Photoelastic Study of the Support Structures of Distal-Extension Removable Partial Dentures

Purpose: The double system of support, in which the distal-extension removable partial denture adapts, causes inadequate stress around abutment teeth, increasing the possibility of unequal bone resorption. Several ways to reduce or more adequately distribute the stress between abutment teeth and residual ridges have been reported; however, there are no definitive answers to the problem. The purpose of this study was to analyze, by means of photoelasticity, the most favorable stress distribution using three retainers: T bar, rest, proximal plate, I bar (RPI), and circumferential with mesialized rest. Materials and Methods: Three photoelastic models were made simulating a Kennedy Class II inferior arch. Fifteen dentures with long saddles, five of each design, were adjusted to the photoelastic patterns and submitted first to uniformly distributed load, and then to a load localized on the last artificial tooth. The saddles were then shortened and the tests repeated. The quantitative and qualitative analyses of stress intensity were done manually and by photography, respectively. For intragroup analyses the Wilcoxon test for paired samples was used, while for intergroup analyses Friedman and Wilcoxon tests were used to better identify the differences (p < 0.05). Results: The RPI retainer, followed by the T bar, demonstrated the best distribution of load between teeth and residual ridge. The circumferential retainer caused greater concentration of stress between dental apexes. Stress distribution was influenced by the type of retainer, the length of the saddle, and the manner of load application. Conclusions: The long saddles and the uniformly distributed loads demonstrated better distribution of stress on support structures.

Growth hormone receptor and IGF-1 receptor immunoreactivity during orthodontic tooth movement in the prednisolone-treated rat

Bone remodeling during tooth movement is regulated by local and systemic factors. Two regulators of bone metabolism are growth hormone (GH) and insulin-like growth factor-I (IGF-1). Their effects are mediated via binding to GH receptor (GHR) and IGF-I receptor (IGF-IR) in target tissues. Corticosteroids may affect the activity of these growth factors. This study examined the effect of prednisolone on GHR and IGF-IR expression in dental tissues following orthodontic tooth movement. The corti ticosteroid-treated group (N = 6) was administered prednisolone ( 1 mg/kg,) daily and the control group (N = 6) received equivalent volumes of saline. An orthodontic force (30 g) was applied to the maxillary first molar. Animals were sacrificed 12 days postappliance insertion. Sagittal sections of the first molar were stained for GHR and IGF-IR immunoreactivity. GHR and IGF-IR cell counts were elevated following appliance-treatment. Orthodontic tooth movement appeared to up-regulate GHR and IGF-IR immunoreactivity, but this up-regulation was reduced following prednisolone treatment. The suppression of GHR and IGF-I immunoreactivity in steroid-treated animals infers the mechanism whereby bone resorption and deposition, necessary for orthodontic tooth movement, may be inhibited by prednisolone. However, at 12 days postappliance insertion. no difference in orthodontic tooth movement was observed following low-dose prednisolone treatment.

Destructive periodontitis lesions are determined by the nature of the lymphocytic response

It is now 35 years since Brandtzaeg and Kraus (1965) published their seminal work entitled Autoimmunity and periodontal disease. Initially, this work led to the concept that destructive periodontitis was a localized hypersensitivity reaction involving immune complex formation within the tissues. In 1970, Ivanyi and Lehner highlighted a possible role for cell-mediated immunity, which stimulated a flurry of activity centered on the role of lymphokines such as osteoclast-activating factor (OAF), macrophage-activating factor (MAF), macrophage migration inhibition factor (MIF), and myriad others. In the late 1970s and early 1980s, attention focused on the role of polymorphonuclear neutrophils, and it was thought that periodontal destruction occurred as a series of acute exacerbations. As well, at this stage doubt was being cast on the concept that there was a neutrophil chemotactic defect in periodontitis patients. Once it was realized that neutrophils were primarily protective and that severe periodontal destruction occurred in the absence of these cells, attention swung back to the role of lymphocytes and in particular the regulatory role of T-cells. By this time in the early 1990s, while the roles of interleukin (IL)-1, prostaglandin (PG) E-2, and metalloproteinases as the destructive mediators in periodontal disease were largely understood, the control and regulation of these cytokines remained controversial. With the widespread acceptance of the Th1/Th2 paradigm, the regulatory role of T-cells became the main focus of attention, Two apparently conflicting theories have emerged. One is based on direct observations of human lesions, while the other is based on animal model experiments and the inability to demonstrate IL-4 mRNA in gingival extracts. As part of the Controversy series, this review is intended to stimulate debate and hence may appear in some places provocative. In this context, this review will present the case that destructive periodontitis is due to the nature of the lymphocytic infiltrate and is not due to periodic acute exacerbations, nor is it due to the so-called virulence factors of putative periodontal pathogens.

Genetic dependence of the specific T-cell cytokine response to Porphyromonas gingivalis in mice

Background: Susceptibility to periodontal infections may, in part, be genetically determined. Porphyromonas gingivalis is a major periodontopathogen, and the immune response to this organism requires T-cell help. The aim of the present study was to examine the specific T-cell cytokine responses to P gingivalis outer membrane antigens in a mouse model and their relationship with H-2 haplotype. Methods: BALB/c and DBA/2J (H-2(d)), CBACaH (H-2(k)), and C57BL6 (H-2(b)) mice were immunized with P gingivalis outer membrane antigens weekly for 3 weeks. One week after the final injection, the spleens were removed, and 6 T-cell lines specific for P gingivalis were established for each mouse strain. The percentage of CD4 and CD8 cells in the P gingivalis-specific T-cell lines staining positive for intracytoplasmic interleukin (IL)-4, interferon (IFN)-gamma, and IL-10 was determined by 2-color flow cytometry. Results: The cytokine profiles of T-cell lines from BALB/c and DBA/2J mice showed no significant differences. Significantly fewer IL4+, IFN-gamma+, and IL-10+ CD4 cells than IL-4+, IFN-gamma+, and IL-10+ CD8 cells, respectively, were demonstrated for both strains. P gingivalis-specific T-cell lines generated from CBACaH mice were similar to those generated from BALB/c and DBA/2J mice; however, the mean percentage of IL4+ CD4 cells in CBACaH mice was lower than the percentage of IFN-gamma+ CD4 cells. Also, the mean percentage of IFN-gamma+ CD4 cells in CBACaH mice was significantly increased compared to DBA/2J mice. Unlike the other 3 strains, T-cell lines established from C57BL6 mice contained similar percentages of cytokine-positive cells, although the percentage of IL-4+ CD4 cells was reduced in comparison to the percentage of CD8 cells. However, comparisons with the other 3 strains demonstrated a higher percentage of IL-4+ CD4 cells than in lines established from the spleens of DBA/2J mice, IFN-gamma+ CD4 cells than in lines established from BALB/c and CBACaH mice, and IL-10+ CD4 cells than in lines established from all 3 other strains. No significant differences in the percentage of positive CD8 cells were demonstrated between lines in the 4 strains of mice. Conclusion: The specific T-cell response to P gingivalis in mice may, in the case of the CD4 response, depend on MHC genes. These findings are consistent with the concept that patient susceptibility is important to the outcome of periodontal infection and may, in part, be genetically determined.

Differential expression and distribution of syndecan-1 and-2 in periodontal wound healing of the rat

Cell-surface proteoglycans participate in several biological functions including interactions with adhesion molecules, growth factors and a variety of other effector molecules. Accordingly, these molecules play a central role in various aspects of cell-cell and cell-matrix interactions. To investigate the expression and distribution of the cell surface proteoglycans, syndecan-1 and -2, during periodontal wound healing, immunohistochemical analyses were carried out using monoclonal antibodies against syndecan-1, or -2 core proteins. Both syndecan-1 and -2 were expressed and distributed differentially at various stages of early inflammatory cell infiltration, granulation tissue formation, and tissue remodeling in periodontal wound healing. Expression of syndecan-1 was noted in inflammatory cells within and around the fibrin clots during the earliest stages of inflammatory cell infiltration. During granulation tissue formation it was noted in fibroblast-like cells and newly formed blood vessels. Syndecan-1 was not seen in newly formed bone or cementum matrix at any of the time periods studied. Syndecan-1 expression was generally less during the late stages of wound healing but was markedly expressed in cells that were close to the repairing junctional epithelium. In contrast, syndecan-2 expression and distribution was not evident at the early stages of inflammatory cell infiltration. During the formation of granulation tissue and subsequent tissue remodeling, syndecan-2 was expressed extracellularly in the newly formed fibrils which were oriented toward the root surface. Syndecan-2 was found to be significantly expressed on cells that were close to the root surface and within the matrix of repaired cementum covering root dentin as well as at the alveolar bone edge. These findings indicate that syndecan-1 and -2 may have distinctive functions during wound healing of the periodontium. The appearance of syndecan-1 may involve both cell-cell and cell-matrix interactions, while syndecan-2 showed a predilection to associate with cell-matrix interactions during hard tissue formation.

Pamidronate results in symptom control of hypertrophic pulmonary osteoarthropathy in cystic fibrosis

Hypertrophic pulmonary osteoarthropathy (HPOA) may complicate the advanced lung disease that is associated with cystic fibrosis, resulting in severe joint pain and early-morning stiffness. Symptoms are usually controlled with the administration of nonsteroidal anti-inflammatory drugs, physiotherapy, and, on occasions, oral corticosteroids. I This report describes a case of refractory HPOA with complete remission following the administration of IV pamidronate, which is a potent inhibitor of osteoclastic bone resorption. Symptom relief resulted for up to 3 months, but repeated courses of pamidronate have been required to maintain symptom control.

Immunohistochemical localization of fibromodulin in the periodontium during cementogenesis and root formation in the rat molar

Background: Cementum is essential for periodontal regeneration, as it provides anchorage between the root surface and the periodontal ligament. A variety of macromolecules present in the extracellular matrix of the periodontium, including proteoglycans, are likely to play a regulatory role in cementogenesis. Recently, the small leucine-rich proteoglycan, fibromodulin, has been isolated from bovine periodontal ligament and localized in bovine cementum, as well as in human periodontal ligament. Objective: The aim of this study was to examine the distribution of fibromodulin during cementogenesis and root formation. Methods: A standard indirect immunoperoxidase technique was employed, using an antifibromodulin polyclonal antibody on sections of molar teeth from rats aged 3, 5 and 8 weeks. Results: Immunoreactivity to fibromodulin was evident in the periodontal ligament in all sections. An intense positive stain was observed in the extracellular matrix where the periodontal ligament fibers insert into the alveolar bone and where the Sharpey's fibers insert into the cementum. There was no staining evident in the mineralized cellular and acellular cementum. The intensity of immunoreactivity to the antifibromodulin antibody increased proportionally with increasing tissue maturation. Conclusion: The results from this study suggest that fibromodulin is a significant component of the extracellular matrix in the periodontal ligament during development, and may play a regulatory role in the mineralization process or maintaining homeostasis at the hard-soft tissue interface during cementogenesis.

Inter-relationships between rheumatoid arthritis and periodontal disease

This review considers the considerable similarities between periodontal disease and rheumatoid arthritis (RA). While the etiology of these two diseases may differ, the underlying pathogenic mechanisms are remarkably similar and it is possible that individuals manifesting both periodontitis and RA may suffer from a unifying underlying systemic dysregulation of the inflammatory response. In light of these findings, the implications for the use of disease-modifying medications in the management of these two chronic inflammatory conditions is apparent. Further longitudinal studies and medication-based intervention studies are required to determine just how closely these two conditions are allied.

Matrix metalloproteinase-2 and-9 involvement in canine tumors

Matrix metalloproteinases (MMPs) are a family of enzymes implicated in the degradation and remodeling of extracellular matrix and in vascularization. They are also involved in pathologic processes such as tumor invasion and metastasis in experimental cancer models and in human malignancies. We used gelatin zymography and inummohistochemistry to determine whether MMP-2 and MMP-9 are present in canine tumors and normal tissues and whether MMP production correlates with clinicopathologic parameters of prognostic importance. High levels of pro-MMP-9, pro-MMP-2, and active MMP-2 were detected in most canine tumors. Significantly higher MMP levels were measured in canine tumors than in nontumors, malignancies had higher MMP levels than benign tumors, and sarcomas had higher active MMP-2 than carcinomas. Cartilaginous tumors produced higher MMP levels than did nonsarcomatous malignancies, benign tumors, and normal tissues, and significantly greater MMP-2 than osteosarcomas and fibrosarcomas. Pro-MMP-9 production correlated with the histologic grade of osteosarcomas. The 62-kd form of active MMP-2 was detected only in high-grade, p53-positive, metastatic malignancies. Zymography proved to be a sensitive and quantitative technique for the assessment of MMP presence but has the limitation of requiring fresh tissue; inummohistochemistry is qualitative and comparatively insensitive but could be of value in archival studies. MMP presence was shown in a range of canine tumors, and their link to tumor type and grade was demonstrated for the first time. This study will allow a substantially improved evaluation of veterinary cancer patients and provides baseline information necessary for the design of clinical trials targeting MMPs.

Patofisiologia de osteonecrose induzida por bisfosfonatos e inibidores de RANK-L

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Periodontal aspects of the juvenile form of paracoccidioidomycosis

Three cases of the juvenile form of paracoccidioidomycosis are reported. Emphasis has been given to the oral manifestations, particularly the periodontal involvement. The main periodontal findings were: generalized and progressive alveolar bone destruction leading to gingival recession with exposure of the tooth roots, and spontaneous tooth losses. The gingival mucosa was predominantly smooth, erithematous and slightly swollen. These aspects, although rare, may be the earliest signs of the disease and sometimes its only manifestation.

Optimization of the Tartrate-Resistant Acid Phosphatase Detection by Histochemical Method

According to the new KDIGO (Kidney Disease Improving Global Outcomes) guidelines, the term of renal osteodystrophy, should be used exclusively in reference to the invasive diagnosis of bone abnormalities. Due to the low sensitivity and specificity of biochemical serum markers of bone remodelling,the performance of bone biopsies is highly stimulated in dialysis patients and after kidney transplantation. The tartrate-resistant acid phosphatase (TRACP) is an iso-enzyme of the group of acid phosphatases, which is highly expressed by activated osteoclasts and macrophages. TRACP in osteoclasts is in intracytoplasmic vesicles that transport the products of bone matrix degradation. Being present in activated osteoclasts, the identification of this enzyme by histochemistry in undecalcified bone biopsies is an excellent method to quantify the resorption of bone. Since it is an enzymatic histochemical method for a thermolabile enzyme, the temperature at which it is performed is particularly relevant. This study aimed to determine the optimal temperature for identification of TRACP in activated osteoclasts in undecalcified bone biopsies embedded in methylmethacrylate. We selected 10 cases of undecalcified bone biopsies from hemodialysis patients with the diagnosis of secondary hyperparathyroidism. Sections of 5 μm were stained to identify TRACP at different incubation temperatures (37º, 45º, 60º, 70º and 80ºC) for 30 minutes. Activated osteoclasts stained red and trabecular bone (mineralized bone) was contrasted with toluidine blue. This approach also increased the visibility of the trabecular bone resorption areas (Howship lacunae). Unlike what is suggested in the literature and in several international protocols, we found that the best results were obtained with temperatures between 60ºC and 70ºC. For technical reasons and according to the results of the present study, we recommended that, for an incubation time of 30 minutes, the reaction should be carried out at 60ºC. As active osteoclasts are usually scarce in a bone section, the standardization of the histochemistry method is of great relevance, to optimize the identification of these cells and increase the accuracy of the histomosphometric results. Our results, allowing an increase in osteoclasts contrast, also support the use of semi-automatic histomorphometric measurements.

Patologia óssea do insuficiente renal crónico: desafio clínico-biológico ; Caracterização da osteodistrofia renal e efeitos da biocompatibilidade de membranas de hemodiálise, na remodelação óssea

Resumo: Os resultados das nossas investigações, apresentadas ao longo desta dissertação,contribuíram para a otimização do diagnóstico invasivo e não invasivo da osteodistrofia renal e permitiram evidenciar a relevância, para a expressão clínica e histológica da ODR, de algumas articularidades específicas da população hemodialisada, nomeadamente: a utilização de membranas de hemodiálise mais biocompatíveis e com elevada permeabilidade, o recurso a técnicas de hemodiafiltração com otimização da capacidade convectiva, as limitações dos marcadores bioquímicos de remodelação óssea ou a insuficiência / deficiência em vitamina D nativa (bem como os resultados da suplementação com esta vitamina). Testámos, pela primeira vez em doentes hemodialisados, novos marcadores da formação e reabsorção óssea, que validámos mediante a comparação com os resultados da histomorfometria óssea. No seu conjunto, e de forma integrada, as nossas investigações permitiram-nos: - Evidenciar a diminuição da expressão do recetor da PTH/PTHrP na cartilagem de crescimento, num modelo animal de IRC, o que explica, pelo menos em parte, o atraso de crescimento observado nesta patologia, bem como a diminuição da resposta à ação da PTH; - Demonstrar as vantagens da determinação da isoforma óssea da fosfatase alcalina, em relação à fosfatase alcalina total, no diagnóstico diferencial entre baixa e elevada remodelação óssea; - Utilizar, pela primeira vez em hemodialisados, a piridinolina e a desoxipiridinolina no diagnóstico da reabsorção óssea. Este foi o primeiro marcador sérico específico da atividade osteoclástica, utilizado com sucesso em doentes anúricos em hemodiálise. Evidenciámos uma excelente correlação destes dois marcadores bioquímicos com a superfície osteoclástica e com o número de osteoclastos/mm2;- Demonstrar as acentuadas limitações de outros marcadores da formação e reabsorção óssea (nomeadamente a osteocalcina, o propeptido carboxiterminal do procolagénio tipo I-PICP, e o Telopeptido do colagénio tipo I – ICTP) com base nas correlações entre os doseamentos séricos ou plasmáticos destes marcadores e a biópsia óssea com avaliação histomorfométrica; -Evidenciar as limitações induzidas pela sobrecarga alumínica na interpretação dos níveis séricos dos marcadores não invasivos da remodelação óssea;-Testar a eficácia e segurança da utilização de “microdoses” de desferroxamina na terapêutica da intoxicação alumínica, em doentes com acentuada exposição a este metal;-Demonstrar que os doentes hemodialisados cronicamente com dialisadores de poliacrilonitrilo (membranas de alta permeabilidade),apresentavam menor ativação osteoblástica e osteoclástica, que os doentes dialisados com membranas de cuprofano(baixa permeabilidade), sendo os níveis de iPTH semelhantes em ambos os grupos estudados. Estes resultados apontam para uma menor ativação da remodelação óssea quando se utilizam membranas de hemodiálise mais biocompatíveis e/ou de maior permeabilidade, o que se poderá relacionar com a ultrafiltração de mediadores da ativação celular ou com a menor ativação dos mecanismos estimuladores da remodelação óssea, por parte destas membranas. Entre os mediadores da remodelação óssea que demonstrámos serem relevantes e estarem aumentados no soro de hemodialisados com membranas de baixo fluxo, contam-se a beta-2-microglobulina (2-M) e algumas citoquinas, com ação estimuladora das linhagens celulares envolvidas na remodelação óssea. Demonstrámos igualmente uma correlação positiva dos níveis séricos de 2-M com os níveis séricos da osteocalcina, da isoenzima óssea da fosfatase alcalina (marcadores da formação óssea) e com os níveis séricos da piridinolina (marcador da reabsorção óssea). Os níveis séricos de 2-M correlacionaram-se ainda, de forma negativa, com o volume osteoide (matriz óssea não calcificada). Nestes doentes hemodialisados, demonstrámos a presença de níveis séricos aumentados da interleucina-1, do antagonista do recetor da interleucina-1, da interleucina-6 e do recetor solúvel da interleucina-6. Salientamos as relações inversas que observámos, por um lado entre os níveis de antagonista do recetor da interleucina-1 e a superfície osteoblástica, e por outro lado entre o rácio do recetor da interleucina-6 / interleucina-6 (IL6-r/IL6) e a superfície osteoclástica. De acordo com estes nossos resultados originais, entendemos que a interferência nos níveis circulantes e na ativação local destes mediadores poderá justificar, em grande parte, o aumento da prevalência de doença óssea adinâmica, descrita por nós e por outros grupos. Evidenciámos uma elevadíssima prevalência de doença adinâmica (>50% dos doentes), numa população de hemodialisados sem exposição prévia ao alumínio, tratados de acordo com os K/DOQI “guidelines” e que ao longo de um ano mantiveram níveis séricos de cálcio e de fósforo controlados. Consequentemente, os doentes tratados de forma otimizada apresentaram uma prevalência surpreendentemente elevada de doença adinâmica. Os nossos resultados (classificados com o grau de evidência máxima pelos peritos KDIGO) contribuíram para dar suporte à grande diferença nos guidelines K/DOQI (2003) e KDIGO (2009) no que respeita aos valores alvo da PTH. Estamos conscientes que de que o facto de termos uma percentagem tão elevada de doença óssea adinâmica nas nossas populações de hemodialisados, bem como a demonstração de que alguns doentes com valores de PTH intacta (2ª geração) de cerca de 600 pg/ml tinham doença óssea adinâmica, condicionaram os novos objetivos KDIGO para a PTH. Os nossos resultados suportam, em nossa opinião, a adequação e vantagem da utilização dos critérios da KDIGO em vez dos KDOQI. Tendo em conta que os primeiros definem objetivos para a PTH entre 2 e 9 vezes o limite superior do normal e não se comprometem com valores alvo absolutos e rígidos (definidos previamente nos KDOQI entre 150 e 300 pg/mL), esta nova abordagem parece-nos mais correta.Na nossa investigação clínica, caracterizámos ainda a população hemodialisada portuguesa no que respeita aos níveis séricos de calcidiol, identificando a população com suficiência, insuficiência ou deficiência em vitamina D3. Documentámos uma acentuada prevalência de insuficiência e mesmo de deficiência nesta vitamina, numa vasta população de hemodialisados, a qual, muito provavelmente, reflete de forma fidedigna, o que se pode observar na restante população de doentes portugueses IRC em estádio 5d (em diálise). Descrevemos, pela primeira vez em doentes hemodialisados, uma associação entre deficiência em calcidiol e a presença de fatores de risco cardiovascular (que têm sido identificados nos doentes urémicos). A nossa investigação conduziu-nos a resultados originais, ao identificar os níveis baixos de 25(OH)vitamina D3 como um provável fator de risco cardiovascular em hemodialisados, visto que a deficiência nesta vitamina se associou, de forma muito significativa, ao aumento da prevalência de calcificações vasculares, a inflamação, a pressão de pulso mais elevada, a hipertrofia ventricular esquerda, a insuficiência cardíaca e a níveis séricos aumentados de “BNP-Brain natriuretic peptide”. Finalmente, numa avaliação prospetiva, de intervenção terapêutica, corrigimos a insuficiência ou deficiência em 25(OH)vitamina D3 e demonstrámos que essa correção se associou a uma redução dos fatores de risco cardiovascular. Esta última intervenção foi totalmente inovadora, visto ser a primeira avaliação prospetiva da evolução dos fatores de risco cardiovasculares, em função da suplementação com vitamina D nativa, em doentes hemodialisados. Em resumo, pensamos que os resultados das nossas investigações, acima sumarizadas e apresentadas ao longo dos diversos capítulos desta dissertação,contribuiram para uma nova perspetiva da osteodistrofia renal e para recolocar o foco da atenção dos nefrologistas no tecido ósseo e no eixo paratormona – vitamina D – remodelação óssea. Este eixo surje claramente envolvido em múltiplos processos fisiopatológicos, que suportam a elevada morbilidade e mortalidade (nomeadamente de causa cardiovascular) observada nos doentes urémicos.---------ABSTRACT: The results of our research, presented throughout this thesis, contributed towards the optimisation of the invasive and non-invasive diagnosis of renal osteodystrophy. They have also highlighted the importance, to the clinical and histological expression of the ODR, of some specific characteristics of the haemodialysis population, including: the use of biocompatible high permeability haemodialysis membranes, the use of haemodiafiltration techniques with convection enhancement, as well as the limitations of biochemical markers of bone turnover or native vitamin D insufficiency/deficiency (along with the supplementation results of this vitamin). New bone formation and resorption markers, which were validated by comparison with the results of bone histomorphometry, have been tested for the first time on haemodialysis patients.As a whole, and in an integrated approach, our research enabled us to: - Show the decrease of the PTH/PTHrP receptor expression in cartilage growth, used on an IRC animal model, which explains, to some extent, not only the delayed growth observed in this pathology, but also the slow response to PTH. - Point out the advantages of the determination of bone isoform of alkaline phosphatase, in relation to the total alkaline phosphatase, in the differential diagnosis between low and high-bone turnover.- Use pyridinoline and deoxypyridinoline in the diagnosis of bone resorption for the first time on haemodialysis patients. This was the first specific serum market of the osteoclastic activity, which was successfully used on anuric patients undergoing haemodialysis treatment. We also observed an excellent correlation of these biochemical markers with the osteoclastic surface and the number of osteoclasts/mm2. - Demonstrate the sharp limitations of other markers of bone formation and resorption (namely osteocalcin, carboxyterminal propeptide of type I-PICP procollagen and telopeptide of type I-ICTP collagen) based on correlations between these markers’ serum or plasma assays and bone biopsy with histomorphometric assessment.-Show the limitations induced by aluminium overload in the interpretation of serum levels of bone remodelling non-invasive markers.-Test the efficacy and the safety of the use of deferoxamine “microdoses” for treatment of aluminium overload among patients with high levels of serum aluminium. - Demonstrate that patients with chronic haemodialysis dialysers of polyacrylonitrile (high permeability membranes) show a lower osteoblastic and osteoclastic activation than those undergoing dialysis with cuprofan membranes (low permeability), being the iPTH levels similar in both groups of patients. These findings point towards a lower activation of bone remodelling when using more biocompatible dialysis membranes and/or of higher permeability, which may relate to the ultrafiltration of cell activation mediators or to the lower activation of the stimulating mechanisms of bone remodelling, regarding the membranes. Beta-2-microglobulin (2-M) and some cytokines that play a role/participate in bone remodelling are among the bone remodelling mediators, which we demonstrated to be relevant and to be increased in the serum of haemodialysis with low flow membranes. We also proved that there is a positive correlation of serum 2-M levels not only with serum osteocalcin levels, of the bone isoenzyme of alkaline phosphatase (bone forming markers), but also with levels of serum pyridinoline (bone resorption marker).Serum 2-M levels correlate negatively with the volume of osteoid (uncalcified bone matrix). We also demonstrated the presence of elevated serum levels of interleukin-1,interleukin-1 receptor antagonist, interleukin-6 and soluble interleukin-6 receptor in haemodialysis patients. We stress the inverse relationship which we observed on one hand between the interleukin-1 receptor antagonist levels and the osteoblastic surface and on the other between the ratio of interleukin-6 receptor / interleukin-6 (IL6-r/IL6) and the osteoblastic surface. According to these unique findings, we believe that the interference in the circulating levels and in the local activation of these mediators may partly explain the rising prevalence of adynamic bone disease. A high prevalence of adynamic disease has also been observed in a haemodialysis population (>50% of patients) with no previous exposure to aluminium. The patients were treated according to K/DOQI guidelines and maintained controlled serum calcium and phosphorus levels over one year. As a result, the patients who received optimised treatment showed a surprisingly high prevalence of adynamic disease. Our results, which were ranked with the highest degree of evidence by KDIGO experts, contributed to the great difference regarding the target values of PTH in the K/DOQI (2003) and KDIGO (2009) guidelines. We are aware that the finding of such a high percentage of adynamic bone disease in our haemodialysis population, as well as the evidence that some patients with intact PTH values (2nd generation) of 600 pg/ml suffered from adynamic bone disease, have hindered, the new KDIGO objectives to PTH.In our opinion, our results support the suitability and the advantage of using KDIGO criteria instead of KDOQI. This seems to be the right approach when taking into consideration that KDIGO sets objectives to PTH between 2 and 9 times the normal upper limit and does not compromise with the rigid and absolute target values (between 150 and 300 pg/mL) previously defined by KDOQI. In our clinical research, the Portuguese haemodialysis population was characterised in terms of serum clacidiol levels and identified as having vitamin D3 sufficiency, insufficiency or deficiency. It was also recorded the prevalence of severe vitamin D3 insufficiency and even deficiency in a large haemodialysis population, which most likely provides a reliable picture of the rest of the population in IRC Portuguese patients with 5d stage (undergoing dialysis). We described for the first time in aemosialysis patients an association between calcidiol deficiency and the presence of ardiovascular risk factors, (which have been identified on uraemic patients).Our research led us to unique findings by having identified the low levels of 25(OH) vitamin D3 as a likely cardiovascular risk factor in patients undergoing haemodialysis treatment, given that deficiency in this vitamin has been significantly associated not only with a rise in the prevalence of vascular calcifications, but also inflammation, left ventricular hypertrophy, high pulse pressure and high serum BNPBrain natriuretic peptide levels. Finally, based on a prospective assessment of therapeutic intervention, 25(OH)vitamin D3 insufficiency or deficiency was corrected and we were able to demonstrate that this same correction was associated with a reduction in cardiovascular risk factors. This was a forward-looking intervention regarding the supplementation of native vitamin D in haemodialysis patients, since it was the first prospective assessment of the evolution of cardiovascular risk factors. In short, the results of our research, summarised above and presented throughout the various chapters of this thesis, contributed towards a new perspective of the renal osteodystrophy and also to draw the nephrologists’ attention to the bone tissue and to the axis PTH – vitamin D – bone remodelling. This axis appears clearly involved in multiple physiopathological processes, which support the high morbidity and mortality rate, (particularly of cardiovascular causes), observed in uraemic patients.

Osteoclast activity in ankylosing spondylitis patients before and after TNF-blocking therapy

Ankylosing spondylitis (AS) is a chronic inflammatory rheumatic disease of the axial skeleton. The major outcome of this disease is defined by new bone formation, commonly observed in the ligaments of the intervertebral joints, that can lead to the formation of bony spurs, known as syndesmophytes. Previous studies have shown that serum levels of TNF, IL-6 and IL-17 are increased in AS patients and may be implicated in the development of secondary osteoporosis, since these cytokines are able to induce osteoclast (OC) differentiation and, therefore, bone resorption. In this work we aimed to assess the effects of TNF-blocking therapy in the systemic inflammatory environment of AS patients with active disease as well as in OC differentiation and activity. To accomplish this objective, we cultured circulating monocytes from AS patients, before and after therapy, under osteoclastogenic conditions and we performed two functional assays (TRAP staining and resorption pit assay) and analyzed the expression of osteoclast specific genes. We have shown that AS patients with active disease have increased levels of pro-inflammatory cytokines when compared with healthy subjects. We also found that IL-17, TGF-β and osteoprotegerin are decreased after TNF-blocking therapy. Interestingly, we also observed that after TNF-blocking therapy the expression of some genes is favoring osteoclastogenesis and that differentiated OCs have increased resorption activity. These results suggest that in active AS there may be an uncoupling between inflammation and OC activity that is reset by TNF-blocking therapy.