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Final Version BONE AND PHOSPHATE IN RELATION TO HEALTH, SURVIVAL AND GENETIC FACTORS natalia campos obando Cover: Yuliana Cruz Zuñiga Lay-out: Marta Aguilar Díaz ISBN: 978-9968-48-518-9 Bone and phosphate in relation to health, survival and genetic factors Bot en fosfaat in relatie tot gezondheid, overleving en genetische factoren Proefschrift ter verkrijging van de graad van doctor aan de Erasmus Universiteit Rotterdam op gezag van der Rector Magnificus Prof. Dr. R.C.M.E. Engels en volgens het besluit van het College voor Promoties. De openbare verdediging zal plaatsvinden op donderdag 28 mei 2020 om 15:30 uur door natalia campos obando geboren te SAN JOSE, Costa Rica A DIOS, Origen de todo bien y Fuente insondable de Misericordia A la Inmaculada Virgen del Carmen y al Patriarca San José, por su generoso Auxilio y Protección en todo momento A mis padres, por su amor y apoyo incondicional y por estar a mi lado siempre To my Promotors, Prof. Dr. MC Zillikens & Prof. Dr. AG Uitterlinden, for allowing me to become part of your wonderful group and for all your teachings A mis queridos pacientes, por sus muestras de apoyo y sus Oraciones. Ustedes son la razón de ser de nosotros los médicos. PROMOTIECOMISSIE Promotoren: Prof. Dr. M.C. Zillikens Prof. Dr. A.G. Uitterlinden Overige leden: Prof. Dr. Ewout Hoorn Prof. Dr. Paul Lips Prof. Dr. Bruno Stricker CONTENTS Propositions of this thesis Chapter 1. Introduction of this thesis 1 PART I. Bone traits and phosphate in relation to health & survival Chapter 2. Bone mineral density and chronic lung disease mortality: 31 the Rotterdam Study Chapter 3. Bone health and coronary artery calcification: 57 the Rotterdam Study Chapter 4. Serum phosphate is associated with fracture risk: 83 the Rotterdam Study and MrOS Chapter 5. Serum phosphate levels are related to all-cause, 127 cardiovascular and COPD mortality in men Chapter 6. Genetic evidence for a causal role of serum phosphate in 165 coronary artery calcification: the Rotterdam Study PART II. Sex differences in calcium and phosphate levels Chapter 7. Influence of sex hormones on sexual dimorphism in calcium 213 and phosphate homeostasis Chapter 8. Age-dependent sex differences in calcium and phosphate 249 homeostasis PART III. Genetic studies in relation to bone and phosphate Chapter 9. PLS3 mutations in X-linked osteoporosis with fractures 275 Chapter 10. Osteoporotic vertebral fractures during pregnancy: 299 be aware of a potential underlying genetic cause Chapter 11. Genome-wide association study of human serum phosphate 317 levels: a large Biobanks approach Chapter 12. General discussion 381 Chapter 13. Summary / Samenvatting 441 Chapter 14. Acknowledgements / Publications 461 PROPOSITIONS OF THIS THESIS Bone and phosphate in relation to health, survival and genetic factors 1. The relation between low bone mineral density and increased mortality in men is in part explained by higher mortality from chronic obstructive pulmonary disease. [Looker, 2014 & this thesis] 2. Bone mineral density of the femoral neck, composed predominantly of cortical bone, is not causally related to arterial calcification. [Schulz et al, 2004; Chow et al, 2008 & this thesis] 3. Increased serum phosphate levels within the normal range are causally related to coronary artery calcification in the general population, and, as such, must be considered a cardiovascular risk factor. [Dhingra, 2007 & this thesis] 4. The associations we found between low bone mineral density and increased yet normal phosphate levels with decreased survival, lung emphysema, and coronary artery calcification (P), strongly resemble the premature ageing syndrome described in Fgf23-/- and kl/kl mouse phenocopies. [Kuro-o et al, 1997; Shimada et al, 2004 & this thesis] 5. Regardless of kidney function, increased phosphate levels are related to fracture risk in men, especially at trabecular-enriched bones (such as vertebral bodies and wrist); this finding is partly attributable to a predominant synthesis of FGF23 at trabecular osteocytes. [Pereira et al, 2009; Delgado-Calle et al, 2011 & this thesis] 6. In pregnancy and lactation associated osteoporosis, a persistent low bone mineral density should trigger investigation for secondary causes for osteoporosis, including potential underlying genetic factors. [this thesis] 7. Bone metabolism plays an important role in the anti-ageing FGF23/Klotho axis, as indicated by osteocytes being the main source of FGF23, Klotho being expressed also in osteocytes, and our findings of low bone mineral density being related to decreased survival. [Riminucci et al, 2003; Komaba et al, 2017; Kuro-o, 2018 & this thesis] 8. Additional evidence to support that bone metabolism plays an important role in ageing and survival is indicated by the findings of nitrogenated bisphosphonates being related to decreased mortality -mediated through a reduction in bone loss and independent of fracture prevention. [Reid et al, 2020 & Bliuc et al, 2019] 9. The sex difference in the association of serum phosphate with several clinical cardiovascular outcomes is not explained by sex dimorphism in its genetic factors. [Felsenfeld et al, 1999; Calvo et al, 1988; Kemi et al, 2006 & this thesis] 10. Entropy-based methods (ε) are required to disentangle the strong linkage disequilibrium of the Major Histocompatibility Complex (6p21.3) to identify causal variants in genetic association studies (such as in the GWAS of serum phosphate). [Nothnagel et al, 2002; Hirata et al, 2019 & this thesis] 11. Very early-on global collaboration and sharing of clinical, epidemiological, and genetic data in local infectious disease outbreaks, can limit societal and economic consequences for all countries in potential pan-epidemic outbreaks. PROPOSICIONES DE ESTA TESIS Hueso y fosfato en relación con salud, supervivencia y factores genéticos 1. La relación entre baja densidad mineral ósea y aumento en la mortalidad en los hombres se explica parcialmente por una mayor mortalidad por enfermedad pulmonar obstructiva crónica. [Looker, 2014 & esta tesis] 2. La densidad mineral ósea del cuello femoral, compuesta predominantemente de hueso cortical, no está causalmente relacionada con calcificación arterial. [Schulz y otros, 2004; Chow et al, 2008 & esta tesis] 3. El nivel elevado de fosfato sérico - aún dentro del rango normal - está causalmente relacionado con calcificación de las arterias coronarias en la población general, y como tal, debe ser considerado un factor de riesgo cardiovascular. [Dhingra, 2007 & esta tesis] 4. Las asociaciones que encontramos entre baja densidad mineral ósea y aumento en los niveles normales de fosfato - aún dentro del rango normal - con disminución de la supervivencia, enfisema pulmonar y calcificación de las arterias coronarias (P), se asemejan fuertemente al síndrome de envejecimiento prematuro descrito en fenocopias de ratones Fgf23-/- y kl/ kl. [Kuro-o et al, 1997; Shimada et al, 2004 & esta tesis] 5. Independientemente de la función renal, el aumento en los niveles de fosfato está asociado con riesgo de fractura en los hombres, especialmente en los huesos enriquecidos en componente trabecular (como los cuerpos vertebrales y el radio distal); este hallazgo es parcialmente atribuible a una síntesis predominante de FGF23 en los osteocitos trabeculares. [Pereira et al, 2009; Delgado-Calle et al, 2011 & esta tesis] 6. En la osteoporosis asociada a embarazo y lactancia, la persistencia de una densidad mineral ósea disminuida debe desencadenar la investigación de factores secundarios de osteoporosis, incluyendo potenciales factores genéticos subyacentes. [esta tesis] 7. El metabolismo óseo desempeña un papel importante en el eje anti- envejecimiento FGF23/Klotho, indicado por los siguientes hallazgos: los osteocitos son la fuente principal de FGF23, la expresión de Klotho también ocurre en osteocitos, y nuestros hallazgos de baja densidad mineral ósea asociados con disminución en la supervivencia. [Riminucci et al, 2003; Komaba et al, 2017; Kuro-o, 2018 & esta tesis] 8. La evidencia adicional para apoyar que el metabolismo óseo tiene un papel importante en el envejecimiento y la supervivencia está basada en el hallazgo que los bifosfonatos nitrogenados están relacionados con disminución de la mortalidad - mediada por una reducción en la pérdida ósea e independientemente de la prevención de fracturas. [Reid et al, 2020 y Bliuc et al, 2019] 9. La diferencia por sexo en la asociación de fosfato sérico con diversos resultados cardiovasculares clínicos no se explica por dimorfismo sexual en los factores genéticos del fosfato. [Felsenfeld et al, 1999; Calvo et al, 1988; Kemi et al, 2006 & esta tesis] 10. Se requieren métodos basados ​​en entropía (ε) para dilucidar el fuerte desequilibrio de ligamiento del Complejo Mayor de Histocompatibilidad (6p21.3) y así poder identificar las variantes causales en los estudios de asociación genética (como en el GWAS de fosfato sérico). [Nothnagel y et al, 2002; Hirata et al, 2019 & esta tesis] 11. La implementación de colaboración temprana a nivel global y el intercambio de datos clínicos, epidemiológicos y genéticos durante los brotes locales de enfermedades infecciosas, pueden limitar las consecuencias sociales y económicas para todos los países en potenciales brotes de pandemias. Some abbreviations implemented in this thesis: BMD: bone mineral density LS: lumbar spine P: serum phosphate levels CAC: coronary artery calcification FN: femoral neck COPD: chronic obstructive pulmonary disease HR: hazard ratio CVD: cardiovascular disease RS: Rotterdam Study
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