الفهرس 
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Abstract
Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease that causes chronic inflammation of the synovium with subsequent destruction and deformity of the joints.The etiology of RA remains unclear, but it is known to be associated with genetic and environmental factors.Osteoporosis is more common in patients with RA than in the general population. The prevalence of concurrent osteoporosis is 50%. Osteoporosis can cause pain and loss of height, and increases the risk of fractures after falling . The chronic synovial inflammation in RA can promote osteoclastogenesis, leading directly to both focal and generalized bone loss and increased risk of fractures. In addition, many indirect factors associated with inflammatory arthritis contribute to the risk of osteoporosis. These include immobility ,weight loss, and use of medications known to promote bone loss, such as glucocorticoids . Vitamin K is a cofactor of γ-carboxylase, which converts three glutamic acid (Glu) residues in osteocalcin (OC) to γ-carboxyglutamic acid (Gla),and is thus essential for γ-carboxylation of OC.Without this modification, OC becomes undercarboxylated OC (ucOC), which lacks structural integrity and the ability to bind to the mineral hydroxyapatite. The carboxylation reaction is completed as an intracellular posttranslational event, and secreted OC can no longer be carboxylated. Vitamin K deficiency impairs γ-carboxylation of OC, resulting in high serum concentrations of ucOC . Sixty premenopausal patients diagnosed as RA according ACR/EULAR 2010 criteria with age more than 16 years old and disease duration more than 2 years were included in this study and thirty healthy premenopausal control females with matched age who were free from earlier fractures, chronic diseases and medications influencing bone metabolism (e.g. GCs, anticonvulsants, thyroxine….etc) were included Exclusion criteria:( Postmenopausal RA female patients, RA male patients, Patients suffering from serious cardiovascular and/or pulmonary disease, Patients having an abnormal thyroid function or a serious infection, Patients with hyperparathyroidism, Patient with hepatic or renal dysfunction, Patient taking any drugs or hormones that affect bone metabolism . Methods All patients were subjected to the following: 1)Demographic data recording. 2) Clinical assessment:-*-Medical history :- (Menstrual history, disease duration, information about medications ( DMARDs, antiresorptive drugs, glucocorticoids treatments…..etc). *Clinical examination(General Examination):This included chest, heart , abdomen examination and locomotory system examination included assessment of right and left shoulder ,elbow,wrist,MCP,PIP and knee joints. Joints were examined for both tenderness and swelling due to synovitis. 3) Disease activity assessment :Disease Activity Score (DAS 28) with three variables (erythrocyte sedimentation rate, the number of swelled joints and number of tender joins) was used . DAS28-3 = [0.56* √ (TJC28) + 0.28* √ (SJC28) + 0.70*ln (ESR)] 1.08 + 0.16 4) Laboratory Investigations:-Complete blood count (CBC) -Erythrocyte sedimentation rate (ESR; mm/h) by Westergren method.-Rheumatoid factor (RF by Rose waller method). -Anti ccp level, -C-reactive protein (CRP; mg/dL).-Serum levels of ucOC , -Liver function tests.-Total serum calcium-T3, T4, TSH level, -Parathyroid hormone level. 5)Radiographic assessment : Bone mineral density was measured in the femoral neck, at the lumbar spine L2–4 and distal radius by dual-energy X-ray absorptimetry (DEXA) equipment.BMD was expressed in standard deviation (SD) from the mean of healthy age- and sex-matched people (the Z-score) and as the number of SD from the mean of healthy, young sex-matched people (the T-score) was recorded. By the WHO classification and the 2005 International Society for Clinical Densitometry (ISCD) official positions,a T-score of (-2.5) or lower in postmenopausal women was defined as ‘osteoporosis’,normal defined asT score ≥-1 and osteopenia T score ˂-1but˃-2.5 and a Z-score (-2.0) or lower in females prior to menopause was defined as ‘below the expected range for age’. To determine the most prevalent site of osteoporosis in patients with RA at the time of the examination, osteoporosis in the lumbar , femoral neck and distal radius were evaluated separately. 6)Statistical analysis of the data. The results showed the following: In this study the level of ucOC was significantly higher in patients of RA than controls ( highly significant difference p <0.001 ). BMD in patients was found to be significantly lower than controls in spine,femoral neck and distal radius areas. The most frequent osteoporotic site according to Z score was spine(16.7%) followed by femoral neck (8.3 %) then distal radius (6.7%). While the commonest osteopenic site according to (Z score ≤ -1) was spine(31.7%) followed by femoral neck (21.7 %)then (16.7% ) in the distal radius. This work showed that ucOC level was found to be high in premenopausal RA patients with higher DAS values than those with lower DAS value (highly significant differencep <0.001) . In this work BMD measured by DEXA scan was found to be lower with higher DAS values and vice versa.