
==== Front
Medicine (Baltimore)
Medicine (Baltimore)
MD
Medicine
0025-7974
1536-5964
Lippincott Williams & Wilkins Hagerstown, MD

MD-D-24-02810
00021
10.1097/MD.0000000000039642
3
3400
Research Article
Systematic Review and Meta-Analysis
Effect of denosumab, an anti-osteoporosis drug, on vascular calcification: A meta-analysis
Wang Di MM Wangdidr@163.com
abc
Liu Tongqiang MM LiuTQiang@163.com
c
Lu Jingkui MM lujingkui@163.com
ab
https://orcid.org/0009-0001-6591-292X
Xu Wei MM abd*
a Department of Nephrology, The Wujin Clinical College of Xuzhou Medical University, Changzhou, Jiangsu Province, China
b Jiangsu Key Laboratory of New Drug Research and Clinical Pharmacy, Xuzhou Medical University, Xuzhou, Jiangsu Province, China
c Department of Nephrology, The Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, Jiangsu Province, China
d Department of Nephrology, People’s Hospital of Hainan Tibetan Autonomous Prefecture, Hainan Tibetan Autonomous Prefecture, Qinghai Province, China.
* Correspondence: Wei Xu, Department of Nephrology, The Wujin Clinical College of Xuzhou Medical University, Changzhou, Jiangsu Province 213000, China; Jiangsu Key Laboratory of New Drug Research and Clinical Pharmacy, Xuzhou Medical University, Xuzhou, Jiangsu Province 221004, China; Department of Nephrology, People’s Hospital of Hainan Tibetan Autonomous Prefecture, Hainan Tibetan Autonomous Prefecture, Qinghai Province 813099, China (e-mail: xuwei@wjrmyy.com).
13 9 2024
13 9 2024
103 37 e3964216 3 2024
16 8 2024
20 8 2024
Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.
2024
https://creativecommons.org/licenses/by-nc/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially without permission from the journal.

Background:

Denosumab is an effective drug for the treatment of osteoporosis. This meta-analysis was conducted to evaluate efficacy of denosumab on the treatment of vascular calcification (VC).

Methods:

Databases including PubMed, EMbase, the Cochrane Library, CNKI, Wanfang database were searched from the inception to January 10th, 2024. Eligible studies comparing denosumab versus no denosumab treatment on VC were included. Data were analyzed using Review Manager Version 5.3.

Results:

Five studies were included in this meta-analysis. Three were RCTs and 2 were non-randomized studies. As a whole, 961 patients were included in denosumab group and 890 patients were included in no denosumab group. The follow-up period was from 6 to 36 months. Compared with the no denosumab group, the denosumab group demonstrated a decrease on VC score or area in all enrolled patients (SMD −0.85, 95% CI −1.72–0.02, P = .05). In the subgroup of patients with non-CKD, there was no statistical difference between the denosumab and no denosumab group concerning the change of VC score (SMD −0.00, 95% CI −0.12–0.12, P = .98). In the subgroup of patients with CKD 3b-4, there was no significant difference between the denosumab and no denosumab group concerning the change of VC score (SMD 0.14, 95% CI −0.72–1.00, P = .75). In the subgroup of CKD patients undergoing dialysis, the denosumab group demonstrated a significant decrease on VC score or area compared with the no denosumab group (SMD −2.30, 95% CI −3.78–0.82, P = .002).

Conclusion:

Our meta-analysis revealed that denosumab did not show a very definite inhibitory effect on VC. However, denosumab showed the effective effect on inhibiting VC in CKD patients undergoing dialysis. More large RCTs are needed to verify these results.

chronic kidney disease
denosumab
meta-analysis
vascular calcification
Open Research Project of Key Laboratories in Jiangsu Province UniversitiesNo.XZSYSKF2023022 Wei XuYoung Talent Development Plan of Changzhou Health CommissionNo.CZQM2021026) Wei XuGuiding planning Project of Qinghai Health Commission- Wei XuOPEN-ACCESSTRUE
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pmc 1. Introduction

Vascular calcification (VC) is closely related to reduced vascular compliance and can lead to plaque rupture and thrombosis, which is an important risk factor for cardiovascular disease and mortality.[1] At present, there is no effective treatment for VC. Thus, it is important to research the mechanism of VC and find the drugs to inhibit VC.

Recently, epidemiological and clinical studies showed that patients with low bone density were at increased risk of VC.[2,3] Some studies also showed that the drugs that were effective for osteoporosis might be effective for VC.[4,5] Denosumab is a new and effective drug for the treatment of osteoporosis, which is a monoclonal antibody for receptor activator of nuclear factor-kappa B ligand (RANKL), impedes osteoclast formation by binding to RANKL and preventing the interaction between receptor activator of nuclear factor-kappa B (RANK) and RANKL, reduces bone resorption in osteoporosis.[6,7] At present, denosumab has been researched for the VC treatment. However, it is uncertain about the efficacy of denosumab on the VC. Thus, we conducted a meta-analysis based on the previous researches to evaluate efficacy of denosumab on the VC treatment.

2. Materials and methods

Our meta-analysis was reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (registration number: CRD42024519798). Ethical approval was not necessary because our meta-analysis is a statistical analysis based on previous literature.

2.1. Search strategy

We searched PubMed, EMbase, the Cochrane Library, CNKI (China National Knowledge Infrastructure), Wanfang database from the inception to January 10th, 2024. The combined text and MeSH terms included (“denosumab”) and (“vascular calcification” or “vascular calcinosis”). In addition, the relevant references and cited papers were searched manually to identify additional studies meeting the inclusion criteria. There was no language restrictions.

2.2. Inclusion and exclusion criteria

The inclusion criteria were randomized controlled trials (RCTs) and observational studies, the study that compared denosumab versus no denosumab treatment in patients with VC, outcomes included VC score or area evaluated by X-ray or CT. The denosumab treatment group was treated with denosumab 60 mg subcutaneously every 6 months.

Exclusion criteria were case series, comments, reviews, no control group, study duration < 6 months, lack of relevant outcomes data.

2.3. Data extraction and quality assessment

Data were extracted independently by 2 investigators using standard data extraction forms. In the case of disagreement, a third investigator was consulted. We extracted characteristics including first author, year of publication, location, study design, population, follow-up period, sample size, mean age, sex, estimated glomerular filtration rate, calcium, phosphate, intact parathyroid hormone, treatment outcomes. The Cochrane assessment tool was used to assess the quality of RCTs,[8] whereas the Newcastle–Ottawa scale was used to assess non-randomized studies.[9]

2.4. Statistical analysis

This meta-analysis was performed using Review Manager Version 5.3 (Cochrane Collaboration). We summarized treatment outcomes as weighted mean differences for continuous variables with 95% confidence intervals (CIs). P ≦ .05 was considered statistically significant. We used the I2 statistic to assess heterogeneity among studies. We considered I2 > 50% and P < .10 to indicate significant heterogeneity. Meta-analysis with insignificant heterogeneity were performed using the fixed-effects model. For meta-analyses with significant heterogeneity, the random-effects model was used. Publication bias was assessed using subgroup analysis.

3. Results

3.1. Study selection and characteristics

A flow diagram of literature search is shown in Figure 1. Finally, a total of five studies were included in this meta-analysis.[10–14] Of the 5 studies, three were RCTs and 2 were non-randomized studies. As a whole, 961 patients were included in denosumab group and 890 patients were included in no denosumab group. The follow-up period was from 6 to 36 months. The risk of bias in included RCTs were moderate. The non-randomized studies achieved scores of ≥ 6 points, which were considered to be of high quality. The baseline characteristics of the included studies are listed in Table 1. The Cochrane assessments are listed in Table 2 and the Newcastle–Ottawa scale assessments are listed in Table 3.

Table 1 Characteristics of the included studies.

Study (yr)	Country	Design	Follow-up period	Population	Sample size	Mean age (yr)	Male (n, %)	eGFR (mL/min)	Calcium (mg/dL)	Phosphate (mg/dL)	iPTH (pg/mL)	25 (OH) vitamin D (ng/mL)	Outcome evaluated	
Elizabeth (2013)	USA	RCT	3 yr	Postmenopausal women with osteoporosis	Denosumab 843
Control 782	74 ± 5
74 ± 5	0 (0)
0 (0)	64 ± 20
64 ± 19	–	–	–	–	AAC score by X-ray	
 Chen (2020)	Taiwan	Prospective study	6 mo	Patients undergoing dialysis with severe hyperparathyroidism and low bone mass	Denosumab 21
Control 21	62.14 ± 2.50 54.76 ± 2.00	3 (14)
9 (43)	–	9.96 ± 0.20
9.73 ± 0.20	5.50 ± 0.32
5.69 ± 0.21	1310.50 ± 108.40
1044.74 ± 61.24	27.01 ± 2.29
25.16 ± 2.54	CAC score by CT	
  Jin (2024)	Korea	RCT	1 yr	Postmenopausal women aged > 50 years with osteoporosis and CKD 3b–4	Denosumab 20
Control 7	73.7 ± 8.2
80.3 ± 4.2	0 (0)
0 (0)	30.1 ± 12.3
30.7 ± 10.6	9.3 ± 0.5
9.4 ± 0.5	4.01 ± 0.77
4.16 ± 0.46	107.0 ± 71.4
114.8 ± 116.1	27.01 ± 2.29
25.16 ± 2.54	CAC score by CT	
 Tania (2021)	United Kingdom	RCT	2 yr	Patients with calcific aortic stenosis	Denosumab 49
Control 50	72 ± 8
72 ± 7	38 (77)
40 (80)	–	–	–	–	–	Aortic valve calcium score by CT	
 Shunji (2020)	Japan	Retrospective study	30 mo	Adults undergoing hemodialysis for >8 yr	Denosumab 28
Control 0	65.9 ± 13.3
68.1 ± 11.6	21 (75)
23 (77)	–	8.9 ± 1.1
8.9 ± 1.0	6.6 ± 1.8
5.9 ± 1.8	230 ± 180
260 ± 365	–	Aortic arch calcification area by X-ray	
AAC = abdominal aortic calcification, CAC = coronary artery calcification, CKD = chronic kidney disease, Control = no treatment of denosumab, eGFR = estimated glomerular filtration rate, iPTH = intact parathyroid hormone.

Table 2 Quality assessment of randomized control trial.

Study	Random sequence generation	Allocation concealment	Blinding of participants and personnel	Incomplete outcome data	Selective reporting	Other bias	
Elizabeth (2013)	?	+	?	+	+	?	
  Jin (2024)	?	+	?	+	+	?	
 Tania (2021)	?	+	+	+	+	?	
The randomized control trial was evaluated using the Cochrane assessment tool. +, low risk of bias; ?, unclear risk of bias.

Table 3 Quality assessment of non-randomized control trial.

Studies	Selection	Comparability	Outcome	Score	
Chen (2020)	★★★★	★	★★	7	
Shunji (2020)	★★★	★	★★★	7	
The Cohort studies were evaluated using the Newcastle–Ottawa scale, which are comprised of the study of selection (representativeness of the exposed group, representativeness of the non-exposed group, ascertainment of exposure, demonstration that outcome of interest was not present at start of study), group comparability (controls for the most important factor, controls for any additional factor), outcome measures (assessment of outcome, was follow-up long enough for outcomes to occur, adequacy of follow up of cohorts), a total of 9 points. ★, 1 point.

Figure 1. Flow diagram of the literature search.

3.2. Meta-analysis results of VC progression

Five studies reported the data about the change of VC score or area in all enrolled patients between the denosumab and no denosumab group. Compared with the no denosumab group, the denosumab group demonstrated a decrease on VC score or area (SMD −0.85, 95% CI −1.72–0.02, P = .05; Fig. 2).

Figure 2. Forest plots comparing the change in VC score or area in all included patients between the denosumab and no denosumab group. CI = confidence interval, CKD = chronic kidney disease, SD = standard deviation, VC = vascular calcification.

3.3. Sensitivity analyses and subgroup analysis

Sensitivity analyses were used to judge the dependability of the result concerning the change of VC score or area. We deleted one of all studies at a time. When we deleted the study of Jin (2024), the denosumab group demonstrated a decrease on VC score or area compared with the no denosumab group. When we deleted one of the 4 other studies at a time, there were all no statistical difference between the 2 groups concerning the change of VC score or area.

Subgroup analysis concerning the change of VC score or area was performed according to patient population with chronic kidney disease (CKD) or non-CKD. In the subgroup of patients with non-CKD, there was no statistical difference between the denosumab and no denosumab group concerning the change of VC score (SMD −0.00, 95% CI −0.12–0.12, P = .98; Fig. 3). In the subgroup of patients with CKD 3b-4, there was no significant difference between the denosumab and no denosumab group concerning the change of VC score (SMD 0.14, 95% CI −0.72–1.00, P = .75; Fig. 3). In the subgroup of CKD patients undergoing dialysis, the denosumab group demonstrated a significant decrease on VC score or area compared with the no denosumab group (SMD −2.30, 95% CI −3.78–0.82, P = .002; Fig. 3).

Figure 3. Subgroup analysis according patient population comparing the change in VC score or area between the denosumab and no denosumab group. CI = confidence interval, CKD = chronic kidney disease, SD = standard deviation, VC = vascular calcification.

4. Discussion

Denosumab is an effective drug for the treatment of osteoporosis. Our meta-analysis was conducted to evaluate efficacy of denosumab on the treatment of VC. As a whole, denosumab therapy demonstrated a decrease on VC score or area compared with no denosumab therapy, but the significance of this difference needs to be further verified because the P value was just .05. Thus, we performed subgroup analysis. In patients with non-CKD or CKD 3b-4, denosumab still did not show the effective effect on inhibiting VC. However, in CKD patients undergoing dialysis, denosumab showed the effective effect on inhibiting VC.

The differentiation of vascular smooth muscle cells (VSMCs) into osteoblast-like cells is considered to play a key role in the progression of VC.[15,16] Various factors, such as phosphate, soluble Kloth and fibroblast growth factor 23 were presumed to start the osteoblast-like differentiation of VSMCs. Recently, some studies showed that RANKL promotes VSMCs osteoblast-like differentiation and VC via RANKL/RANK signaling pathway.[17,18] In addition, RANKL also promotes osteoporosis.[19] Therefore, in theory, denosumab may have an effective effect on both osteoporosis and VC.

In the included studies of our meta-analysis, denosumab had an effective effect on osteoporosis, but it only showed have an effective effect on inhibiting VC in CKD patients undergoing dialysis. The possible reasons are as follows. The prevalence of systemic inflammatory response increases with the progression of CKD stage.[20,21] Dialysis treatment fails to adequately remove inflammatory factor, meanwhile dialysis itself may promote inflammation due to vascular access, limited biocompatibility of the membranes and surfaces, solutions or catheters with either live microorganisms or with microbial components.[22] Inflammation induces increased expression of RANKL,[23] which promote VC. Thus, CKD patients undergoing dialysis may benefit more from denosumab on the treatment of VC because denosumab has the inhibitory effect on RANKL. However, in the include study of JIN, denosumab did not inhibit VC in patients with CKD 3b-4. The reasons JIN explained were that 1 year might be too short to observe the effect and the degree of VC was less severe, less progressive. In addition, for non-CKD patients in our meta-analysis, the mechanism of VC might be more dependent on aging or other pathway than on the RANKL/RANK pathway.[14]

There was a limitation in our meta-analysis. At present, denosumab is primarily used to treat osteoporosis. There are few studies focusing on the effect of denosumab on inhibiting VC, so the number of studies included in our meta-analysis was still small. We still need more clinical trials to strengthen the verification of conclusions.

5. Conclusions

Our meta-analysis revealed that denosumab, an anti-osteoporosis drug, did not demonstrate a very definite inhibitory effect on VC. However, denosumab showed the effective effect on inhibiting VC in CKD patients undergoing dialysis. More large RCTs are needed to verify these results.

Author contributions

Conceptualization: Di Wang, Wei Xu.

Data curation: Di Wang, Tongqiang Liu, Wei Xu.

Investigation: Tongqiang Liu, Jingkui Lu.

Methodology: Di Wang, Wei Xu.

Supervision: Wei Xu.

Writing – original draft: Di Wang, Wei Xu.

Writing – review & editing: Di Wang, Wei Xu

Abbreviations:

CIs confidence intervals

CKD chronic kidney disease

CNKI China National Knowledge Infrastructure

RANK receptor activator of nuclear factor-kappa B

RANKL receptor activator of nuclear factor-kappa B Ligand

RCTs randomized controlled trials

VC vascular calcification

VSMCs vascular smooth muscle cells

The research was supported by the Open Research Project of Key Laboratories in Jiangsu Province Universities (No. XZSYSKF2023022), the Young Talent Development Plan of Changzhou Health Commission (No. CZQM2021026) and the Guiding planning Project of Qinghai Health Commission.

The authors have no conflicts of interest to disclose.

All data generated or analyzed during this study are included in this published article [and its supplementary information files].

How to cite this article: Wang D, Liu T, Lu J, Xu W. Effect of denosumab, an anti-osteoporosis drug, on vascular calcification: A meta-analysis. Medicine 2024;103:37(e39642).
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References

[1] Li M Wang ZW Fang LJ Cheng S-Q Wang X Liu N-F . Programmed cell death in atherosclerosis and vascular calcification. Cell Death Dis. 2022;13 :467.35585052
[2] Danilevicius CF Lopes JB Pereira RM . Bone metabolism and vascular calcification. Braz J Med Biol Res. 2007;40 :435–42.17401486
[3] von der Recke P Hansen MA Hassager C . The association between low bone mass at the menopause and cardiovascular mortality. Am J Med. 1999;106 :273–8.10190374
[4] Esposito K Capuano A Sportiello L Giustina A Giugliano D . Should we abandon statins in the prevention of bone fractures? Endocrine. 2013;44 :326–33.23526261
[5] Santos LL Cavalcanti TB Bandeira FA . Vascular effects of bisphosphonates-a systematic review. Clin Med Insights Endocrinol Diabetes. 2012;5 :47–54.23133318
[6] Cummings SR San Martin J McClung MR . FREEDOM Trial. Denosumab for prevention of fractures in postmenopausal women with osteoporosis. N Engl J Med. 2009;361 :756–65.19671655
[7] Ayers C Kansagara D Lazur B Fu R Kwon A Harrod C . Effectiveness and safety of treatments to prevent fractures in people with low bone mass or primary osteoporosis: a living systematic review and network meta-analysis for the American College of Physicians. Ann Intern Med. 2023;176 :182–95.36592455
[8] Furlan AD Malmivaara A Chou R . Editorial Board of the Cochrane Back, Neck Group. Updated method guideline for systematic reviews in the cochrane back and neck group. Spine. 20152015;40 :1660–73.
[9] Stang A . Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol. 2010;25 :603–5.20652370
[10] Samelson EJ Miller PD Christiansen C . RANKL inhibition with denosumab does not influence 3-year progression of aortic calcification or incidence of adverse cardiovascular events in postmenopausal women with osteoporosis and high cardiovascular risk. J Bone Miner Res. 2014;29 :450–7.23873632
[11] Chen CL Chen NC Wu FZ Wu M-T . Impact of denosumab on cardiovascular calcification in patients with secondary hyperparathyroidism undergoing dialysis: a pilot study. Osteoporos Int. 2020;31 :1507–16.32246167
[12] Kim JT Kim YM Jung KY . Efficacy and safety of denosumab treatment for Korean patients with stage 3b-4 chronic kidney disease and osteoporosis. Korean J Intern Med. 2024;39 :148–59.38145616
[13] Pawade TA Doris MK Bing R . Effect of denosumab or alendronic acid on the progression of aortic stenosis: a double-blind randomized controlled trial. Circulation. 2021;143 :2418–27.33913339
[14] Suzuki S Suzuki M Hanafusa N Tsuchiya K Nitta K . Denosumab recovers aortic arch calcification during long-term hemodialysis. Kidney Int Rep. 2020;6 :605–12.33732975
[15] Durham AL Speer MY Scatena M Giachelli CM Shanahan CM . Role of smooth muscle cells in vascular calcification: implications in atherosclerosis and arterial stiffness. Cardiovasc Res. 2018;114 :590–600.29514202
[16] Jaminon A Reesink K Kroon A Schurgers L . The role of vascular smooth muscle cells in arterial remodeling: focus on osteogenic marker processes. Int J Mol Sci . 2019;20 :5694.31739395
[17] Ndip A Wilkinson FL Jude EB Boulton AJM Alexander MY . RANKL-OPG and RAGE modulation in vascular calcification and diabetes: novel targets for therapy. Diabetologia. 2014;57 :2251–60.25112376
[18] Zhao L Wang S Liu H . The pharmacological effect and mechanism of lanthanum hydroxide on vascular calcification caused by chronic renal failure hyperphosphatemia. Front Cell Dev Biol. 2021;9 :639127.33928079
[19] Yasuda H . Discovery of the RANKL/RANK/OPG system. J Bone Miner Metab. 2021;39 :2–11.33389131
[20] Cobo G Lindholm B Stenvinkel P . Chronic inflammation in end-stage renal disease and dialysis. Nephrol Dial Transplant. 2018;33 (suppl_3 ):iii35–40.30281126
[21] Kooman JP Dekker MJ Usvyat LA . Inflammation and premature aging in advanced chronic kidney disease. Am J Physiol Renal Physiol. 2017;313 :F938–50.28701312
[22] Ebert T Neytchev O Witasp A Kublickiene K Stenvinkel P Shiels PG . Inflammation and oxidative stress in chronic kidney disease and dialysis Patients. Antioxid Redox Signal. 2021;35 :1426–48.34006115
[23] Lee GL Yeh CC Wu JY . TLR2 promotes vascular smooth muscle cell chondrogenic differentiation and consequent calcification via the concerted actions of osteoprotegerin suppression and il-6-mediated RANKL induction. Arterioscler Thromb Vasc Biol. 2019;39 :432–45.30626205
