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Using opportunistic screening with abdominal CT to identify osteoporosis and osteopenia in patients with diabetes

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Abstract

Summary

Opportunistic osteoporosis screening involves measuring the attenuation of L1 vertebrae on abdominal computed tomography (CT), which correlates with DXA T-score. We found that this approach is useful for detecting low bone mass in patients with diabetes and propose L1 attenuation ≤ 135 Hounsfield units (HU) as a threshold for which DXA should be strongly considered.

Introduction

Attenuation of the L1 vertebrae on computer tomography (CT) images done for other reasons (“Opportunistic Osteoporosis Screening”) has been found to correlate well with DXA-derived T-score. However, the method and the thresholds have never been tested specifically in those with diabetes mellitus (DM), in whom the fracture risk is greater than explained by BMD.

Methods

In a retrospective study of subjects with DM who had both abdominal CT and DXA within 6 months of each other, we compared L1 attenuation and DXA T-score to define the sensitivity and specificity of thresholds previously established in the general population.

Results

There were 313 subjects among whom 18 (5.8%) had prior major osteoporotic fracture (MOF). Subjects with MOF had lower T-scores (− 2.3 ± 1.4 vs. − 0.9 ± 1.4, p < 0.001) and L1 attenuation (104 HU ± 46 vs. 149 HU ± 47, p < 0.001) than non-fracture subjects. L1 attenuation ≤ 160 HU was 91% sensitive for osteoporosis, while ≤ 110 HU was 80% specific. For a higher T-score of ≤ − 1.5, L1 attenuation ≤ 135 HU showed balanced sensitivity and specificity (65% and 69%, respectively).

Conclusion

Opportunistic osteoporosis screening with abdominal CT is useful in determining the need for DXA screening in subjects with diabetes. We propose L1 attenuation ≤ 135 HU as a reasonable threshold for detecting the T-score of ≤ − 1.5, which is likely associated with increased fragility in DM.

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References

  1. Schwartz AV, Sellmeyer DE, Ensrud KE, Cauley JA, Tabor HK, Schreiner PJ, Jamal SA, Black DM, Cummings SR, Study of Osteoporotic Features Research Group (2001) Older women with diabetes have an increased risk of fracture: a prospective study. J Clin Endocrinol Metab 86:32–38

    Article  CAS  Google Scholar 

  2. Strotmeyer ES, Cauley JA, Schwartz AV, Nevitt MC, Resnick HE, Bauer DC, Tylavsky FA, de Rekeneire N, Harris TB, Newman AB (2005) Nontraumatic fracture risk with diabetes mellitus and impaired fasting glucose in older white and black adults: the health, aging, and body composition study. Arch Intern Med 165:1612–1617

    Article  Google Scholar 

  3. Giangregorio LM, Leslie WD, Lix LM, Johansson H, Oden A, McCloskey E, Kanis JA (2012) FRAX underestimates fracture risk in patients with diabetes. J Bone Miner Res 27:301–308

    Article  Google Scholar 

  4. Ferrari SL, Abrahamsen B, Napoli N et al (2018) Diagnosis and management of bone fragility in diabetes: an emerging challenge. Osteoporos Int 29:2585–2596

    Article  CAS  Google Scholar 

  5. American Diabetes Association (2020) Comprehensive, medical evaluation and assessment of comorbidities: standards of medical care in diabetes-2020. Diabetes Care 43:S37

  6. Gillespie CW, Morin PE (2017) Trends and disparities in osteoporosis screening among women in the United States, 2008-2014. Am J Med 130:306–316

    Article  Google Scholar 

  7. Pickhardt PJ, Pooler BD, Lauder T, del Rio AM, Bruce RJ, Binkley N (2013) Opportunistic screening for osteoporosis using abdominal computed tomography scans obtained for other indications. Ann Intern Med 158:588–595

    Article  Google Scholar 

  8. Romme EA, Murchison JT, Phang KF et al (2012) Bone attenuation on routine chest CT correlates with bone mineral density on DXA in patients with COPD. J Bone Miner Res 27:2338–2343

    Article  Google Scholar 

  9. Buckens CF, Dijkhuis G, de Keizer B, Verhaar HJ, de Jong PA (2015) Opportunistic screening for osteoporosis on routine computed tomography? An external validation study. Eur Radiol 25:2074–2079

    Article  Google Scholar 

  10. Alacreu E, Moratal D, Arana E (2017) Opportunistic screening for osteoporosis by routine CT in Southern Europe. Osteoporos Int 28:983–990

    Article  Google Scholar 

  11. Schwartz AV, Vittinghoff E, Bauer DC, Hillier TA, Strotmeyer ES, Ensrud KE, Donaldson MG, Cauley JA, Harris TB, Koster A, Womack CR, Palermo L, Black DM, Study of Osteoporotic Fractures (SOF) Research Group, Osteoporotic Fractures in Men (MrOS) Research Group, Health, Aging, and Body Composition (Health ABC) Research Group (2011) Association of BMD and FRAX score with risk of fracture in older adults with type 2 diabetes. Jama 305:2184–2192

    Article  CAS  Google Scholar 

  12. Leslie WD, Johansson H, McCloskey EV et al (2018) Comparison of methods for improving fracture risk assessment in diabetes: the Manitoba BMD registry. J Bone Miner Res 33:1923–1930

    Article  Google Scholar 

  13. Lee SJ, Binkley N, Lubner MG, Bruce RJ, Ziemlewicz TJ, Pickhardt PJ (2016) Opportunistic screening for osteoporosis using the sagittal reconstruction from routine abdominal CT for combined assessment of vertebral fractures and density. Osteoporos Int 27:1131–1136

    Article  CAS  Google Scholar 

  14. Genant HK, Wu CY, van Kuijk C, Nevitt MC (1993) Vertebral fracture assessment using a semiquantitative technique. J Bone Miner Res 8:1137–1148

    Article  CAS  Google Scholar 

  15. Delmas PD, Genant HK, Crans GG, Stock JL, Wong M, Siris E, Adachi JD (2003) Severity of prevalent vertebral fractures and the risk of subsequent vertebral and nonvertebral fractures: results from the MORE trial. Bone 33:522–532

    Article  CAS  Google Scholar 

  16. Levin A, Stevens PE, Bilous RW et al (2013) Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl 3:1–150

    Article  Google Scholar 

  17. Jain RK, Weiner MG, Zhao H, Williams KJ, Vokes T (2019) Diabetes-related fracture risk is different in African Americans compared with Hispanics and Caucasians. J Clin Endocrinol Metab 104:5729–5736

    Article  Google Scholar 

  18. Graffy PM, Lee SJ, Ziemlewicz TJ, Pickhardt PJ (2017) Prevalence of vertebral compression fractures on routine CT scans according to L1 trabecular attenuation: determining relevant thresholds for opportunistic osteoporosis screening. Am J Roentgenol 209:491–496

    Article  Google Scholar 

  19. Lee SJ, Graffy PM, Zea RD, Ziemlewicz TJ, Pickhardt PJ (2018) Future osteoporotic fracture risk related to lumbar vertebral trabecular attenuation measured at routine body CT. J Bone Miner Res 33:860–867

    Article  CAS  Google Scholar 

  20. Pasco JA, Seeman E, Henry MJ, Merriman EN, Nicholson GC, Kotowicz MA (2006) The population burden of fractures originates in women with osteopenia, not osteoporosis. Osteoporos Int 17:1404–1409

    Article  CAS  Google Scholar 

  21. Cho HJ, Morey V, Kang JY, Kim KW, Kim TK (2015) Prevalence and risk factors of spine, shoulder, hand, hip, and knee osteoarthritis in community-dwelling Koreans older than age 65 years. Clin Orthop Relat Res 473:3307–3314

    Article  Google Scholar 

  22. Yu EW, Thomas BJ, Brown JK, Finkelstein JS (2012) Simulated increases in body fat and errors in bone mineral density measurements by DXA and QCT. J Bone Miner Res 27:119–124

    Article  Google Scholar 

  23. Binkley N, Krueger D, Vallarta-Ast N (2003) An overlying fat panniculus affects femur bone mass measurement. J Clin Densitom 6:199–204

    Article  Google Scholar 

  24. Evans EM, Mojtahedi MC, Kessinger RB, Misic MM (2006) Simulated change in body fatness affects Hologic QDR 4500A whole body and central DXA bone measures. J Clin Densitom 9:315–322

    Article  Google Scholar 

  25. Anderson PA, Polly DW, Binkley NC, Pickhardt PJ (2018) Clinical use of opportunistic computed tomography screening for osteoporosis. JBJS 100:2073–2081

    Article  Google Scholar 

  26. Pickhardt PJ, Lauder T, Pooler BD, Muñoz del Rio A, Rosas H, Bruce RJ, Binkley N (2016) Effect of IV contrast on lumbar trabecular attenuation at routine abdominal CT: correlation with DXA and implications for opportunistic osteoporosis screening. Osteoporos Int 27:147–152

    Article  CAS  Google Scholar 

  27. Pompe E, Willemink MJ, Dijkhuis GR, Verhaar HJJ, Hoesein FAAM, de Jong PA (2015) Intravenous contrast injection significantly affects bone mineral density measured on CT. Eur Radiol 25:283–289

    Article  Google Scholar 

  28. Curry SJ, Krist AH, Owens DK et al (2018) Screening for osteoporosis to prevent fractures: US Preventive Services Task Force recommendation statement. Jama 319:2521–2531

    Article  Google Scholar 

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Authors and Affiliations

  1. Section of Endocrinology, Diabetes, and Metabolism, Lewis Katz School of Medicine at Temple University, 3322 N Broad St, Ste 205, Philadelphia, PA, 19140, USA

    R.K. Jain

  2. Lewis Katz School of Medicine at Temple University, Philadelphia, PA, 19140, USA

    E. Lee

  3. Section of Endocrinology, Diabetes, and Metabolism, Temple University Hospital, Philadelphia, PA, 19140, USA

    C. Mathai & P. Gogineni

  4. Department of Radiology, University of Maryland Medical Center, Baltimore, MD, 21201, USA

    F. Dako

  5. Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, NY, 10038, USA

    M.G. Weiner

  6. Department of Medicine, Section of Endocrinology, Diabetes, and Metabolism, The University of Chicago, Chicago, IL, 60637, USA

    T. Vokes

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  1. R.K. Jain
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Correspondence to R.K. Jain.

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Conflicts of interest

Rajesh K Jain receives research support from the Amgen Foundation.

Eunjae Lee, Christine Mathai, Farouk Dako, Preethi Gogineni, and Mark G Weiner have nothing to disclose.

Tamara Vokes is an investigator, consultant, and speaker for Radius, investigator and consultant for Takeda, and investigator for Ascendis.

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Supplemental Fig. 1

Receiver operating curve for predicting “moderate osteopenia” by bone mineral density using L1 attenuation by CT (PNG 6662 kb)

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Jain, R., Lee, E., Mathai, C. et al. Using opportunistic screening with abdominal CT to identify osteoporosis and osteopenia in patients with diabetes. Osteoporos Int 31, 2189–2196 (2020). https://doi.org/10.1007/s00198-020-05521-x

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  • DOI: https://doi.org/10.1007/s00198-020-05521-x

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