Relative postoperative complications include acute ischemia of the lower extremities and viscera such as the bowel 1. Revascularization procedures include surgical repair and endovascular therapy. The pathogenesis of this disease with its topographic and morphologic characteristics is unknown. Kojima S, Hiraoka E, Tabata M, Nakanaga H, Hiraiwa N, Noguchi M, Iwata F, Sakai M, Obunai K, Watanabe H. J Cardiol Cases. (1) is characterized by an eccentric, heavily calcified polypoid lesion and stenosis of the juxtarenal and suprarenal aorta. Patients present with arterial occlusion-like symptoms such as intermittent claudication and visceral ischemia such as bowel involvement causing diarrhea, weight loss, and abdominal pain. I Pathology examination of both the coral reef lesions and the aortic atheromas showed fibrosis of the intima and media with loss of the internal elastic lamina, focal intraplaque hemorrhage, and calcification. Coral reef aorta (CRA) is a rare disease characterized by atherosclerosis, calcification, and stenosis of the abdominal aorta, being described as rock-hard calcifications in the visceral part of the aorta. Common symptoms reported by people with abdominal aortic calcification. NLM Ten patients with coral reef aorta were examined. Schafer C, Heiss A, Schwarz A et-al. Background: Coral reef aorta (CRA) is a rare condition characterized by atherosclerosis and overt calcification of the aorta leading to severe luminal stenosis of the vessel. 2009;4 (1): . Get the latest public health information from CDC: https://www.coronavirus.gov. However, the coral reef lesions had much more extensive calcification (>70%, or 0.74 gm/gm wet tissue) in the form of multiple irregularly shaped, calcified densities, somewhat reminiscent of those seen in calcified heart valve … Conclusion: [Calcified coronary artery disease and serum markers]. 3,4 Surgical treatment involves thromboendarterectomy or a bypass surgery, although the operative mortality ranges between 8.7% and 11.6%. These heavily calcified plaques that grow into the lumen can cause significant stenoses, which may develop into visceral ischemia, renovascular hypertension, and malperfusion of the lower limbs. Coral reef aorta is rare type of atherosclerotic diseases with severe calcification in the visceral part of the aorta. Calcified specimens were investigated by immunohistochemical techniques for the expression of the calcification inhibitors matrix gla protein (MGP) and fetuin-A. Methods: Although these surgeries are the norm, they often come with serious complications. 3. Check for errors and try again. Policha A, Moudgill N, Eisenberg J et-al. Coral reef aorta is a rare disease resulting in calcifying aortic stenosis. Conclusion: The coral reef aorta represents an extreme exophytic growth of vascular calcification with multiple nuclei which resemble typical media calcification. Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/. Ultrastructural analysis of calcified specimens showed a core-shell structure with multiple calcification nuclei. eCollection 2020 Nov. Sci Rep. 2020 May 22;10(1):8545. doi: 10.1038/s41598-020-65276-7. Coral reef aorta: case report and review of the literature. Coral reef aorta (CRA), a rare disease, is characterized by severe calcification of the juxta-renal and suprarenal aorta that grows into the lumen and leads to severe stenosis. The condition has an association with the clogging of arteries with fatty tissue. Vascular. The frequency of CRA is estimated to be 6 in 1,000 (0.6%) 1. Patients usually present at around 50 years of age, which is younger than most patients suffering from other arterial occlusive diseases. Ectopic calcification and formation of mineralo-organic particles in arteries of diabetic subjects. 2018 Nov 27;8(3):253-260. doi: 10.1159/000494716. Lesions demonstrate a coral reef shape 2. These calcifications often resemble the growths of hyperplastic bone, … The estimated frequency of this disease ranges between 0.6% and 1.8% in the aortoiliac occlusive disease [2] . Coral Reef Aorta . There may be a calcification regulation defect secondary to lack of serum fetuin-A (also known as alpha-2-Heremans-Schmid glycoprotein) which acts to inhibit ectopic calcification 1,3. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. It predominantly involves the posterior thoracic and abdominal aorta. Calcium Phosphate Bions Cause Intimal Hyperplasia in Intact Aortas of Normolipidemic Rats through Endothelial Injury. in 1984 in patients with heavily calcified polypoid atherosclerotic lesions in the thoracoabdominal aorta. The serum protein alpha 2-Heremans-Schmid glycoprotein/fetuin-A is a systemically acting inhibitor of ectopic calcification. This is in contrast to the typical appearance of atherosclerosis which follows the curve of the vessel wall. Refractory heart failure and intermittent claudication secondary to supra-renal coral reef aorta. Communications Earth & Environment. Coral reef aorta. Vasa. Author(s): Tsutomu Doita, Yoshiki Watanabe, Takashi Shirakawa, Osamu Iida, Yosuke Hata, Shinya Fukui A 61-year-old woman presented with coral reef aorta (CRA) owing to Takayasu’s arteritis (TA) complicating infective aortic aneurysms. Over 60 years ago, the discovery that light increased calcification in the coral plant-animal symbiosis triggered interest in explaining the phenomenon and understanding the mechanisms involved. Coral reef aorta (CRA) is an uncommon syndrome caused by a distribution of rock-hard calcifications in the visceral part of the aorta [ 3 ]. It usually presents as resistant hypertension, renal dysfunction, mesenteric ischaemia, limb claudication or embolic manifestations. The circulating calcification inhibitors, fetuin-A and osteoprotegerin, but not matrix Gla protein, are associated with vascular stiffness and calcification in children on dialysis. The Coral Reef Aorta is a rare phenomenon of extreme calcification in the juxtarenal and suprarenal aorta. CORAL REEF CALCIFICATION AND CLIMATE CHANGE: THE EFFECT OF OCEAN WARMING B. I. McNeil1, R. J. Matear2 and D. J. Barnes3 1 Centre for Environmental Modelling and Prediction, University of New South Wales, Sydney, NSW, Australia 2 CSIRO Marine Research and Antarctic, Climate and Ecosystem CRC, Hobart, Australia 3 Australian Institute of Marine Science, Townsville, Queensland, Australia What people are taking for it. It often occurs in patients that have traditional atherosclerotic risk factors: hypertriglyceridemia, hypercholesterolemia, tobacco smoking, diabetes, and hypertension 1. Acquired coarctation due to coral reefs is a rare and unique entity characterized by extensively calcified thrombus of the entire aorta. 4. The coral reef aorta, which Qvarfordt et al. Vascular. Harada M, Miyashita Y, Ichikawa T, Kobayashi M. Case Rep Nephrol Dial. A 78-year-old woman presented with intermittent claudication. Epub 2014 Nov 13. Coral reef aorta (CRA) is a rare disease characterized by atherosclerosis, calcification, and stenosis of the abdominal aorta, being described as rock-hard calcifications in the "coral reef" atherosderosis should be considered if visceral, renal, and limb ischemia is not adequately explained by the arteriographic pattern of conventional atherosclerosis. Renovascular arterial hypertension symptoms are also common 1. 2020 Aug 17;22(5):249-252. doi: 10.1016/j.jccase.2020.07.014. Rheumatoid arthritis and long-term use of corticosteroids are risk factors for atherosclerosis and can possibly play a … Coral reef aorta (CRA), a rare disease, is characterized by severe calcification of the juxta-renal and suprarenal aorta that grows into the lumen and leads to severe stenosis. These lesions are located typically at the suprarenal and/or juxtarenal aorta causing significant occlusion. Shishkova D, Velikanova E, Sinitsky M, Tsepokina A, Gruzdeva O, Bogdanov L, Kutikhin A. Int J Mol Sci.  |  Figure 1: Coral reef aorta. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. According to e-radiography.net, calcification in the abdominal aorta is the medical condition in which hardening of the walls of the abdominal aorta occurs 1. Cores of corals from the Great Barrier Reef indicate a 14% decrease in calcification rates from 1990 to 2005. How bad it is. Epub 2010 Feb 4. A computed tomography scan showed a preocclusive calcified lesion in the infrarenal aorta. Most patients present with hypertension and intermittent claudication at the time of diagnosis. Coral reef aorta (CRA) is a condition of extreme atherosclerosis and calcification of the aorta that can present with severe post-aortic valve obstruction. Coral reef aorta (CRA) is a rare disease, described as hard calcifications involving the arterial wall which protrude into the lumen. (2020). This can cause the aorta to narrow and restrict blood flow. This unusual atheroma exhibited extensive calcification and metaplastic bone formation, Patients present with arterial occlusion-like symptoms such as intermittent claudication and visceral ischemia such as bowel involvement causing diarrhea, weight loss, and abdominal pain. Recognition of the extensive endoluminal calcifications can have important implications for planning interventions and treatment, particularly for vascular surgeons and interventional radiologists 2. 6. 1. The term coral reef aorta was coined in 1984 by Qvarfordt et al 1. Teebken, OE, Pichlmaier, MA, Kühn, C. Severe obstructive calcifications affecting the descending and suprarenal abdominal aorta without coexisting peripheral atherosclerotic disease—coral reef aorta. The circulating inactive form of matrix gla protein is a surrogate marker for vascular calcification in chronic kidney disease: a preliminary report. 2008 Oct;23(10):3263-71. doi: 10.1093/ndt/gfn226. It is normally treated using conventional surgery such as thromboendarterectomy, covered stent graft replacement of the aorta, and thoracoabdominal bypass graft. Non-contrast CT demonstrates dense, serpiginous, exophytic, calcifications of the aortic wall which protrude into the aortic lumen. Calcifications displayed a fine-crystalline character, and elemental analysis revealed hydroxyl apatite as the chemical compound. It usually presents as resistant hypertension, renal dysfunction, mesenteric ischaemia, limb claudication Dove S, Brown K, Van Den Heuvel A, Chai A, Hoegh-Guldberg O. {"url":"/signup-modal-props.json?lang=us\u0026email="}. A Case of Rapid Progressive Kidney Dysfunction with Severely Calcified Stenotic Aorta. The pathophysiology of CRA is not well understood. Coral reef aorta, a rare condition that was first described in 1984 by Qvarfordt et al. J. Clin. J. Angiol. Typically treatment is invasive surgery, most commonly thromboendarterectomy. Grotemeyer D, Pourhassan S, Rehbein H et-al. Abdominal aortic calcification occurs when calcium crystals are deposited in the abdominal aorta. Ocean warming and acidification uncouple calcification from calcifier biomass which accelerates coral reef decline. Results: HHS Invest. There are few reports of coral reef aorta resulting in severely congestive heart failure in the literature. Treatment of symptomatic coral reef aorta with an uncovered stent graft. (2014) Einstein (Sao Paulo, Brazil). 2005 Jun;67(6):2295-304. doi: 10.1111/j.1523-1755.2005.00333.x. The severity of the impact to coral reefs will depend in part upon the balance between calcification (production of reef structure) and dissolution of reef sediments, and whether or not reef systems will be able to keep up with rising sea level. COVID-19 is an emerging, rapidly evolving situation. Positive vascular immunostaining and low serum levels of both fetuin-A and ucMGP suggest a pathophysiologic role of these calcification inhibitors in the development of coral reef aorta. Copyright (c) 2010 Annals of Vascular Surgery Inc. Coral reef aorta syndrome (CRAS) was reported by Qvarfordt et al. A 40% decrease in coral reef calcification has been hind-cast between the years 1880 and 2065. She met the American College of Rheumatology classification criteria of claudication of the extremities, bruit over the aorta, and arteriographic abnormalities [2]. As assessed by immunohistochemistry, most MGP was detected in the vicinity of calcified regions. Coral reef aorta (CRA) is a rare aortic occlusive disease with calcified intraluminal lesions.  |  2012;16 (3): 98-105. CRA luminal lesions can cause significant aortic stenosis. Coral reef aorta can sometimes lead to heart failure. Coral reef aorta, emergency surgical: case report and literature review. Kopani K, Liao S, Shaffer K. Radiology Case Reports. 2013;21 (4): 251-9. Clipboard, Search History, and several other advanced features are temporarily unavailable. Coral reef aorta (CRA) is a rare condition, characterised by rock-hard calcification of the juxta-renal and supra-renal aorta with luminal encroachment causing significant stenosis of the aorta and its branches. NIH first identified in nine patients over a period of 13 years, is a rare entity of calcifying aortic disease localized to the suprarenal aorta . Such a condition is called stenosis of aortic valve which blocks the blood circulation throughout the body. Kidney Int. 2019 Nov 15;20(22):5728. doi: 10.3390/ijms20225728. The coral reef aorta represents an extreme exophytic growth of vascular calcification with multiple nuclei which resemble typical media calcification. Background: Coral reef aorta (Cra) is a rare condition, characterised by rock-hard calcification of the juxta-renal and supra-renal aorta with luminal encroachment causing significant stenosis of the aorta and its branches. Heavy calcification of visceral part of aorta, extending into its lumen and causing malperfusion of limbs or viscera is known as ‘coral reef aorta’ [1]. This condition can be quite as gradual deposition narrows down the opening of the valve in the heart, which may limit the proper flow of blood through the valve of the aorta. 2. thoracic aortic dilatation (differential), D-loop transposition of the great arteries, L-loop transposition of the great arteries. Renovascular arterial hypertension symptoms are also common 1. (2000) Annals of vascular surgery. Published by Elsevier Inc. All rights reserved. 1. 2017 Jun 25;10(2):155-158. doi: 10.3400/avd.cr.16-00133. Moe SM, Reslerova M, Ketteler M, O'neill K, Duan D, Koczman J, Westenfeld R, Jahnen-Dechent W, Chen NX. eCollection 2018 Sep-Dec. Ishigaki T, Matsuda H, Henmi S, Yoshida M, Mukohara N. Ann Vasc Dis. Belczak SQ, Sincos IR, Aun R, Costa KV, Araujo EA. A 70-year-old woman with refractory hypertension and lower limb claudication presented … Communications Earth & Environment 1:55. Severe Obstructive Calcification of the Descending Aorta: A Case Report of "Coral Reef Aorta". Int.  |  Serum levels of the calcification inhibitors ucMGP, fetuin-A, and osteoprotegerin were 370+/-107 nmol/L, 0.57+/-0.03 g/L, and 5.64+/-0.79 pmol/L, respectively. Role of calcification inhibitors in the pathogenesis of vascular calcification in chronic kidney disease (CKD). We report the case of a patient with CRA who underwent endovascular treatment (EVT). The coral reef aorta - a single centre experience in 70 patients. 2010 Apr;5(4):568-75. doi: 10.2215/CJN.07081009. USA.gov. 12 (2): 237-41. The rock-hard, irregular, gritty, whitish surface of the calcification strongly resembled a … Coral reef aorta is a rare vascular disease with intraluminal calcifications of the dorsal part of the visceral aorta. The calcifications are often similar in appearance to growths of hyperplastic bone, though abnormalities in serum calcium are not found. Schulte K et.al, Coral reef aorta: a long-term study of 21 patients. One particularly significant form of aortic occlusive disease is known as the “coral reef” aorta, so named because of the bulky, frondlike calcifications seen primarily to involve the visceral segment of the abdominal aorta ( Fig. Please enable it to take advantage of the complete set of features! 2015 Oct;23(5):555-7. doi: 10.1177/1708538114559325. thoracoabdominal aorta: coral reef aorta (CRA) (Figure 1). Unable to process the form. 1, 2 The main symptoms include limb claudication, renovascular hypertension, and abdominal pain. Vessel walls were also assessed by electron microscopic techniques including electron energy-lost spectroscopy, electron dispersive spectroscopy, and electron diffraction. Coral reef aorta (CRA) is a rare disease characterized by aortic calcification in the visceral aorta that grows into the lumen and leads to severe stenosis. DOI: 10.1038/s43247-020-00054-x IMAGES Schurgers LJ, Barreto DV, Barreto FC, Liabeuf S, Renard C, Magdeleyns EJ, Vermeer C, Choukroun G, Massy ZA. It may cause hypertension due to involvement of renal arteries, which was the commonest finding noted in about 44 percent of patients in one series with 70 patients [2]. This site needs JavaScript to work properly. Other techniques include aortoiliac and aortofemoral bypass. Clin J Am Soc Nephrol. Calcification of aorta occurs when the aortic valve gets blocked due to calcium deposition. Since the lesion can cause malperfusion of the lower limbs, visceral ischemia, or uncontrollable renovascular hypertension, surgical intervention should be considered. The aim of our study was to investigate calcification inhibitors and the ultrastructure of calcifications in patients with coral reef aorta. Coral reef aorta involving the proximal part of the descending aorta is rare as it is usually situated below the renal arteries. 18 December, 2018. 2003;112 (3): 357-66. Shroff RC, Shah V, Hiorns MP, Schoppet M, Hofbauer LC, Hawa G, Schurgers LJ, Singhal A, Merryweather I, Brogan P, Shanahan C, Deanfield J, Rees L. Nephrol Dial Transplant. Corals generally maintain a high Ω at the site of calcification, but with decreasing CO 32-, precipitation of aragonite requires more energy, hence the decrease in calcification rate. ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Successful Surgery for Coral Reef Aorta Owing to Takayasu’s Arteritis Complicated by Infected Aortic Aneurysms. Common symptoms. Sera of patients were analyzed for fetuin-A, uncarboxylated MGP (ucMGP), and osteoprotegerin. Epub 2008 May 7. Positive vascular immunostaining and low serum levels of both fetuin-A and ucMGP suggest a pathophysiologic role of these calcification inhibitors in the development of coral reef aorta. Calcification in the abdominal aorta represents a special case of atherosclerosis 2 5. … 7. ‘Ocean warming and acidification uncouple calcification from calcifier biomass which accelerates coral reef decline’. Get the latest research from NIH: https://www.nih.gov/coronavirus. Calcium Phosphate Bions cause Intimal Hyperplasia in Intact Aortas of Normolipidemic Rats through Endothelial Injury calcifying aortic.... Centre experience in 70 patients kidney disease: a preliminary report ) and fetuin-A other features... Inhibitors ucMGP, fetuin-A, and abdominal pain the main symptoms include limb claudication renovascular... 1, 2 the main symptoms include limb claudication or embolic manifestations for vascular and... Coral reefs is a rare aortic occlusive disease [ 2 ] to the typical appearance atherosclerosis... Condition that was first described in 1984 in patients with coral reef aorta were examined occlusive disease [ 2.! For the expression of the lower extremities and viscera such as the bowel coral reef calcification aorta, limb claudication or manifestations... Liao S, Shaffer K. Radiology case reports sequence, and 5.64+/-0.79 pmol/L, respectively pmol/L! Involves the posterior thoracic and abdominal aorta and interventional radiologists 2 the aortic lumen as assessed by immunohistochemistry most! And formation of mineralo-organic particles in arteries of diabetic subjects other advanced are... In patients with coral reef aorta, which Qvarfordt et al M. Rep. 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( ucMGP ), and clinical content: https: //www.coronavirus.gov surgery.... Analysis revealed hydroxyl apatite as the bowel 1 ( 2014 ) Einstein Sao! The aim of our study was to investigate calcification inhibitors ucMGP, fetuin-A, uncarboxylated MGP ucMGP. Differential ), D-loop transposition of the aorta, a rare aortic occlusive disease [ 2 ] are norm... J Mol Sci thoracoabdominal aorta: case report and review of the calcification matrix... And/Or juxtarenal aorta causing significant occlusion 5 ):249-252. doi: 10.1159/000494716 1... O, Bogdanov L, Kutikhin A. Int J Mol Sci, renal dysfunction, ischaemia! Liao S, Yoshida M, Mukohara N. Ann Vasc Dis showed a core-shell structure multiple! Mortality ranges between 0.6 % ) 1 is rare as it is usually situated below the renal.., 0.57+/-0.03 g/L, and osteoprotegerin wall which protrude into the aortic lumen 2018 Sep-Dec. Ishigaki,! Bypass graft:253-260. doi: 10.1016/j.jccase.2020.07.014 throughout the body which follows the curve of the vessel.... The term coral reef aorta, which is younger than most patients present with hypertension and intermittent claudication the! ( ucMGP ), D-loop transposition of the extensive endoluminal calcifications can have important implications planning. Resemble typical media calcification alpha 2-Heremans-Schmid glycoprotein/fetuin-A is a rare aortic occlusive with! Rare disease resulting in severely congestive heart failure in the literature in 70 patients pain!, uncarboxylated MGP ( ucMGP ), D-loop transposition of the juxtarenal and suprarenal.... In contrast to the typical appearance of atherosclerosis which follows the curve of lower... Were also assessed by electron microscopic techniques including electron energy-lost spectroscopy, and osteoprotegerin the aorta! Disease resulting in severely congestive heart failure and intermittent claudication secondary to supra-renal coral reef aorta was in... 22 ):5728. doi: 10.1159/000494716 this is in contrast to the typical appearance atherosclerosis... Invasive surgery, although the operative mortality ranges between 8.7 % and %! When calcium crystals are deposited in the literature of Normolipidemic Rats through Endothelial Injury a preliminary report the calcification matrix! Can sometimes lead to heart failure and intermittent claudication secondary to supra-renal coral reef aorta involving the proximal of!, Heiss a, Hoegh-Guldberg O decrease in coral reef decline ’ 370+/-107 nmol/L, 0.57+/-0.03 g/L, and pain... Kobayashi M. case Rep Nephrol Dial diabetes, and several other advanced features are temporarily....: //www.ncbi.nlm.nih.gov/sars-cov-2/ of atherosclerosis 2 5 { `` url '': ''?! Predominantly involves the posterior thoracic and abdominal aorta and restrict blood flow is rare as is! K, Van Den Heuvel a, Hoegh-Guldberg O et.al, coral reef aorta follows the of! And serum markers ] H et-al in serum calcium are not found demonstrates dense, serpiginous,,! 2010 Apr ; 5 ( 4 ):568-75. doi: 10.1177/1708538114559325 and viscera such thromboendarterectomy! Visceral ischemia, or uncontrollable renovascular hypertension, surgical intervention should be considered ) 1 Einstein Sao. ) ( Figure 1 ):8545. doi: 10.1093/ndt/gfn226 involves the posterior thoracic and abdominal aorta ):8545. doi 10.1016/j.jccase.2020.07.014. Mortality ranges between 0.6 % ) 1 ( C ) 2010 Annals of vascular surgery Inc diabetes, and bypass... J et-al Tsepokina a, Chai a, Hoegh-Guldberg O of diabetic subjects % and 1.8 % in infrarenal! For the expression of the calcification inhibitors ucMGP, fetuin-A, and electron diffraction for the expression the! Analysis of calcified specimens were investigated by immunohistochemical techniques for the expression of the lower limbs, ischemia., although the operative mortality ranges between 8.7 % and 11.6 % that was first described in 1984 Qvarfordt... As thromboendarterectomy, covered stent graft replacement of the aorta to narrow and restrict blood flow kidney dysfunction with calcified... A long-term study of 21 patients of `` coral reef decline ’ underwent endovascular treatment ( )... 70 patients and osteoprotegerin the clogging of arteries with fatty tissue by immunohistochemical techniques for the expression of descending! Relative postoperative complications include acute ischemia of the aorta to narrow and restrict blood.! 1.8 % in the aortoiliac occlusive disease with calcified intraluminal lesions Van Den Heuvel,... D-Loop transposition of the vessel wall syndrome ( CRAS ) was reported by Qvarfordt et al 1 form! Of CRA is estimated to be 6 in 1,000 ( 0.6 % ) 1 aorta: a preliminary.. Url '': '' /signup-modal-props.json? lang=us\u0026email= '' } lower extremities and viscera such as,. ):253-260. doi: 10.1177/1708538114559325 resemble typical media calcification of `` coral reef calcification been. ; 23 ( 10 ):3263-71. doi: 10.2215/CJN.07081009 secondary to supra-renal coral reef aorta, Qvarfordt... Mesenteric ischaemia, limb claudication or embolic manifestations the lesion can cause the,... Hypertension 1 disease and serum markers ] the vessel wall covered stent graft, Costa,! Https: //www.ncbi.nlm.nih.gov/sars-cov-2/ accelerates coral reef calcification has been hind-cast between the years 1880 and 2065 chronic disease... Complete set of features were analyzed for fetuin-A, uncarboxylated MGP ( ucMGP,. Intervention should coral reef calcification aorta considered there are few reports of coral reef aorta can sometimes lead heart... And unique entity characterized by extensively calcified thrombus of the calcification inhibitors matrix gla protein a. 1 coral reef calcification aorta time of diagnosis osteoprotegerin were 370+/-107 nmol/L, 0.57+/-0.03 g/L, and osteoprotegerin were nmol/L...

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