Wnt Signaling Regulation in Bone of Postmenopausal Women With Type 2 Diabetes

Reviewer #1 (Public Review):

Summary:
Leanza et al. investigated the regulation of Wnt signaling factors in the bone tissue obtained from individuals with or without type 2 diabetes. They showed that typical canonical Wnt ligands and downstream factors (Wnt10b, LEF1) are down-regulated, while Wnt5a and sclerostin mRNA are unregulated in diabetic bone tissue. Further, Wnt5a and sclerostin associated with the content of AGEs and SOST mRNA levels also correlated with glycemic control and disease duration.

Strengths:
- A strength of the study is the investigation of Wnt signaling in bone tissue from humans with type 2 diabetes. Most studies measure only serum levels of Wnt inhibitors, but this study takes it further and looks into bone specifically.
- The measurement of AGEs and its correlation to the Wnt signaling molecules is interesting and important. The correlation of sclerostin and Wnt5a with AGEs and disease duration suggests that inhibited Wnt signaling is paralleled by higher AGE levels and potentially weaker bone.
- The methodology in terms of obtaining the bone samples and the rigorous evaluation of RNA integrity is great and provides a solid basis for further analyses.

Weaknesses:
- A weakness may include the rather limited number of samples. Especially for some sub-analyses (e.g. RNA analyses), only a subset of samples was used.
- How was the sample size determined? It seems like more samples might have been necessary to obtain significant results for methods with a higher standard deviation (e.g. histomorphometry).
- Why is the number of samples different for the mRNA measurements? In most cases, there were 9, but in some 8 and in some 10?

Overall, this study validates findings from the group that reported similar findings in 2020. This validates their methodology and shows that alterations in Wnt signaling are reproducible in human bone tissue.

Reviewer #2 (Public Review):

Summary:
This study reports the levels of expression of selected genes implicated in Wnt signaling in trabecular bone from femur heads obtained after surgery from post-menopausal women with (15 women) or without (21 women) type 2 diabetes. They found higher expression levels of SOST and WNT5A, and lower expression levels of LEF-1 and WNT10B in tissues from subjects with T2D, correlating with glycemia and advanced glycation products. No significant differences in bone density were observed. Overall, this is a cross-sectional, observational study measuring a limited set of genes found to vary with glycemia in postmenopausal women undergoing hip surgery.

Strengths:
The study demonstrates the feasibility of measuring gene expression in post-surgical trabecular bone samples, and finds differences associated with glycemia despite a relatively small number of subjects. It can form the basis for further research on the causes and consequences of changes in elements of the WNT signaling pathway in bone biology and disease.

Weaknesses:
The small number of targeted genes does not provide a comprehensive view of the transcriptional landscape within which the effects are observed. The gene expression changes are not associated with cellular or physiological properties of the tissue, raising questions about the biological significance of the observations.

Reviewer #3 (Public Review):

Summary:
The manuscript by Leanza and colleagues explores the regulation of Wnt signaling and its association with advanced glycation end products (AGEs) accumulation in postmenopausal women with type 2 diabetes (T2D). The paper provides valuable insights into the potential mechanisms underlying bone fragility in individuals with T2D. Overall, the manuscript is well-structured, and the methodology is sound. I would suggest some minor revisions to improve clarity.

Strengths:
The study addresses an important and clinically relevant question concerning the mechanisms underlying bone fragility in postmenopausal women with T2D.

The study's methodology appears sound, and the inclusion of postmenopausal women with and without T2D undergoing hip arthroplasty adds to the clinical relevance of the findings. Additionally, measuring gene expression and AGEs in bone samples provides direct insights into the study's objectives.

The manuscript presents data clearly, and the results are well-organized.

Weaknesses:
Title. The title could be more specific to better reflect the content of the study. Also, the abstract should concisely summarize the study's main findings, providing some figures.

Introduction: the introduction would benefit from the addition of a clearer, more focused statement of the research questions or hypotheses guiding this study.

Methods: more information is needed on the hystomorphometry analysis. Surgical samples from 8 T2D and 9 non-diabetic subjects were used for histomorphometry analysis. How did these subjects compare with the other subjects in the T2D and control groups? Were they representative? How were they selected?