Older age at Initiation of Antiretroviral Therapy Predicts Low Bone Mineral Density in Children with perinatally-infected HIV in Zimbabwe

AbstractBackgroundPerinatally-acquired HIV infection commonly causes stunting in children, but how this affects bone and muscle development is unclear. We investigated differences in bone and muscle mass and muscle function between children with HIV (CWH) and uninfected children.SettingCross-sectional study of CWH (6–16 years) receiving antiretroviral therapy (ART) for >6 months and children in the same age-group testing HIV-negative at primary health clinics in Zimbabwe.MethodsFrom Dual-energy X-ray Absorptiometry (DXA) we calculated total-body less-head (TBLH) Bone Mineral Content (BMC) for lean mass adjusted-for-height (TBLH-BMCLBM) Z-scores, and lumbar spine (LS) Bone Mineral Apparent Density (BMAD) Z-scores.ResultsThe 97 CWH were older (mean age 12.7 vs. 10.0 years) and therefore taller (mean height 142cm vs. 134cm) than those 77 uninfected. However, stunting (height-for-age Z-score≤-2) was more prevalent in CWH (35% vs. 5%, p<0.001). Amongst CWH, 15% had low LS-BMAD (Z-score ≤-2) and 13% had low TBLH-BMCLBM, vs. 1% and 3% respectively in those uninfected (both p≤0.02). After age, sex, height and puberty adjustment, LS-BMAD was 0.33 SDs (95%CI −0.01, 0.67; p=0.06) lower in CWH, with no differences in TBLH-BMCLBM, lean mass or grip strength by HIV status. However, there was a strong relationship between age at ART initiation and both LS-BMAD Z-score (r=-0.33, p=0.001) and TBLH-BMCLBM Z-score (r=-0.23, p=0.027); for each year ART initiation was delayed a 0.13 SD reduction in LS-BMAD was seen.ConclusionSize-adjusted low bone density is common in CWH. Delay in initiating ART adversely affects bone density. Findings support immediate ART initiation at HIV diagnosis.

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Tracking of Bone Mass and Density during Childhood and Adolescence

The Journal of Clinical Endocrinology & Metabolism ◽

10.1210/jc.2009-2319 ◽

2010 ◽

Vol 95 (4) ◽

pp. 1690-1698 ◽

Cited By ~ 73

Author(s):

Heidi J. Kalkwarf ◽

Vicente Gilsanz ◽

Joan M. Lappe ◽

Sharon Oberfield ◽

John A. Shepherd ◽

...

Keyword(s):

Bone Mineral Density ◽

Bone Density ◽

Bone Mineral ◽

Sexual Maturation ◽

Childhood And Adolescence ◽

Z Score ◽

Mineral Density ◽

Growth Status ◽

Low Bone Density ◽

Z Scores

Abstract Context: Whether a child with low bone mineral density (BMD) at one point in time will continue to have low BMD, despite continued growth and maturation, is important clinically. The stability of a characteristic during growth is referred to as “tracking.” Objective: We examined the degree of tracking in bone mineral content (BMC) and BMD during childhood and adolescence and investigated whether tracking varied according to age, sexual maturation, and changes in growth status. Design: We conducted a longitudinal study with measurements at baseline and annually for 3 yr. Setting: The Bone Mineral Density in Childhood Study was conducted at five clinical centers in the United States. Study Participants: A total of 1554 girls and boys, ages 6–16 yr at baseline, participated in the study. Main Outcome Measures: Whole body, spine, hip, and forearm BMC and BMD were measured by dual-energy x-ray absorptiometry, and age-, sex-, and race-specific Z-scores were calculated. Deviation from tracking was calculated as the Z-score at yr 3 minus baseline. Results: Correlations between Z-scores at baseline and yr 3 ranged from 0.76–0.88. Among children with a Z-score below −1.5 at baseline, 72–87% still had a Z-score below −1 after 3 yr. Age, sexual maturation, and deviations in growth status (P < 0.01) were associated with deviation from tracking; however, tracking was strongly evident even after adjusting for the effects of age, maturation, and growth. Conclusions: Bone density showed a high degree of tracking over 3 yr in children and adolescents. Healthy children with low bone density will likely continue to have low bone density unless effective interventions are instituted.

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A Three-Year Longitudinal Study Comparing Bone Mass, Density, and Geometry Measured by DXA, pQCT, and Bone Turnover Markers in Children with PKU Taking L-Amino Acid or Glycomacropeptide Protein Substitutes

Nutrients ◽

10.3390/nu13062075 ◽

2021 ◽

Vol 13 (6) ◽

pp. 2075

Author(s):

Anne Daly ◽

Wolfgang Högler ◽

Nicola Crabtree ◽

Nick Shaw ◽

Sharon Evans ◽

...

Keyword(s):

Amino Acid ◽

Bone Density ◽

Bone Turnover ◽

Bone Mineral ◽

Bone Turnover Markers ◽

Blood Biochemistry ◽

Reference Ranges ◽

Mineral Density ◽

Bone Mineral Apparent Density ◽

Turnover Markers

In patients with phenylketonuria (PKU), treated by diet therapy only, evidence suggests that areal bone mineral density (BMDa) is within the normal clinical reference range but is below the population norm. Aims: To study longitudinal bone density, mass, and geometry over 36 months in children with PKU taking either amino acid (L-AA) or casein glycomacropeptide substitutes (CGMP-AA) as their main protein source. Methodology: A total of 48 subjects completed the study, 19 subjects in the L-AA group (median age 11.1, range 5–6 years) and 29 subjects in the CGMP-AA group (median age 8.3, range 5–16years). The CGMP-AA was further divided into two groups, CGMP100 (median age 9.2, range 5–16years) (n = 13), children taking CGMP-AA only and CGMP50 (median age 7.3, range 5–15years) (n = 16), children taking a combination of CGMP-AA and L-AA. Dual X-ray absorptiometry (DXA) was measured at enrolment and 36 months, peripheral quantitative computer tomography (pQCT) at 36 months only, and serum blood and urine bone turnover markers (BTM) and blood bone biochemistry at enrolment, 6, 12, and 36 months. Results: No statistically significant differences were found between the three groups for DXA outcome parameters, i.e., BMDa (L2–L4 BMDa g/cm2), bone mineral apparent density (L2–L4 BMAD g/cm3) and total body less head BMDa (TBLH g/cm2). All blood biochemistry markers were within the reference ranges, and BTM showed active bone turnover with a trend for BTM to decrease with increasing age. Conclusions: Bone density was clinically normal, although the median z scores were below the population mean. BTM showed active bone turnover and blood biochemistry was within the reference ranges. There appeared to be no advantage to bone density, mass, or geometry from taking a macropeptide-based protein substitute as compared with L-AAs.

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Influence of Mediterranean Diet Adherence and Physical Activity on Bone Health in Celiac Children on a Gluten-Free Diet

Nutrients ◽

10.3390/nu13051636 ◽

2021 ◽

Vol 13 (5) ◽

pp. 1636

Author(s):

Teresa Nestares ◽

Rafael Martín-Masot ◽

Carlos de Teresa ◽

Rocío Bonillo ◽

José Maldonado ◽

...

Keyword(s):

Physical Activity ◽

Mediterranean Diet ◽

Bone Mineral ◽

Lean Mass ◽

Bone Health ◽

Gluten Free ◽

Z Score ◽

Mineral Density ◽

Diet Adherence ◽

Mediterranean Diet Adherence

We aimed to assess the influence of the Mediterranean Diet adherence and physical activity (PA) on body composition, with a particular focus on bone health, in young patients with celiac disease (CD). The CD group (n = 59) included children with CD with a long (>18 months, n = 41) or recent (<18 months, n = 18) adherence to a gluten-free diet (GFD). The non-celiac group (n = 40) included non-celiac children. After adjusting for potential confounders, the CD group showed lower body weight (p = 0.034), lean mass (p = 0.003), bone mineral content (p = 0.006), and bone Z-score (p = 0.036) than non-celiac children, even when the model was further adjusted for adherence to a GFD for at least 18 months. Among CD children, spending greater time in vigorous physical activity was associated with higher lean mass (p = 0.020) and bone mineral density with evidence of statistical significance (p = 0.078) regardless of the time they followed a GFD. In addition, a greater Mediterranean Diet adherence was associated with a higher bone Z-score (p = 0.020). Moreover, lean mass was strongly associated with bone mineral density and independently explained 12% of its variability (p < 0.001). These findings suggest the importance of correctly monitoring lifestyle in children with CD regarding dietary habits and PA levels to improve lean mass and, consequently, bone quality in this population.

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EVALUATION OF GLUTATHIONE-S-TRANSFERASE P1 POLYMORPHISM AND ITS RELATION TO BONE MINERAL DENSITY IN EGYPTIAN CHILDREN AND ADOLESCENTS WITH BETA- THALASSEMIA MAJOR

Mediterranean Journal of Hematology and Infectious Diseases ◽

10.4084/mjhid.2016.004 ◽

2016 ◽

Vol 8 ◽

pp. 2016004 ◽

Cited By ~ 3

Author(s):

Seham Ragab

Keyword(s):

Bone Mineral Density ◽

Bone Mineral ◽

Thalassemia Major ◽

Beta Thalassemia ◽

Z Score ◽

Glutathione S Transferase ◽

Mineral Density ◽

Beta Thalassemia Major ◽

Egyptian Children ◽

Z Scores

Background:Osteoporosis is a major problem in beta thalassemia major (TM) patients. Increased oxidative stress and its controlling genes were linked to osteoporosis. Glutathione S-transferase P1 (GSTP1),Ile105 Val variant is a functional mutation with reduced ant-oxidative property .No data are available about this variant or its association with osteoporosis among thalassemia patients yet. Objectives: The aim of this study was to investigate Ile105Val polymorphism and its possible association with bone mineral density (BMD) values in a group of TM children. Methods:Thirty five TM patients and 30 age and sex matched healthy controls were included. Liver and renal functions, serum ferritin, calcium, phosphorous, alkaline phosphatase and osteocalcin were assayed. BMD was determined by DXA with calculation of Z-scores at lumbar spine (Ls) and femoral neck (Fn).Height for age z- score (HAZ) adjusted BMD Z-scores were considered . GSTP1 Ile105Val polymorphism was studied by polymerase chain reaction-restriction fragment length polymorphism. Results:The relative frequency of 105 Val allele was significantly higher in TM patients than the controls (P<0.0001). Significant association between genotype subgroups and BMD parameters was detected. Mutant homozygotes had significant lower BMD , Z –score and haz -adjusted BMD Z-score at both Ls and Fn compared to wild homozygotes ( Ps =0.029, 0.008, 0.011, 0.001,0.02, 0.001) with significant higher osteocalcin level compared to heterozygotes and wild homozygotes (P=0.012 and P=0.013,respectively). Conclusion: The results indicated that 105Val allele was frequent among TM patients and could increase their susceptibility to osteoporosis. Large sample studies are required to confirm these findings.

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Evaluation of Bone Mineral Density in Children with Sickle Cell Anemia.

Blood ◽

10.1182/blood.v104.11.106.106 ◽

2004 ◽

Vol 104 (11) ◽

pp. 106-106

Author(s):

Ashutosh Lal ◽

Ellen Fung ◽

Bamidele Kammen ◽

Zahra Pakbaz ◽

Nancy Sweeters ◽

...

Keyword(s):

Bone Mineral Density ◽

Lumbar Spine ◽

Sickle Cell ◽

Bone Mineral ◽

Reference Data ◽

Growth Failure ◽

Red Cell ◽

Z Score ◽

Mineral Density ◽

Z Scores

Abstract Background : Reduced bone mineral density (BMD) has been reported in adults and children with sickle cell anemia (SCA). Dual energy x-ray absorptiometry (DXA) is routinely used for measuring BMD because of less radiation exposure and lower cost. However, changes in vertebral body shape, marrow hyperplasia and bone infarction due to SCA may affect the evaluation of BMD with DXA. Hence, we compared DXA with quantitative computerized tomography (QCT), which measures true volumetric density, and may be less influenced by bone changes. Methods : The study enrolled children between 9–19 years of age with SCA, and one or more severe manifestations: >2 hospital admissions/year, growth failure, avascular necrosis, or regular red cell transfusions for sickle cell-related complications. BMD of lumbar spine was determined by performing DXA of lumbar spine (Hologic Delphi-A, Bedford, MA). The apparent volumetric bone mineral density (BMAD) was calculated from bone mineral content, and compared to age, sex and ethnicity-matched reference data. BMD of the lumbar spine was also measured by QCT (Mindways Software, San Francisco, CA), and compared to age and sex-appropriate reference data. Results : The study has enrolled 25 patients (13 females and 12 males), of which 16 were younger than 14 years. In 6 children the height was <10th centile for age. Thirteen patients were on regular transfusions for >6 months, including 10 who had been transfused for >2 years. Calcium intake, assessed by a standardized questionnaire, was less than recommended dietary allowance in 13 patients. The z-score for BMAD determined by DXA was > −1.0 in 8, between −1.0 and −2.0 in 5, and < −2.0 in 12 patients. The z-score for lumbar spine by QCT was > −1.0 in 20, between −1.0 and −2.0 in 1 and < −2.0 in 4 patients. DXA-derived BMD (areal density) and BMAD (apparent volumetric density) z-scores did not differ significantly (p=0.16). On the other hand, the paired values of z-scores by DXA (BMAD) and QCT were significantly different (p=.002). When z-scores were categorized as greater or less than −1.0, the results were concordant in 13 (both DXA and QCT normal in 8, and both DXA and QCT abnormal in 5), and discordant in 12 cases (abnormal DXA with normal QCT in every case). Among patients in discordant group, 9/12 had been on regular red cell transfusions for >6 months, compared to 4/13 with concordant results (p=.047). There was no difference in the serum ferritin values between the two groups (p=.685). No significant difference in the prevalence of low BMAD z-scores was detected between groups based upon age, calcium intake, or growth failure. Five out of the 12 patients with BMAD z-score < −2.0 were not on regular transfusion program. Conclusions : Almost half of the children with SCA had BMD below −2 standard deviations compared to age-matched controls. Low BMD was observed in chronically transfused as well as non-transfused children. In comparison, 16% of the patients were classified as low BMD (z < −2.0) by QCT. The paired DXA/QCT results were discordant in half of the sample, with patients on regular transfusions for >6 months more likely to have normal QCT results. It is likely that the reduction in marrow hyperplasia following initiation of regular transfusions may disproportionately affect the trabecular BMD measured by QCT. Longitudinal evaluation of BMD in patients starting on transfusion program could help to define the effect of transfusions on measures of BMD in SCA.

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CRHR1 Polymorphisms Predict Bone Density in Survivors of Acute Lymphoblastic Leukemia

Journal of Clinical Oncology ◽

10.1200/jco.2007.14.6399 ◽

2008 ◽

Vol 26 (18) ◽

pp. 3031-3037 ◽

Cited By ~ 37

Author(s):

Terreia S. Jones ◽

Sue C. Kaste ◽

Wei Liu ◽

Cheng Cheng ◽

Wenjian Yang ◽

...

Keyword(s):

Acute Lymphoblastic Leukemia ◽

Bone Density ◽

Bone Mineral ◽

Lymphoblastic Leukemia ◽

Quantitative Computed Tomography ◽

Nucleotide Polymorphisms ◽

Mineral Density ◽

Specific Manner ◽

Osteoporosis Risk Factors ◽

Z Scores

Purpose Corticosteroids are a critical component of therapy for acute lymphoblastic leukemia (ALL) but are associated with late effects, such as osteoporosis. Risk factors remain poorly defined. Because CRHR1 polymorphisms have been associated with other corticosteroid effects, our goal was to define whether CRHR1 polymorphisms predict which patients with ALL are likely to develop bone mineral deficits. Patients and Methods The mean bone mineral density z scores of 309 long-term survivors of ALL were determined by quantitative computed tomography of the trabecular lumbar spine. We analyzed whether CRHR1 genotypes, adjusted for sex, ALL treatment regimen, and weight, could predict bone density. Results We found that three single nucleotide polymorphisms (SNPs), all in linkage disequilibrium, were associated with bone density in a sex-specific manner. Bone density was lower in males (P = .001), in nonblack patients (P < .08), in those who were not overweight (P < .001), and in those who received intensive antimetabolites and glucocorticoids (P < .001). After adjustment for these features, the G allele at the rs1876828 SNP was associated with lower z scores (P = .02) in males but tended to have the opposite association in females (P = .09). Conclusion CRHR1 polymorphisms may impact the risk of bone density deficits in patients treated with corticosteroids and antimetabolites in a sex-specific manner.

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OR27-04 Risk Factors For Low Baseline Bone Mineral Density In Gender Diverse Youth

Journal of the Endocrine Society ◽

10.1210/jendso/bvaa046.1296 ◽

2020 ◽

Vol 4 (Supplement_1) ◽

Author(s):

Juanita K Hodax ◽

Charles Brady ◽

Sara A DiVall ◽

Kristen Carlin ◽

Hedieh Khalatbari ◽

...

Keyword(s):

Bone Mineral Density ◽

Vitamin D ◽

Hormone Therapy ◽

Bone Mineral ◽

Calcium Intake ◽

Z Score ◽

Mineral Density ◽

Transgender Youth ◽

Z Scores ◽

Dxa Scans

Abstract Background Sex steroids such as testosterone and estrogen are necessary for accumulation of bone mass. Transgender youth treated with gonadotropin releasing hormone analogues (GnRHa) to block natal puberty for gender-affirming care are at risk of low bone mineral density (BMD). Previous studies indicate that transfemale patients assigned male at birth (AMAB) have low BMD at baseline, during and after GnRHa treatment despite cross hormone treatment. Transmales assigned female at birth (AFAB), however, have normal BMD at baseline that decreases upon GnRHa treatment, with normalization upon cross hormone therapy. The reason(s) for the low baseline BMD in transfemales is unclear. We aimed to assess the baseline characteristics of transgender youth at a single multidisciplinary gender clinic prior to medical intervention and determine factors associated with BMD. Methods This is a retrospective chart review of patients <19 years old evaluated in the gender clinic. Dual-energy x-ray absorptiometry (DXA) scans were obtained prior to initiation of GnRHa or cross-hormone therapy per Endocrine Society guidelines for the treatment of gender dysphoria. We included patients with DXA scans completed prior to initiation of treatment with GnRHa or cross gender hormones and excluded those with concurrent medical diagnoses that may affect bone density. Data collected were bone mineral density (BMD) Z-scores, anthropometric data, vitamin D and calcium levels, and calcium intake. Multivariable linear regression models were used to assess the impact of vitamin D levels, height Z-score, weight Z-score, and BMI Z-score on subtotal body BMD Z-score, adjusted for sex assigned at birth and age. Results Sixty-four patients were included in our analysis. Of these, 73% were AMAB and 27% AFAB. Gender identity was male in 14%, female in 44%, and non-binary in 42%. Average height Z-score was 0.12, weight Z-score 0.27, and BMI Z-score 0.22 (using sex assigned at birth). Subtotal body BMD Z-scores were greater than zero in 11%, between zero and greater than -2 in 59%, and less than or equal to -2 in 30% of tested patients. AMAB patients had lower BMD Z-scores compared to those AFAB (p<0.05 for all Z-scores). There was a positive association with BMI, height, and weight Z-scores and increasing BMD Z-scores after adjusting for sex assigned at birth and age (p<0.05 for all Z-scores). Patients who consumed <2 servings of calcium per day had lower BMD Z-scores (p<0.05 for all Z-scores). Average vitamin D level was 24 ng/ml (+/- 9.5 SD) with no significant association with BMD Z-scores (adjusted for sex assigned at birth). Conclusions Patients AMAB and patients with calcium intake of < 2 servings/day are associated with lower baseline BMD in a cohort of adolescents seen in a multidisciplinary gender clinic. Height, weight, and BMI are associated linearly with BMD Z-score, following patterns previously described in other populations.

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Bone Mineral Density in Transfusion Independent Thalassemia Patients.

Blood ◽

10.1182/blood.v108.11.3353.3353 ◽

2006 ◽

Vol 108 (11) ◽

pp. 3353-3353

Author(s):

Zahra Pakbaz ◽

Zhe Zhang ◽

Ellen Fung ◽

Nancy Sweeters ◽

Sylvia Singer ◽

...

Keyword(s):

Bone Mineral Density ◽

Family History ◽

Bone Mineral ◽

Z Score ◽

Low Bone Mass ◽

Mineral Density ◽

Patients Âgés ◽

Z Scores ◽

History Of ◽

The Mean

Abstract Low bone mineral density (BMD) is commonly seen in regularly transfused thalassemia patients; however, there have been few reports for bone mineral density assessment in transfusion independent thalassemia patients. The present report includes the results of BMD assessments in patients with transfusion independent thalassemia who were referred to the bone density clinic through 2002–2006. BMD was evaluated by dual energy x-ray absorptiometry (DXA, Hologic Delphi A). A convenience sample of 24 patients (Females=15) with transfusion independent thalassemia were measured with a mean age of 22.1 ± 13.8 years. Subjects younger than 10 yrs old (n = 7) underwent scans for Lumbar spine (LS; L1-L4) and whole body (WB), patients ages 10–20 (n = 5) were assessed for LS, WB, and non-dominant hip, and for patients older than 20 (n = 12), LS and hip scans were completed. Z-scores specific for age and gender were generated using Zemel BS et al.(J. Bone Min Res 2004) database. Z-scores less than −2.0 were considered as low bone density. Calcium intake was assessed by a brief food frequency questionnaire. Past medical history, medications, history of fractures, and family history of osteoporosis were obtained by chart review and patient interview. Data is presented as Mean ± SD. T-test was used to assess differences in continuous variables. The mean LS Z-score (n = 24) was −1.5 ± 1.0 and the mean hip Z-score (n = 17) was −0.5 ± 1.1. Mean WB Z-score (n = 10) was −2.0 ± 1.2. There was a significant (p<0.001) difference between spine and hip Z-scores. Overall 46% had a Z-score less than −2.0. Thirty-three percent of patients have spine Z-scores of less than −2.0 and 25% spine Z-scores between −2.0 and −1.0. Average spine Z-score in patients younger than 10 years old (n=7) was −1.6 ± 0.5. In WB scans, 50% of the patients had WB Z-scores worse than −2.0. None of the young patients (5–9 yrs; n = 7) consumed inadequate intake of calcium (< 2/3 of RDA age specific) while 75% of patients ages 10–20 (n = 4) years old consumed inadequate intake of calcium (dietary + supplement). Neither spine nor hip Z-score was related to patients’ gender, age, and calcium intake. Two patients reported fractures in the past and two reported family history of osteoporosis. Six patients had delayed puberty and one has hypogonadism. Seven patients have short stature. This data suggests that low bone mass is not only a problem in transfused thalassemia patients, but is also observed in non-transfused patients. The significance and pathophysiology of low bone mass should be studied further in non-transfused patient population, especially in younger children.

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Effect of suppression of puberty and cross-sex hormone therapy on bone turnover markers and BMAD in transgender adolescents

Problems of Endocrinology ◽

10.14341/probl201662522-23 ◽

2016 ◽

Vol 62 (5) ◽

pp. 22-23

Author(s):

Mariska Caroline Vlot ◽

Daniel T. Klink ◽

Martin Den Heijer ◽

Marinus A. Blankenstein ◽

Joost Rotteveel ◽

...

Keyword(s):

Bone Turnover ◽

Hormone Therapy ◽

Bone Mineral ◽

Bone Turnover Markers ◽

Sex Hormone ◽

Added Value ◽

Mineral Density ◽

Bone Mineral Apparent Density ◽

Z Scores ◽

Turnover Markers

Background: Puberty is highly important for the accumulation of bone mass. Bone turnover and bone mineral density can be affected in transgender adolescents when puberty is suppressed by gonadotropin-releasing hormone analogues (GnRHa), followed by treatment with cross-sex hormone therapy (CSHT).Objective: To investigate the effect of GnRHa and CSHT on bone turnover markers (BTMs) and bone mineral apparent density (BMAD) in transgender adolescents.Methods: Thirty four female-to-males (FtMs) and 22 male-to-females (MtFs) were divided into a young and old pubertal group, based on the bone age of 14 years in the FtMs and 15 years in the MtFs. All patients received GnRHa triptorelin. CSHT was prescribed in incremental doses from the age of 16 years. FtMs received testosterone ester mixture and MtFs were treated with 17-β estradiol. BTMs P1NP, osteocalcin and ICTP and the BMD of lumbar spine (LS) and femoral neck (FN) were measured at three time points. Furthermore, BMAD and Z-scores were calculated.Results: P1NP and 1CTP decreased during GnRHa treatment, indicating decreased bone turnover. Osteocalcin showed an aberrant pattern. A low BMAD Z-score of both FN and LS was observed in the MtFs at start of GnRHa treatment. The decrease in bone turnover upon GnRHa treatment was accompanied by an unchanged BMAD of both FN and LS, however BMAD Z-scores of predominantly the LS decreased. Twenty-four months after CSHT the BTMs P1NP and ICTP were even more decreased. During CSHT BMAD Z-scores increased and returned towards normal, especially of the LS.Conclusion: Suppressing puberty by GnRHa leads to a decrease of BTMs in transgender adolescents. The increase of BMAD and BMAD Z-scores predominantly in the LS as a result of treatment with CSHT is accompanied by decreasing BTM concentrations after 24 months of CSHT. Therefore, the added value of evaluating BTMs seems to be limited and DEXA-scans remain important in follow-up of transgender adolescents.

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