Simon P. Robins
University of Heidelberg
Heidelberg, Germany
The Rowett Research Institute
Aberdeen, Scotland
John P. Bilezikian
College of Physicians and Surgeons,
Columbia University
New York, New York
Address all correspondence and requests for reprints to: Markus J. Seibel, M.D., Department of Medicine, University of Heidelberg, Bergheimerstrasse 58, 69115 Heidelberg, Germany.
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Introduction |
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The relevance of vitamin K deficiency to possible abnormalities in osteocalcin function, by virtue of undercarboxylation, was highlighted by Price et al. (4), who demonstrated that the skeleton was sensitive to deficiency in this vitamin. Clinical studies showed subsequently that vitamin K deficiency, and other factors such as aging, may in fact lead to an impairment in the carboxylation of osteocalcin, resulting in a disproportionate increase in the undercarboxylated form of osteocalcin (ucOC) in the circulation (5, 6). Vitamin K2 levels have been shown by Hodges et al. (7) to be lower in women with osteoporotic fractures than in healthy individuals. Szulc et al. showed that in elderly, institutionalized women followed for 1836 months, increased serum levels of ucOC were predictive of hip fracture (8, 9). These latter results, however, might have been indicative merely of an association between poor nutritional status and hip fracture risk among institutionalized subjects and not necessarily a general biological mechanism that could be relevant to a more representative sampling of the population.
In this issue of The Journal of Clinical Endocrinology and Metabolism, Vergnaud et al. (10) address this important question. In a nested case control study based upon a large population of healthy elderly women from the EPIDOS study of 7598 women, increased serum levels of immunoreactive ucOC, but not of total osteocalcin, were shown to be predictive of hip fracture risk (odds-ratio: 2.0, 95% confidence interval: 1.23.2). Although serum levels of ucOC showed a significant negative correlation with bone mineral density (BMD), adjustment for BMD did not change the odds ratios significantly. Adjustment for a factor related to risk of falling, namely gait speed, also did not change the predictive value of ucOC. Thus, ucOC appears to be an independent predictor of hip fracture risk. When BMD (lowest quartile) and serum ucOC (highest quartile) were considered together, the odds-ratio increased to 5.5 (confidence interval: 2.711.2). It is important to note that the mean baseline levels of both total and undercarboxylated osteocalcin were indistinguishable among the fracture and the control groups.
The article of Vergnaud et al. (10) supports previous investigations that have suggested that measurements of bone markers are useful predictors of fracture risk. Previously published studies have shown that the combined analysis of several markers of bone formation and resorption can predict a major proportion of the variability in bone loss. These studies have included relatively small, preselected study populations (11), but also larger prospective studies such as the European Vertebral Osteoporosis Study (EVOS; 12) and, subsequently, the EPIDOS study (13). Although the data would tend to favor markers of bone resorption over those of bone formation as more useful predictors, further analysis of the EVOS study did reveal that low serum osteocalcin concentrations were associated with increased risk of hip fracture (odds ratio: 3.1; 95% confidence interval: 1.09.2; HA Pols, personal communications). In another prospective study, low serum levels of another bone formation marker, carboxyterminal propeptide of type I collagen, were associated with increased risk of hip fracture (14).
Although measurement of ucOC may be useful in providing an integrated assessment of the factors that are responsible for gamma carboxylation of osteocalcin, such as vitamins K and D, underlying biochemical mechanisms by which ucOC could be associated with impaired bone metabolism are not known. Analyses of osteocalcin in bone samples from a relatively small number of patients with osteoporosis have shown negligible differences in the proportion of undercarboxylated residues compared with bone specimens from healthy controls (15). The lower affinity of the undercarboxylated protein for bone mineral may also serve to diminish its relative importance in influencing bone metabolism. On the other hand, in transgenic mice engineered to be deficient in osteocalcin, bone formation is actually enhanced (16), suggesting an inhibitory function of osteocalcin on osteoblast activity. It is conceivable that ucOC, a direct product of the osteoblast, is more inhibitory on osteoblast function than the posttranslational, carboxylated form. Further studies of the functional properties of carboxylated and noncarboxylated osteocalcin on bone metabolism are clearly needed.
A further important feature of this study lies in the development of a simple, enzyme-linked ELISA assay for ucOC (10). It appears to be superior to the standard but much more cumbersome binding assays with hydroxyapatite or barium sulfate (17, 18). Although determination of the long-term utility of this new assay awaits the results of additional studies, the preliminary results are encouraging. The need for further studies is evident when reviewing the history of assays for the measurement of the fully carboxylated protein. Circulating osteocalcin appears to be heterogenous both in size and in antigenicity, with the intact peptide and a large (143) fragment constituting the major circulating fractions. Some fragments result from susceptibility of osteocalcin to degradation by serum proteases after phlebotomy. In addition, prolonged storage or repeated freeze-thaw cycles result in greatly reduced and often variable assay signals. Measurement of ucOC could conceivably share in these methodological pitfalls. For the undercarboxylated protein, there are additional uncertainties about the affinity of the antibodies for partially carboxylated forms. Clearly, standardization of both the osteocalcin assay and the newer ucOC assays is a high priority.
A future role for assays of bone markers in the clinical assessment of patients at risk for osteoporotic fractures is still not well defined. Clearly, measurement of bone markers does not substitute for bone mass measurement, the latter giving, at this time, the most useful information about fracture risk. Bone markers, however, may well become a complimentary tool because they give information about the dynamics of bone turnover, a feature that is not found in the static measurement of bone mass (19). Already, such assessments are helpful clinically when confirmation of antiresorptive properties of therapeutic agents is sought (3, 20). Beyond this point, however, the measurement of a bone marker like ucOC could yield information more useful than the simple quantification of bone turnover. Such markers may begin to address issues of mechanism. The observations of Vergnaud et al. (10) thus point in the right direction, i.e. the potential usefulness of biochemical markers as reflectors of normal and abnormal mechanisms of bone metabolism. If they provide this information, certain bone markers may become useful adjuncts in the assessment of fracture risk.
Received January 2, 1997.
Accepted January 2, 1997.
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References |
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