de biopsies RA. NALP-1, -2. -3, -10, -12, and -14 ainsi que ASC, caspase-1 et -5 étaient exprimés de façon similaire par les synoviocytes RA non stimulés et stimulés. Dans les synoviocytes seuls ASC et caspase-1 étaient détéctable au niveau protéique. NALP-1, -3 et -12 n'était pas détéctables. Cependant après stimulation il n'y avait d'IL-Ιβ sécrété que ce soit dans les surnageants de cultures de synoviocytes RA ou OA.

Generation and validation of a normative, age-specific reference curve for lumbar spine trabecular bone score (TBS) in French women.

Age-related changes in lumbar vertebral microarchitecture are evaluated, as assessed by trabecular bone score (TBS), in a cohort of 5,942 French women. The magnitude of TBS decline between 45 and 85 years of age is piecewise linear in the spine and averaged 14.5 %. TBS decline rate increases after 65 years by 50 %. INTRODUCTION: This study aimed to evaluate age-related changes in lumbar vertebral microarchitecture, as assessed by TBS, in a cohort of French women aged 45-85 years. METHODS: An all-comers cohort of French Caucasian women was selected from two clinical centers. Data obtained from these centers were cross-calibrated for TBS and bone mineral density (BMD). BMD and TBS were evaluated at L1-L4 and for all lumbar vertebrae combined using GE-Lunar Prodigy densitometer images. Weight, height, and body mass index (BMI) also were determined. To validate our all-comers cohort, the BMD normative data of our cohort and French Prodigy data were compared. RESULTS: A cohort of 5,942 French women aged 45 to 85 years was created. Dual-energy X-ray absorptiometry normative data obtained for BMD from this cohort were not significantly different from French prodigy normative data (p = 0.15). TBS values at L1-L4 were poorly correlated with BMI (r = -0.17) and weight (r = -0.14) and not correlated with height. TBS values obtained for all lumbar vertebra combined (L1, L2, L3, L4) decreased with age. The magnitude of TBS decline at L1-L4 between 45 and 85 years of age was piecewise linear in the spine and averaged 14.5 %, but this rate increased after 65 years by 50 %. Similar results were obtained for other region of interest in the lumbar spine. As opposed to BMD, TBS was not affected by spinal osteoarthrosis. CONCLUSION: The age-specific reference curve for TBS generated here could therefore be used to help clinicians to improve osteoporosis patient management and to monitor microarchitectural changes related to treatment or other diseases in routine clinical practice.

[(18)F]FDG-PET Standard Uptake Value as a Metabolic Predictor of Bone Marrow Response to Radiation: Impact on Acute and Late Hematological Toxicity in Cervical Cancer Patients Treated With Chemoradiation Therapy.

PURPOSE: To quantify the relationship between bone marrow (BM) response to radiation and radiation dose by using (18)F-labeled fluorodeoxyglucose positron emission tomography [(18)F]FDG-PET standard uptake values (SUV) and to correlate these findings with hematological toxicity (HT) in cervical cancer (CC) patients treated with chemoradiation therapy (CRT). METHODS AND MATERIALS: Seventeen women with a diagnosis of CC were treated with standard doses of CRT. All patients underwent pre- and post-therapy [(18)F]FDG-PET/computed tomography (CT). Hemograms were obtained before and during treatment and 3 months after treatment and at last follow-up. Pelvic bone was autosegmented as total bone marrow (BMTOT). Active bone marrow (BMACT) was contoured based on SUV greater than the mean SUV of BMTOT. The volumes (V) of each region receiving 10, 20, 30, and 40 Gy (V10, V20, V30, and V40, respectively) were calculated. Metabolic volume histograms and voxel SUV map response graphs were created. Relative changes in SUV before and after therapy were calculated by separating SUV voxels into radiation therapy dose ranges of 5 Gy. The relationships among SUV decrease, radiation dose, and HT were investigated using multiple regression models. RESULTS: Mean relative pre-post-therapy SUV reductions in BMTOT and BMACT were 27% and 38%, respectively. BMACT volume was significantly reduced after treatment (from 651.5 to 231.6 cm(3), respectively; P<.0001). BMACT V30 was significantly correlated with a reduction in BMACT SUV (R(2), 0.14; P<.001). The reduction in BMACT SUV significantly correlated with reduction in white blood cells (WBCs) at 3 months post-treatment (R(2), 0.27; P=.04) and at last follow-up (R(2), 0.25; P=.04). Different dosimetric parameters of BMTOT and BMACT correlated with long-term hematological outcome. CONCLUSIONS: The volumes of BMTOT and BMACT that are exposed to even relatively low doses of radiation are associated with a decrease in WBC counts following CRT. The loss in proliferative BM SUV uptake translates into low WBC nadirs after treatment. These results suggest the potential of intensity modulated radiation therapy to spare BMTOT to reduce long-term hematological toxicity.

The Lausanne experience with the Wichita fusion nail for arthrodesis of the knee

Background: Arthrodesis of the knee by intramedullary fixation hasbeen reported to have a higher rate of success than external fixationor compression plating. Antegrade nailing however can lead to complicationsdue to the different diameters of the medullary canals, fracturesduring insertion, poor rotational stability, breakage of the IM-nailand insufficient compression at the fusion site.Method: This retrospective study reports all knee fusions performedby the same orthopaedic surgeon with the Wichita (Stryker) fusion nail(WFN) from 2004 to 2010. The Wichita nail is a short nail with a deviceat the knee which allows for coupling of differently sized and interlockedfemoral and tibial components and at the same time for compression.Results: We report of 18 patients with a mean follow up of 28 months(range 3-71 months). Infected TKA was the most common indicationfor arthrodesis in 9 cases. The remaining reasons included asepticfailed TKA in 3 cases, 2 patients after fracture, 1 patient with neurologicalinstability after knee dislocation, 1 patient after tumoral resectionand 1 non union after failed arthrodesis with long antegrade nail.Finally 1 patient with bilateral congenital knee dislocation operated onboth sides. As expected, patients receiving the WFN had undergonea large number of previous knee surgeries with a mean of 3.8 (range0-8) procedures per patient. The complication rate was 27% (5 of 18).Two patients had persistent pain requiring revision surgery to increasestability with plating. One case of periprosthetic fracture needed openreduction and internal fixation. 2 patients with superficial hematomawere treated one with open drainage and the other with physiotherapy.Infection was erradicated in all septic cases, we found no new infectionand the fusion rate was 100%.Conclusion: The results in these often difficult cases are satisfyingand we think that this technique is a valid alternative to the otherknown techniques of knee fusion in patients with a poor bone stockand fragile soft tissues.

Systemic antibodies can inhibit mouse mammary tumor virus-driven superantigen response in mucosa-associated lymphoid tissues.

Many mucosal pathogens invade the host by initially infecting the organized mucosa-associated lymphoid tissue (o-MALT) such as Peyer's patches or nasal cavity-associated lymphoid tissue (NALT) before spreading systemically. There is no clear demonstration that serum antibodies can prevent infections in o-MALT. We have tested this possibility by using the mouse mammary tumor virus (MMTV) as a model system. In peripheral lymph nodes or in Peyer's patches or NALT, MMTV initially infects B lymphocytes, which as a consequence express a superantigen (SAg) activity. The SAg molecule induces the local activation of a subset of T cells within 6 days after MMTV infection. We report that similar levels of anti-SAg antibody (immunoglobulin G) in serum were potent inhibitors of the SAg-induced T-cell response both in peripheral lymph nodes and in Peyer's patches or NALT. This result clearly demonstrates that systemic antibodies can gain access to Peyer's patches or NALT.

Biofilm formation on bone grafts and bone graft substitutes: comparison of different materials by a standard in vitro test and microcalorimetry.

We analyzed the initial adhesion and biofilm formation of Staphylococcus aureus (ATCC 29213) and S. epidermidis RP62A (ATCC 35984) on various bone grafts and bone graft substitutes under standardized in vitro conditions. In parallel, microcalorimetry was evaluated as a real-time microbiological assay in the investigation of biofilm formation and material science research. The materials beta-tricalcium phosphate (beta-TCP), processed human spongiosa (Tutoplast) and poly(methyl methacrylate) (PMMA) were investigated and compared with polyethylene (PE). Bacterial counts (log(10) cfu per sample) were highest on beta-TCP (S. aureus 7.67 +/- 0.17; S. epidermidis 8.14 +/- 0.05) while bacterial density (log(10) cfu per surface) was highest on PMMA (S. aureus 6.12 +/- 0.2, S. epidermidis 7.65 +/- 0.13). Detection time for S. aureus biofilms was shorter for the porous materials (beta-TCP and processed human spongiosa, p < 0.001) compared to the smooth materials (PMMA and PE), with no differences between beta-TCP and processed human spongiosa (p > 0.05) or PMMA and PE (p > 0.05). In contrast, for S. epidermidis biofilms the detection time was different (p < 0.001) between all materials except between processed human spongiosa and PE (p > 0.05). The quantitative analysis by quantitative culture after washing and sonication of the material demonstrated the importance of monitoring factors like specific surface or porosity of the test materials. Isothermal microcalorimetry proved to be a suitable tool for an accurate, non-invasive and real-time microbiological assay, allowing the detection of bacterial biomass without removing the biofilm from the surface.

Tobramycin exposure from active calcium sulfate bone graft substitute.

BACKGROUND: Bone graft substitute such as calcium sulfate are frequently used as carrier material for local antimicrobial therapy in orthopedic surgery. This study aimed to assess the systemic absorption and disposition of tobramycin in patients treated with a tobramycin-laden bone graft substitute (Osteoset® T). METHODS: Nine blood samples were taken from 12 patients over 10 days after Osteoset® T surgical implantation. Tobramycin concentration was measured by fluorescence polarization. Population pharmacokinetic analysis was performed using NONMEM to assess the average value and variability (CV) of pharmacokinetic parameters. Bioavailability (F) was assessed by equating clearance (CL) with creatinine clearance (Cockcroft CLCr). Based on the final model, simulations with various doses and renal function levels were performed. (ClinicalTrials.gov number, NCT01938417). RESULTS: The patients were 52 +/- 20 years old, their mean body weight was 73 +/- 17 kg and their mean CLCr was 119 +/- 55 mL/min. Either 10 g or 20 g Osteoset® T with 4% tobramycin sulfate was implanted in various sites. Concentration profiles remained low and consistent with absorption rate-limited first-order release, while showing important variability. With CL equated to CLCr, mean absorption rate constant (ka) was 0.06 h-1, F was 63% or 32% (CV 74%) for 10 and 20 g Osteoset® T respectively, and volume of distribution (V) was 16.6 L (CV 89%). Simulations predicted sustained high, potentially toxic concentrations with 10 g, 30 g and 50 g Osteoset® T for CLCr values below 10, 20 and 30 mL/min, respectively. CONCLUSIONS: Osteoset® T does not raise toxicity concerns in subjects without significant renal failure. The risk/benefit ratio might turn unfavorable in case of severe renal failure, even after standard dose implantation.