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Ahn SY, Ko GJ, Hwang HS, Jeong KH, Jin K, Kim YG, Moon JY, Lee SH, Lee SY, Yang DH, Jung JY, Oh KH, Lee YK, Kim GH, Kim SW, Kim YH, Lee DY, Hong YA, Park HC, Yoon SA, Choi BS, Ban TH, Kim HJ, Kwon YJ. Understanding the Korean Dialysis Cohort for Mineral, Vascular Calcification, and Fracture (ORCHESTRA) Study: Design, Method, and Baseline Characteristics. Kidney Blood Press Res 2024; 49:326-335. [PMID: 38657581 DOI: 10.1159/000539030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 03/23/2024] [Indexed: 04/26/2024] Open
Abstract
INTRODUCTION End-stage renal disease (ESRD) is a growing disease worldwide, including Korea. This is an important condition that affects patient outcome. To provide optimal management for mineral disturbance, vascular calcification, and bone disease in ESRD patients, the Korean dialysis cohort for mineral, vascular calcification, and fracture (ORCHESTRA) study was conducted by enrolling Korean dialysis patients. METHODS Sixteen university-affiliated hospitals and one Veterans' Health Service Medical Center participated in this study. This prospective cohort study enrolled approximately 900 consecutive patients on dialysis between May 2019 and January 2021. Enrolled subjects were evaluated at baseline for demographic information, laboratory tests, radiologic imaging, and bone mineral densitometry (BMD) scans. After enrollment, regular assessments of the patients were performed, and their biospecimens were collected according to the study protocol. The primary outcomes were the occurrence of major adverse cardiovascular events, invasive treatment for peripheral artery disease, and osteoporotic fractures. The secondary outcomes were hospitalization for cerebrovascular disease or progression of abdominal aortic calcification. Participants will be assessed for up to 3 years to determine whether primary or secondary outcomes occur. RESULTS Between May 2019 and January 2021, all participating centers recruited 900 consecutive dialysis patients, including 786 undergoing hemodialysis (HD) and 114 undergoing peritoneal dialysis (PD). The mean age of the subjects was 60.4 ± 12.3 years. Males accounted for 57.7% of the total population. The mean dialysis vintage was 6.1 ± 6.0 years. The HD group was significantly older, had a longer dialysis vintage, and more comorbidities. Overall, the severity of vascular calcification was higher and the level of BMD was lower in the HD group than in the PD group. CONCLUSION This nationwide, multicenter, prospective cohort study focused on chronic kidney disease-mineral and bone disorder and aimed to provide clinical evidence to establish optimal treatment guidelines for Asian dialysis patients.
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Affiliation(s)
- Shin Young Ahn
- Department of Internal Medicine, Korea University Guro Hospital, Seoul, Republic of Korea,
| | - Gang Jee Ko
- Department of Internal Medicine, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Hyeon Seok Hwang
- Department of Internal Medicine, Kyung Hee University Medical Center, Seoul, Republic of Korea
| | - Kyung Hwan Jeong
- Department of Internal Medicine, Kyung Hee University Medical Center, Seoul, Republic of Korea
| | - Kyubok Jin
- Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Yang Gyun Kim
- Department of Internal Medicine, Kyung Hee University East-West Neo Medical Center, Seoul, Republic of Korea
| | - Ju-Young Moon
- Department of Internal Medicine, Kyung Hee University East-West Neo Medical Center, Seoul, Republic of Korea
| | - Sang Ho Lee
- Department of Internal Medicine, Kyung Hee University East-West Neo Medical Center, Seoul, Republic of Korea
| | - So-Young Lee
- Department of Internal Medicine, CHA Medical School Bundang CHA Medical Center, Seongnam, Republic of Korea
| | - Dong-Ho Yang
- Department of Internal Medicine, CHA Medical School Bundang CHA Medical Center, Seongnam, Republic of Korea
| | - Ji Yong Jung
- Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Republic of Korea
| | - Kook-Hwan Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Young-Ki Lee
- Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Republic of Korea
| | - Gheun-Ho Kim
- Department of Internal Medicine, Hanyang University Seoul Hospital, Seoul, Republic of Korea
| | - Soo Wan Kim
- Department of Internal Medicine, Chonnam National University Medical School and Hospital, Gwangju, Republic of Korea
| | - Yeong Hoon Kim
- Department of Internal Medicine, Inje University Busan Paik Hospital, Busan, Republic of Korea
| | - Dong-Young Lee
- Department of Internal Medicine, Veterans Health Service Medical Center, Seoul, Republic of Korea
| | - Yu Ah Hong
- Department of Internal Medicine, The Catholic University of Korea Daejeon St. Mary's Hospital, Daejeon, Republic of Korea
| | - Hyeong Cheon Park
- Department of Internal Medicine, Gangnam Severance Hospital, Seoul, Republic of Korea
| | - Sun Ae Yoon
- Department of Internal Medicine, The Catholic University of Korea Uijeongbu St. Mary's Hospital, Uijeongbu, Republic of Korea
| | - Bum Soon Choi
- Department of Internal Medicine, The Catholic University of Korea Eunpyeong St. Mary's Hospital, Seoul, Republic of Korea
| | - Tae Hyun Ban
- Department of Internal Medicine, The Catholic University of Korea Eunpyeong St. Mary's Hospital, Seoul, Republic of Korea
| | - Hyo Jin Kim
- Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea
| | - Young Joo Kwon
- Department of Internal Medicine, Korea University Guro Hospital, Seoul, Republic of Korea
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Hong WK, Kim S, Gong HS. Fracture Management in Chronic Kidney Disease: Challenges and Considerations for Orthopedic Surgeons. Clin Orthop Surg 2024; 16:173-183. [PMID: 38562627 PMCID: PMC10973623 DOI: 10.4055/cios23244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/29/2023] [Accepted: 11/24/2023] [Indexed: 04/04/2024] Open
Abstract
Orthopedic surgeons treating fractures need to consider comorbidities, including chronic kidney disease (CKD), which affects millions worldwide. CKD patients are at elevated risk of fractures due to osteoporosis, especially in advanced stages. In addition, fractures in CKD patients pose challenges due to impaired bone healing and increased post-fracture complications including surgical site infection and nonunion. In this article, we will discuss factors that must be considered when treating fractures in CKD patients. Perioperative management includes careful adjustment of hemodialysis schedules, selection of anesthetic methods, and addressing bleeding tendencies. Tourniquet usage for fractures in limbs with arteriovenous fistulae should be cautious. Pain medication should be administered carefully, with opioids like hydromorphone preferred over nonsteroidal anti-inflammatory drugs. Medical management after fractures should address underlying factors and include physical rehabilitation to reduce the risk of subsequent fractures. A comprehensive approach to fracture management in CKD patients can improve outcomes.
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Affiliation(s)
- Wan Kee Hong
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sejoong Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hyun Sik Gong
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
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Vachey C, Candellier A, Toutain S, Mac-Way F. The Bone-Vascular Axis in Chronic Kidney Disease: From Pathophysiology to Treatment. Curr Osteoporos Rep 2024; 22:69-79. [PMID: 38195897 DOI: 10.1007/s11914-023-00858-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/26/2023] [Indexed: 01/11/2024]
Abstract
PURPOSE OF REVIEW This review aims to describe the pathogenic factors involved in bone-vessel anomalies in CKD which are the object of numerous experimental and clinical research. RECENT FINDINGS Knowledge on the pathophysiological mechanisms involved in the regulation of vascular calcification and mineral-bone disorders is evolving. Specific bone turnover anomalies influence the vascular health while recent studies demonstrate that factors released by the calcified vessels also contribute to bone deterioration in CKD. Current therapies used to control mineral dysregulations will impact both the vessels and bone metabolism. Available anti-osteoporotic treatments used in non-CKD population may negatively or positively affect vascular health in the context of CKD. It is essential to study the bone effects of the new therapeutic options that are currently under investigation to reduce vascular calcification. Our paper highlights the complexity of the bone-vascular axis and discusses how current therapies may affect both organs in CKD.
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Affiliation(s)
- Clément Vachey
- CHU de Québec Research Center, L'Hôtel-Dieu de Québec Hospital, Endocrinology and Nephrology Axis, Faculty and Department of Medicine, Université Laval, 10 McMahon, Quebec City, Quebec, G1R 2J6, Canada
| | - Alexandre Candellier
- CHU de Québec Research Center, L'Hôtel-Dieu de Québec Hospital, Endocrinology and Nephrology Axis, Faculty and Department of Medicine, Université Laval, 10 McMahon, Quebec City, Quebec, G1R 2J6, Canada
| | - Soline Toutain
- CHU de Québec Research Center, L'Hôtel-Dieu de Québec Hospital, Endocrinology and Nephrology Axis, Faculty and Department of Medicine, Université Laval, 10 McMahon, Quebec City, Quebec, G1R 2J6, Canada
| | - Fabrice Mac-Way
- CHU de Québec Research Center, L'Hôtel-Dieu de Québec Hospital, Endocrinology and Nephrology Axis, Faculty and Department of Medicine, Université Laval, 10 McMahon, Quebec City, Quebec, G1R 2J6, Canada.
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Yang J, Li Q, Feng Y, Zeng Y. Iron Deficiency and Iron Deficiency Anemia: Potential Risk Factors in Bone Loss. Int J Mol Sci 2023; 24:ijms24086891. [PMID: 37108056 PMCID: PMC10138976 DOI: 10.3390/ijms24086891] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/01/2023] [Accepted: 04/03/2023] [Indexed: 04/29/2023] Open
Abstract
Iron is one of the essential mineral elements for the human body and this nutrient deficiency is a worldwide public health problem. Iron is essential in oxygen transport, participates in many enzyme systems in the body, and is an important trace element in maintaining basic cellular life activities. Iron also plays an important role in collagen synthesis and vitamin D metabolism. Therefore, decrease in intracellular iron can lead to disturbance in the activity and function of osteoblasts and osteoclasts, resulting in imbalance in bone homeostasis and ultimately bone loss. Indeed, iron deficiency, with or without anemia, leads to osteopenia or osteoporosis, which has been revealed by numerous clinical observations and animal studies. This review presents current knowledge on iron metabolism under iron deficiency states and the diagnosis and prevention of iron deficiency and iron deficiency anemia (IDA). With emphasis, studies related to iron deficiency and bone loss are discussed, and the potential mechanisms of iron deficiency leading to bone loss are analyzed. Finally, several measures to promote complete recovery and prevention of iron deficiency are listed to improve quality of life, including bone health.
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Affiliation(s)
- Jiancheng Yang
- Department of Osteoporosis, Honghui Hospital, Xi'an Jiaotong University, Xi'an 710054, China
| | - Qingmei Li
- Department of Osteoporosis, Honghui Hospital, Xi'an Jiaotong University, Xi'an 710054, China
| | - Yan Feng
- Department of Osteoporosis, Honghui Hospital, Xi'an Jiaotong University, Xi'an 710054, China
| | - Yuhong Zeng
- Department of Osteoporosis, Honghui Hospital, Xi'an Jiaotong University, Xi'an 710054, China
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Wang YP, Sidibé A, Fortier C, Desjardins MP, Ung RV, Kremer R, Agharazii M, Mac-Way F. Wnt/β-catenin pathway inhibitors, bone metabolism and vascular health in kidney transplant patients. J Nephrol 2023; 36:969-978. [PMID: 36715822 DOI: 10.1007/s40620-022-01563-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 12/25/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND OBJECTIVES Sclerostin, dickkopf-related protein 1 (DKK1), fibroblast growth factor-23 (FGF23) and α-klotho have been shown to play an important role in bone and vascular disease of chronic kidney disease. We aimed to evaluate the evolution of these bone markers in newly kidney transplanted patients, and whether they are associated with bone metabolism and vascular stiffness. DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS This is a longitudinal single-center observational cohort study. Circulating levels of Wnt/β-catenin pathway inhibitors (sclerostin, DKK1, FGF23 and α-klotho), arterial stiffness (carotid-femoral pulse-wave velocity (PWV), carotid-radial PWV, PWV ratio, augmented index) and bone parameters were assessed before (M0), and at 3 (M3) and 6 months (M6) after transplantation. Generalized estimating equations were conducted for comparative analyses between the three time points. We used a marginal structural model for repeated measures for the impact of changes in bone markers on the evolution of arterial stiffness. Multivariate linear regression analyses were performed for the associations between Wnt/β-catenin pathway inhibitors and mineral metabolism parameters. RESULTS We included 79 patients (70% male; median age of 53 (44-60) years old). The levels of sclerostin (2.06 ± 1.18 ng/mL at M0 to 0.88 ± 0.29 ng/mL at M6, p ≤ 0.001), DKK1 (364.0 ± 266.7 pg/mL at M0 to 246.7 ± 149.1 pg/mL at M6, p ≤ 0.001), FGF23 (5595 ± 9603 RU/mL at M0 to 137 ± 215 RU/mL at M6, p ≤ 0.001) and α-klotho (457.6 ± 148.6 pg/mL at M0 to 109.8 ± 120.7 pg/mL at M6, p < 0.05) decreased significantly after kidney transplant. Sclerostin and FGF23 were positively associated with carotid-femoral (standardized β = 0.432, p = 0.037 and standardized β = 0.592, p = 0.005) and carotid-radial PWV (standardized β = 0.259, p = 0.029 and standardized β = 0.242, p = 0.006) throughout the 6 months of follow-up. The nature of the associations between bone markers and bone metabolism parameters varies after kidney transplant. CONCLUSIONS The circulating levels of Wnt/β-catenin pathway inhibitors and α-klotho significantly decrease after kidney transplantation, while sclerostin and FGF23 levels might be associated with improvement of vascular stiffness and blood pressure.
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Affiliation(s)
- Yue-Pei Wang
- Endocrinology and Nephrology Unit, Faculty and Department of Medicine, CHU de Québec Research Center, L'Hôtel-Dieu de Québec Hospital, Université Laval, 10 McMahon, Quebec, QC, G1R 2J6, Canada
| | - Aboubacar Sidibé
- Endocrinology and Nephrology Unit, Faculty and Department of Medicine, CHU de Québec Research Center, L'Hôtel-Dieu de Québec Hospital, Université Laval, 10 McMahon, Quebec, QC, G1R 2J6, Canada
| | - Catherine Fortier
- Endocrinology and Nephrology Unit, Faculty and Department of Medicine, CHU de Québec Research Center, L'Hôtel-Dieu de Québec Hospital, Université Laval, 10 McMahon, Quebec, QC, G1R 2J6, Canada
| | - Marie-Pier Desjardins
- Endocrinology and Nephrology Unit, Faculty and Department of Medicine, CHU de Québec Research Center, L'Hôtel-Dieu de Québec Hospital, Université Laval, 10 McMahon, Quebec, QC, G1R 2J6, Canada
| | - Roth-Visal Ung
- Endocrinology and Nephrology Unit, Faculty and Department of Medicine, CHU de Québec Research Center, L'Hôtel-Dieu de Québec Hospital, Université Laval, 10 McMahon, Quebec, QC, G1R 2J6, Canada
| | - Richard Kremer
- Faculty and Department of Medicine, McGill University Health Center, Royal Victoria Hospital, McGill University, Montréal, Canada
| | - Mohsen Agharazii
- Endocrinology and Nephrology Unit, Faculty and Department of Medicine, CHU de Québec Research Center, L'Hôtel-Dieu de Québec Hospital, Université Laval, 10 McMahon, Quebec, QC, G1R 2J6, Canada
| | - Fabrice Mac-Way
- Endocrinology and Nephrology Unit, Faculty and Department of Medicine, CHU de Québec Research Center, L'Hôtel-Dieu de Québec Hospital, Université Laval, 10 McMahon, Quebec, QC, G1R 2J6, Canada.
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Abdalbary M, Sobh M, Elnagar S, Elhadedy MA, Elshabrawy N, Abdelsalam M, Asadipooya K, Sabry A, Halawa A, El-Husseini A. Management of osteoporosis in patients with chronic kidney disease. Osteoporos Int 2022; 33:2259-2274. [PMID: 35748896 DOI: 10.1007/s00198-022-06462-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 05/31/2022] [Indexed: 12/19/2022]
Abstract
Patients with CKD have a 4-fivefold higher rate of fractures. The incidence of fractures increases with deterioration of kidney function. The process of skeletal changes in CKD patients is characterized by compromised bone strength because of deterioration of bone quantity and/or quality. The fractures lead to a deleterious effect on the quality of life and higher mortality in patients with CKD. The pathogenesis of bone loss and fracture is complex and multi-factorial. Renal osteodystrophy, uremic milieu, drugs, and systemic diseases that lead to renal failure all contribute to bone damage in CKD patients. There is no consensus on the optimal diagnostic method of compromised bone assessment in patients with CKD. Bone quantity and mass can be assessed by dual-energy x-ray absorptiometry (DXA) or quantitative computed tomography (QCT). Bone quality on the other side can be assessed by non-invasive methods such as trabecular bone score (TBS), high-resolution bone imaging methods, and invasive bone biopsy. Bone turnover markers can reflect bone remodeling, but some of them are retained by kidneys. Understanding the mechanism of bone loss is pivotal in preventing fracture in patients with CKD. Several non-pharmacological and therapeutic interventions have been reported to improve bone health. Controlling laboratory abnormalities of CKD-MBD is crucial. Anti-resorptive therapies are effective in improving BMD and reducing fracture risk, but there are uncertainties about safety and efficacy especially in advanced CKD patients. Accepting the prevalent of low bone turnover in patients with advanced CKD, the osteo-anabolics are possibly promising. Parathyroidectomy should be considered a last resort for intractable cases of renal hyperparathyroidism. There is a wide unacceptable gap in osteoporosis management in patients with CKD. This article is focusing on the updated management of CKD-MBD and osteoporosis in CKD patients. Chronic kidney disease deteriorates bone quality and quantity. The mechanism of bone loss mainly determines pharmacological treatment. DXA and QCT provide information about bone quantity, but assessing bone quality, by TBS, high-resolution bone imaging, invasive bone biopsy, and bone turnover markers, can guide us about the mechanism of bone loss.
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Affiliation(s)
- M Abdalbary
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, 800 Rose Street, Room MN-560, Lexington, KY, 40536-0298, USA
| | - M Sobh
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - S Elnagar
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - M A Elhadedy
- Nephrology and Transplantation Unit, Mansoura Urology and Nephrology Center, Mansoura, Egypt
| | - N Elshabrawy
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - M Abdelsalam
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - K Asadipooya
- Division of Endocrinology, University of Kentucky, Lexington, USA
| | - A Sabry
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - A Halawa
- Sheffield Teaching Hospital, University of Liverpool, Liverpool, UK
| | - A El-Husseini
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, 800 Rose Street, Room MN-560, Lexington, KY, 40536-0298, USA.
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Desbiens LC, Sidibé A, Ung RV, Mac-Way F. FGF23-Klotho Axis and Fractures in Patients Without and With Early CKD: A Case-Cohort Analysis of CARTaGENE. J Clin Endocrinol Metab 2022; 107:e2502-e2512. [PMID: 35139204 PMCID: PMC9113817 DOI: 10.1210/clinem/dgac071] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Whether fibroblast growth factor-23 (FGF23) and α-Klotho are associated with fractures, especially in chronic kidney disease (CKD), remains controversial. OBJECTIVE We evaluated how FGF23, α-Klotho, and traditional mineral parameters predict fractures in individuals with and without early CKD. METHODS We conducted a stratified case-cohort analysis using CARTaGENE, a population-based survey from Quebec, Canada. Individuals aged 40 to 69 years were selected according to outcome and CKD status (non-CKD: eGFR > 60 mL/min/1.73 m2; CKD stage 3: eGFR 30-60 mL/min/1.73 m2]). Baseline levels of c-terminal FGF23 (cFGF23), α-Klotho, parathyroid hormone (PTH), phosphate, and calcium were analyzed for associations with osteoporotic fracture incidence from recruitment (2009-2010) through March 2016. Adjusted Cox models were used, and predictors were treated linearly or flexibly using splines. RESULTS A total of 312 patients (159 non-CKD; 153 CKD) were included; 98 had ≥ 1 fracture at any site during a median follow up of 70 months. Compared with non-CKD, CKD patients had increased levels of cFGF23 but similar levels of α-Klotho. cFGF23 was linearly associated with increased fracture incidence (adjusted HR = 1.81 [1.71, 1.93] per doubling for all participants). The association of α-Klotho with fracture followed a U-curve (overall P = 0.019) but was attenuated by adjustment for potential mediators (bone mineral density, phosphate, PTH). PTH and phosphate also had U-shaped associations with fracture. Associations were mostly similar between non-CKD and CKD. Adjustment for cFGF23 strongly attenuated the association between CKD status and fractures. CONCLUSION cFGF23 is associated linearly with fracture incidence while α-Klotho, PTH, and phosphate levels have a U-shaped association.
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Affiliation(s)
- Louis-Charles Desbiens
- CHU de Québec Research Center, L’Hôtel-Dieu-de-Québec Hospital, Endocrinology and Nephrology Axis, Quebec City, QC G1R 2J6, Canada
- Department and Faculty of Medicine, Université Laval, Quebec City, QC G1V 5C3, Canada
| | - Aboubacar Sidibé
- CHU de Québec Research Center, L’Hôtel-Dieu-de-Québec Hospital, Endocrinology and Nephrology Axis, Quebec City, QC G1R 2J6, Canada
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Quebec City, QC G1V 5C3, Canada
| | - Roth-Visal Ung
- CHU de Québec Research Center, L’Hôtel-Dieu-de-Québec Hospital, Endocrinology and Nephrology Axis, Quebec City, QC G1R 2J6, Canada
| | - Fabrice Mac-Way
- CHU de Québec Research Center, L’Hôtel-Dieu-de-Québec Hospital, Endocrinology and Nephrology Axis, Quebec City, QC G1R 2J6, Canada
- Department and Faculty of Medicine, Université Laval, Quebec City, QC G1V 5C3, Canada
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Khelifi N, Desbiens L, Sidibé A, Mac‐Way F. Vitamin D Analogues and Fracture Risk in Chronic Kidney Disease: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. JBMR Plus 2022; 6:e10611. [PMID: 35434454 PMCID: PMC9009117 DOI: 10.1002/jbm4.10611] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 01/25/2022] [Indexed: 11/15/2022] Open
Abstract
Vitamin D receptor agonists (VDRAs) are commonly prescribed in chronic kidney disease (CKD). However, their protective effects on bone remain controversial. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the effect of VDRAs on fracture risk and bone mineral density (BMD) in adult patients with CKD. We searched MEDLINE, EMBASE, CENTRAL, ClinicalTrials.gov, and the WHO's International Clinical Trials Registry Platform databases from inception to June 19, 2021. We included RCTs comparing VDRAs, to placebo or another medication, in adults with CKD requiring or not dialysis. Conference abstracts and trials involving kidney transplant recipients and/or comparing VDRAs to antiresorptive or anabolic bone therapy were excluded. Primary outcome was fracture at any anatomical site. Secondary outcomes were BMD at femoral neck, lumbar spine, and/or total hip. Prespecified subgroup analyses were conducted according to baseline demographics, overall risk of bias, and follow-up time. From 6868 references retrieved, eight RCTs were eligible: five reported fracture, two reported BMD, and one reported both outcomes. As comparator, one study used no VDRAs, one used nutritional intervention and no medication, and six used placebo. In meta-analysis, VDRAs were not associated with a significant reduction in total fractures in overall (risk ratio = 0.79, 95% confidence interval 0.38-1.65, I2 = 0%, six trials, 1507 participants, 27 fractures) or in prespecified subgroup analyses. Three trials reported BMD at different sites and with different BMD measurements; thus, a meta-analysis could not be performed. Two RCTs were at high risk of bias, notably because of deviations from the intended interventions. As limitation, we have to mention the low total number of fractures included in our meta-analysis. In conclusion, current evidence from RCTs is insufficient to associate VDRAs with bone protection in CKD. Further large and long-term studies specifically designed to evaluate the efficacy of VDRAs on bone outcomes are thus required. © 2022 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Nada Khelifi
- CHU de Québec Research Center, Division of NephrologyEndocrinology and Nephrology AxisQuebec CityCanada
- Faculty and Department of MedicineUniversité LavalQuebec CityCanada
| | - Louis‐Charles Desbiens
- CHU de Québec Research Center, Division of NephrologyEndocrinology and Nephrology AxisQuebec CityCanada
- Faculty and Department of MedicineUniversité LavalQuebec CityCanada
| | - Aboubacar Sidibé
- CHU de Québec Research Center, Division of NephrologyEndocrinology and Nephrology AxisQuebec CityCanada
- Faculty of Medicine, Department of Social and Preventive MedicineUniversité LavalQuebec CityCanada
| | - Fabrice Mac‐Way
- CHU de Québec Research Center, Division of NephrologyEndocrinology and Nephrology AxisQuebec CityCanada
- Faculty and Department of MedicineUniversité LavalQuebec CityCanada
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Ebeling PR, Nguyen HH, Aleksova J, Vincent AJ, Wong P, Milat F. Secondary Osteoporosis. Endocr Rev 2022; 43:240-313. [PMID: 34476488 DOI: 10.1210/endrev/bnab028] [Citation(s) in RCA: 92] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Indexed: 02/07/2023]
Abstract
Osteoporosis is a global public health problem, with fractures contributing to significant morbidity and mortality. Although postmenopausal osteoporosis is most common, up to 30% of postmenopausal women, > 50% of premenopausal women, and between 50% and 80% of men have secondary osteoporosis. Exclusion of secondary causes is important, as treatment of such patients often commences by treating the underlying condition. These are varied but often neglected, ranging from endocrine to chronic inflammatory and genetic conditions. General screening is recommended for all patients with osteoporosis, with advanced investigations reserved for premenopausal women and men aged < 50 years, for older patients in whom classical risk factors for osteoporosis are absent, and for all patients with the lowest bone mass (Z-score ≤ -2). The response of secondary osteoporosis to conventional anti-osteoporosis therapy may be inadequate if the underlying condition is unrecognized and untreated. Bone densitometry, using dual-energy x-ray absorptiometry, may underestimate fracture risk in some chronic diseases, including glucocorticoid-induced osteoporosis, type 2 diabetes, and obesity, and may overestimate fracture risk in others (eg, Turner syndrome). FRAX and trabecular bone score may provide additional information regarding fracture risk in secondary osteoporosis, but their use is limited to adults aged ≥ 40 years and ≥ 50 years, respectively. In addition, FRAX requires adjustment in some chronic conditions, such as glucocorticoid use, type 2 diabetes, and HIV. In most conditions, evidence for antiresorptive or anabolic therapy is limited to increases in bone mass. Current osteoporosis management guidelines also neglect secondary osteoporosis and these existing evidence gaps are discussed.
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Affiliation(s)
- Peter R Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia
| | - Hanh H Nguyen
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Department of Endocrinology and Diabetes, Western Health, Victoria 3011, Australia
| | - Jasna Aleksova
- Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
| | - Amanda J Vincent
- Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Monash Centre for Health Research and Implementation, School of Public Health and Preventative Medicine, Monash University, Clayton, Victoria 3168, Australia
| | - Phillip Wong
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
| | - Frances Milat
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
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10
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Kim Y, Lee E, Lee MJ, Park B, Park I. Characteristics of fracture in patients who firstly starts kidney replacement therapy in Korea: a retrospective population-based study. Sci Rep 2022; 12:3107. [PMID: 35210536 PMCID: PMC8873500 DOI: 10.1038/s41598-022-07178-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 01/31/2022] [Indexed: 11/17/2022] Open
Abstract
The incidence of fractures in patients with end-stage kidney disease (ESKD) is high which is associated with high morbidity and mortality. Since fractures are preventable diseases to some extent, epidemiologic studies are needed a lot. The aim of this study is to explore the epidemiology of fractures by modality of kidney replacement therapy (KRT). We performed a retrospective analysis of 52,777 patients dependent on KRT from 2008 to 2017 using the National Health Insurance System of Republic Korea. Fractures were occurred in 8995 (17.04%) of 52,777 patients with ESKD. Hemodialysis and kidney transplant patients had the highest (57.4 per 1000 person-year) and the lowest (25.2 per 1000 person-year) incidence rate, respectively. The two most common fracture sites were the lower limb and upper limb, regardless of KRT modality. The first fractures were about 2.55 ± 2.07 years after KRT initiation, the earliest in Hemodialysis patients. Diabetes mellitus, cerebrovascular disease, chronic lung and liver disease were risk factors of fractures. The use of steroids, anti-osteoporosis medications, and some classes of psychotropics and opioids was associated with an elevated risk. The results of this study inform the understanding of fractures in KRT patients.
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Affiliation(s)
- Youngrong Kim
- Department of Nephrology, Ajou University School of Medicine, 164 Worldcup-ro, Yeongtong-gu, Suwon, Gyeonggi-do, 16499, Republic of Korea
| | - Eunyoung Lee
- Department of Biomedical Informatics, Ajou University School of Medicine, 164 Worldcup-ro, Yeongtong-gu, Suwon, Gyeonggi-do, 16499, Republic of Korea.,Department of Medical Sciences, Biomedical Informatics, Graduate School of Ajou University, 164 Worldcup-ro, Yeongtong-gu, Suwon, Gyeonggi-do, 16499, Republic of Korea.,Office of Biostatistics, Medical Research Collaborating Center, Ajou Research Institute for Innovative Medicine, Ajou University Medical Center, 164 Worldcup-ro, Yeongtong-gu, Suwon, Gyeonggi-do, 16499, Republic of Korea
| | - Min-Jeong Lee
- Department of Nephrology, Ajou University School of Medicine, 164 Worldcup-ro, Yeongtong-gu, Suwon, Gyeonggi-do, 16499, Republic of Korea
| | - Bumhee Park
- Department of Biomedical Informatics, Ajou University School of Medicine, 164 Worldcup-ro, Yeongtong-gu, Suwon, Gyeonggi-do, 16499, Republic of Korea. .,Office of Biostatistics, Medical Research Collaborating Center, Ajou Research Institute for Innovative Medicine, Ajou University Medical Center, 164 Worldcup-ro, Yeongtong-gu, Suwon, Gyeonggi-do, 16499, Republic of Korea.
| | - Inwhee Park
- Department of Nephrology, Ajou University School of Medicine, 164 Worldcup-ro, Yeongtong-gu, Suwon, Gyeonggi-do, 16499, Republic of Korea.
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11
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Lavainne F, Guillot P, Figueres L. Troubles minéraux et osseux dans la maladie rénale chronique : physiopathologie, conséquences et prise en charge. Rev Med Interne 2022; 43:225-232. [DOI: 10.1016/j.revmed.2022.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 01/26/2022] [Accepted: 01/29/2022] [Indexed: 02/07/2023]
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12
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Wu PH, Lin MY, Huang TH, Lee TC, Lin SY, Chen CH, Kuo MC, Chiu YW, Chang JM, Hwang SJ. Kidney Function Change and All-Cause Mortality in Denosumab Users with and without Chronic Kidney Disease. J Pers Med 2022; 12:jpm12020185. [PMID: 35207673 PMCID: PMC8875658 DOI: 10.3390/jpm12020185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 12/22/2021] [Accepted: 01/24/2022] [Indexed: 12/04/2022] Open
Abstract
Denosumab is approved for osteoporosis treatment in subjects with and without chronic kidney disease (CKD). Confirmation is required for its safety, treatment adherence, renal function effect, and mortality in patients with CKD. A retrospective cohort study was conducted to compare new users of denosumab in terms of their two-year drug adherence in all participants (overall cohort) and CKD participants (CKD subcohort), which was defined as baseline estimated glomerular filtration rate (eGFR) less than 60 mL/min/1.73 m2. The eGFR was calculated using the 2021 CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) equation. We defined high adherence (HA) users as receiving three or four doses and low adherence (LA) users as receiving one or two doses. All-cause mortality was analyzed using Kaplan–Meier curves and Cox regression models. In total, there were 1142 subjects in the overall cohort and 500 subjects in the CKD subcohort. HA users had better renal function status at baseline than LD users in the overall cohort. A decline in renal function was only observed among LD users in the overall cohort. In the CKD subcohort, no baseline renal function difference or renal function decline was demonstrated. The all-cause mortality rate of HA users was lower than LA users in both the overall cohort and CKD. A randomized control trial is warranted to target this unique population to confirm our observations.
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Affiliation(s)
- Ping-Hsun Wu
- Department of Internal Medicine, Division of Nephrology, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan; (P.-H.W.); (M.-Y.L.); (T.-H.H.); (M.-C.K.); (Y.-W.C.); (J.-M.C.); (S.-J.H.)
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
| | - Ming-Yen Lin
- Department of Internal Medicine, Division of Nephrology, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan; (P.-H.W.); (M.-Y.L.); (T.-H.H.); (M.-C.K.); (Y.-W.C.); (J.-M.C.); (S.-J.H.)
| | - Teng-Hui Huang
- Department of Internal Medicine, Division of Nephrology, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan; (P.-H.W.); (M.-Y.L.); (T.-H.H.); (M.-C.K.); (Y.-W.C.); (J.-M.C.); (S.-J.H.)
| | - Tien-Ching Lee
- Department of Orthopedics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80756, Taiwan; (S.-Y.L.); (C.-H.C.)
- Orthopaedic Research Center, College of Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Regenerative Medicine and Cell Therapy Research Center, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Department of Orthopedics, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Department of Orthopedics, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung 80145, Taiwan
- Correspondence: ; Tel.: +886-7-3121101 (ext. 5751)
| | - Sung-Yen Lin
- Department of Orthopedics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80756, Taiwan; (S.-Y.L.); (C.-H.C.)
- Orthopaedic Research Center, College of Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Regenerative Medicine and Cell Therapy Research Center, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Department of Orthopedics, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
| | - Chung-Hwan Chen
- Department of Orthopedics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80756, Taiwan; (S.-Y.L.); (C.-H.C.)
- Orthopaedic Research Center, College of Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Regenerative Medicine and Cell Therapy Research Center, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Department of Orthopedics, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Department of Orthopedics, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung 80145, Taiwan
| | - Mei-Chuan Kuo
- Department of Internal Medicine, Division of Nephrology, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan; (P.-H.W.); (M.-Y.L.); (T.-H.H.); (M.-C.K.); (Y.-W.C.); (J.-M.C.); (S.-J.H.)
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
| | - Yi-Wen Chiu
- Department of Internal Medicine, Division of Nephrology, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan; (P.-H.W.); (M.-Y.L.); (T.-H.H.); (M.-C.K.); (Y.-W.C.); (J.-M.C.); (S.-J.H.)
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
| | - Jer-Ming Chang
- Department of Internal Medicine, Division of Nephrology, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan; (P.-H.W.); (M.-Y.L.); (T.-H.H.); (M.-C.K.); (Y.-W.C.); (J.-M.C.); (S.-J.H.)
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
| | - Shang-Jyh Hwang
- Department of Internal Medicine, Division of Nephrology, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan; (P.-H.W.); (M.-Y.L.); (T.-H.H.); (M.-C.K.); (Y.-W.C.); (J.-M.C.); (S.-J.H.)
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
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13
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Wakasugi M, Yokoseki A, Wada M, Momotsu T, Sato K, Kawashima H, Nakamura K, Onodera O, Narita I. Polypharmacy, chronic kidney disease, and incident fragility fracture: a prospective cohort study. J Bone Miner Metab 2022; 40:157-166. [PMID: 34729651 DOI: 10.1007/s00774-021-01272-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 09/15/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Polypharmacy is associated with an increased risk of fracture in aging populations, but no study has accounted for the impact of kidney function on this association. This study aimed to examine the association between polypharmacy and incident fragility fracture based on chronic kidney disease (CKD) status. MATERIALS AND METHODS Participants were 2023 patients (55% men; mean age, 69 years) of Sado General Hospital enrolled in the Project in Sado for Total Health (PROST) between June 2008 and December 2016. Among these, 65%, 28%, and 7% had non-CKD, non-dialysis-dependent CKD, and dialysis-dependent CKD, respectively. Multivariable Cox proportional hazards analysis was conducted with adjustments for potential confounders. RESULTS Prevalences of polypharmacy (≥ 5 medications) and hyperpolypharmacy (≥ 10 medications) among participants were 43% and 9% for non-CKD, 62% and 23% for non-dialysis-dependent CKD, and 85% and 34% for dialysis-dependent CKD, respectively. During a median follow-up of 5.6 years, 256 fractures occurred. More medications were associated with a higher risk of fractures. Specifically, compared to participants without polypharmacy, adjusted hazard ratios were 1.32 (95% CI 0.96-1.79) and 1.99 (1.35-2.92) for those with polypharmacy and hyperpolypharmacy, respectively, after adjusting for osteoporosis risk factors, CKD status, and comorbidities. No effect modification by CKD status was observed (interaction P = 0.51). Population-attributable fractions of hyperpolypharmacy for fracture were 9.9% in the total cohort and 42.1% in dialysis-dependent CKD patients. CONCLUSION Hyperpolypharmacy is associated with an increased risk of fragility fracture regardless of CKD status, and has a strong impact on incident fragility fractures in dialysis-dependent CKD patients.
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Affiliation(s)
- Minako Wakasugi
- Department of Inter-Organ Communication Research, Niigata University Graduate School of Medical and Dental Sciences, Asahimachi 1-757, Chuo-ku, Niigata, 951-8510, Japan.
| | - Akio Yokoseki
- Department of Inter-Organ Communication Research, Niigata University Graduate School of Medical and Dental Sciences, Asahimachi 1-757, Chuo-ku, Niigata, 951-8510, Japan
| | | | | | | | - Hiroyuki Kawashima
- Division of Orthopedic Surgery, Niigata University Graduate School of Medical and Dental Science, Niigata, Japan
| | - Kazutoshi Nakamura
- Division of Preventive Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Osamu Onodera
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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14
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Yajima A, Tsuchiya K, Burr DB, Murata T, Nakamura M, Inaba M, Tominaga Y, Tanizawa T, Nakayama T, Ito A, Nitta K. Micropetrosis in hemodialysis patients. Bone Rep 2021; 15:101150. [PMID: 34926729 PMCID: PMC8649646 DOI: 10.1016/j.bonr.2021.101150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 11/06/2021] [Accepted: 11/15/2021] [Indexed: 01/03/2023] Open
Abstract
Micropetrosis develops as a result of stagnation of calcium, phosphorus and bone fluid, which appears as highly mineralized bone area in the osteocytic perilacunar/canalicular system regardless of bone turnover of the patients. And microcracks are predisposed to increase in these areas, which leads to increased bone fragility. However, micropetrosis of hemodialysis (HD) patients has not been discussed at all. Micropetrosis area per bone area (Mp.Ar/B·Ar) and osteocyte number per micropetrosis area (Ot.N/Mp.Ar) were measured in nine HD patients with renal hyperparathyroidism (Group I), twelve patients with hypoparathyroidism within 1 year after the treatment of renal hyperparathyroidism (Group II) and seven patients suffering from hypoparathyroidism for over two years (Group III). And bone mineral density (BMD) and tissue mineral density (TMD) were calculated using μCT to evaluate bone mineral content of iliac bone of the patients. These parameters were compared among the three groups. Only Mp.Ar/B·Ar was statistically greater in Group II and III compared to Group I in the parameters of bone mineral content and micropetrosis. However, the other parameters were not statistically different among the three groups. In long-term HD patients, BMD and TMD may be modified by the causes of renal insufficiency and the treatment of renal bone disease. We concluded that Mp.Ar/B·Ar was greater in patients with long-term hypoparathyroidism than both those with short-term hypoparathyroidism and with renal hyperparathyroidism. Special attention should be paid to avoid long-term hypoparathyroidism of the patients from the view point of increased fracture risk caused by increased micropetrosis area.
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Affiliation(s)
- Aiji Yajima
- Department of Anatomy, Cell Biology and Physiology, Indiana University, School of Medicine, Indianapolis, IN, USA.,Department of Urology, Tokyo Teishin Hospital, Tokyo, Japan.,Department of Blood Purification, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Ken Tsuchiya
- Department of Blood Purification, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
| | - David B Burr
- Department of Anatomy, Cell Biology and Physiology, Indiana University, School of Medicine, Indianapolis, IN, USA
| | - Taro Murata
- Department of Urology, Tokyo Teishin Hospital, Tokyo, Japan
| | - Masaki Nakamura
- Department of Nephrology and Urology, NTT East Kanto Hospital, Tokyo, Japan
| | - Masaaki Inaba
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yoshihiro Tominaga
- Department of Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | | | | | - Akemi Ito
- Ito Bone Histomorphometry Institute, Niigata, Japan
| | - Kosaku Nitta
- Department of Medicine, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
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15
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Jafari M, Anwar S, Kour K, Sanjoy S, Goyal K, Prasad B. T Scores, FRAX, Frailty Phenotype, Falls, and Its Relationship to Fractures in Patients on Maintenance Hemodialysis. Can J Kidney Health Dis 2021; 8:20543581211041184. [PMID: 34457317 PMCID: PMC8392815 DOI: 10.1177/20543581211041184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 07/18/2021] [Indexed: 11/15/2022] Open
Abstract
Background: Despite the magnitude of fracture and the consequences in patients receiving hemodialysis, optimal risk assessment tools in this population are not well explored. Frailty and falls—known risk factors for fracture in chronic kidney disease (CKD) and non-CKD populations—are common in patients receiving hemodialysis (HD) therapy. While the relationship between T scores in relation to fractures in patients receiving HD is recognized, there is a paucity of data to the additional contributions of fracture assessment tool (FRAX), frailty status, and falls in its relationship with fracture. Objectives: To evaluate the clinical utility of adding FRAX, frailty status, and falls to T scores at the femoral neck to determine whether it enhances fracture discrimination in patients on maintenance HD. Design: A cross-sectional observational study. Setting: Two main dialysis units in Regina, Saskatchewan, Canada. Patients: A total of 109 patients on maintenance HD at two dialysis units from January 1, 2017, to December 31, 2018, were included in the study. Measurements: Fracture (the main outcome) was documented based on the review of medical charts, self-recall, and additionally vertebral fractures were identified by an x-ray. Areal bone mineral density (BMD) was measured by dual-energy x-ray absorptiometry (DXA). FRAX score was calculated using an online algorithm based on 11 clinical risk factors. We calculated the FRAX score for hip fracture and major osteoprotoic fracture with and without the inclusion of BMD. Frailty was assessed using the Fried criteria, which included assessments of unintentional weight loss, weakness (handgrip strength), slowness (walking speed), and questionnaires for physical activity and self-perceived exhaustion. Patients were enquired about the history and frequency of falls. Methods: A total of 131 patients underwent frailty assessments at the two dialysis units during the dialysis treatment. Following frailty assessments, they were referred for DXA scans and upon receipt of the results undertook FRAX questionnaires. They were additionally sent for lumbar x-rays and contacted for a history of falls. Association between the BMD-T score, FRAX, frailty status, falls, with fracture were examined with sequential multivariable logistic regression models. Differences were considered statistically significant at P values <.05. Results: A total of 109 patients were included in the data analysis. The composite of fracture occurred in 37.6% of patients. About 59.3% were identified as frail, and 29% of the participants had at least one fall in the last year. On multivariate regression analysis, each lower standard deviation (SD) in femoral neck T score was associated with 48% higher odds of fracture (odds ratio [OR] = 1.48; 95% confidence interval [CI] 1.20-1.68, P = .005). With the inclusion for FRAX scores (hip), the OR for fracture remained significant at 1.38 (OR = 1.38, 95% CI 1.04-1.63, P = .043). The addition of frailty status and history of falls did not further improve the model. Low T score and FRAX were both independent risk factors in patients on HD therapy. Limitations: This is a single-center study with a small sample size which limits the generalizability of the findings. Due to the cross-sectional study, associations identified may be difficult to interpret. Conclusions: Both BMD measurements by DXA and FRAX are useful tools to assess fracture in patients receiving HD. The addition of frailty status and history of falls is not associated with fractures in this population. Larger prospective studies are needed to determine whether the inclusion of frailty and falls to the conventional models will improve fracture assessment in the population receiving HD. Trial Registration: The study was not registered on a publicly accessible registry as it did not involve health care intervention on human participants.
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Affiliation(s)
- Maryam Jafari
- Dr. T. Bhanu Prasad Medical Professional Corporation, Regina, SK, Canada
| | - Salman Anwar
- College of Medicine, University of Saskatchewan, Regina, Canada
| | - Kaval Kour
- Dr. T. Bhanu Prasad Medical Professional Corporation, Regina, SK, Canada
| | - Shubrandu Sanjoy
- Research Department, Saskatchewan Health Authority, Regina, Canada
| | - Kunal Goyal
- Department of Radiology, Regina General Hospital, Regina, SK, Canada
| | - Bhanu Prasad
- Section of Nephrology, Department of Medicine, Regina General Hospital, Regina, SK, Canada
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16
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Pawlak K, Sieklucka B, Pawlak D. Paracrine Kynurenic Pathway Activation in the Bone of Young Uremic Rats Can Antagonize Anabolic Effects of PTH on Bone Turnover and Strength through the Disruption of PTH-Dependent Molecular Signaling. Int J Mol Sci 2021; 22:ijms22126563. [PMID: 34207309 PMCID: PMC8234704 DOI: 10.3390/ijms22126563] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/14/2021] [Accepted: 06/14/2021] [Indexed: 01/02/2023] Open
Abstract
Secondary hyperparathyroidism and abnormalities in tryptophan (TRP) metabolism are commonly observed in chronic kidney disease (CKD). The present study aimed to establish potential interactions between endogenous parathyroid hormone (PTH) and activation of the bone kynurenine (KYN) pathway in relation to bone turnover and strength in young rats after one month (CKD-1) and three months (CKD-3) of experimental CKD. TRP, KYN, KYN/TRP ratio and bone turnover markers (BTMs) were measured in trabecular and cortical bone tissue. Expression of aryl hydrocarbon receptor (AhR) and the genes involved in osteogenesis was determined in femoral bone. Biomechanical testing of femoral diaphysis and femoral neck was also performed. Activation of the KYN pathway in trabecular bone during CKD development intensified the expression of genes related to osteogenesis, which led to a decrease in cyclic adenosine monophosphate (cAMP) and BTMs levels, resulting in a stiffer and mechanically weaker femoral neck. In contrast, reduction of the KYN pathway in cortical bone allowed to unblock the PTH-dependent anabolic activating transcription factor 4/parathyroid hormone 1 receptor (PTH1R/ATF4) axis, led to cAMP accumulation, better bone turnover and strength in the course of CKD development. In summary, the paracrine KYN pathway in bone can interfere with the anabolic effects of PTH on bone through disrupting PTH-dependent molecular signaling.
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Affiliation(s)
- Krystyna Pawlak
- Department of Monitored Pharmacotherapy, Medical University of Bialystok, Mickiewicza 2C, 15-222 Bialystok, Poland
- Correspondence: ; Tel.: +48-85748-5600
| | - Beata Sieklucka
- Department of Pharmacodynamics, Medical University of Bialystok, Mickiewicza 2C, 15-222 Bialystok, Poland; (B.S.); (D.P.)
| | - Dariusz Pawlak
- Department of Pharmacodynamics, Medical University of Bialystok, Mickiewicza 2C, 15-222 Bialystok, Poland; (B.S.); (D.P.)
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17
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Iseri K, Carrero JJ, Evans M, Runesson B, Stenvinkel P, Lindholm B, Berg HE, Felländer-Tsai L, Qureshi AR. Secular trends in hip fracture incidence and subsequent mortality in dialysis patients and the general population in Sweden. Bone 2021; 147:115909. [PMID: 33716163 DOI: 10.1016/j.bone.2021.115909] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 03/01/2021] [Accepted: 03/09/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Declining trends of hip fracture incidence in dialysis patients were reported from USA and Japan while studies from Europe are lacking. We investigated trends in hip fracture incidence and subsequent mortality in Swedish dialysis patients, comparing with the Swedish general population. METHODS We used the population-based Swedish national database of fractures and the Swedish National Renal Registry to retrieve data on hip fractures incidence and subsequent mortality for years 2007-2016. Trends for age-standardized hip fracture incidence rate (ASRhip fracture) and age-standardized 30-day (ASMR30day) and 180-day (ASMR180day) post-hip fracture mortality rate in Swedish general population were evaluated by joinpoint regression analysis. Standardized incidence ratios of hip fracture (SIR) and standardized mortality ratios (SMR) were calculated for Swedish dialysis patients. RESULTS In the general population, ASRhip fracture declined significantly: in women from 2007 and in men from 2009. In dialysis patients, SIR was 3-5 times higher compared to the general population and declined over time in women but not in men. In general population, mortality (ASMR30day and ASMR180day) declined significantly in women and men. In dialysis patients, post-fracture mortality (SMR, mainly for 180-day mortality) remained two-fold higher than in general population with no consistent trend towards improvement. CONCLUSIONS Hip fracture incidence and subsequent mortality fell among women and men in the Swedish general population. In dialysis patients, hip fracture incidence declined in women but not in men while post-fracture mortality did not improve, and the incidence and subsequent mortality remained 3 to 5-fold and 2-fold higher than in the general population.
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Affiliation(s)
- Ken Iseri
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan.
| | - Juan Jesús Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Marie Evans
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Björn Runesson
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Peter Stenvinkel
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Bengt Lindholm
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Hans E Berg
- Division of Orthopaedics and Biotechnology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Li Felländer-Tsai
- Division of Orthopaedics and Biotechnology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Abdul Rashid Qureshi
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
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18
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Ferreira AC, Mendes M, Silva C, Cotovio P, Aires I, Navarro D, Caeiro F, Salvador R, Correia B, Cabral G, Nolasco F, Ferreira A. Bone densitometry versus bone histomorphometry in renal transplanted patients: a cross-sectional study. Transpl Int 2021; 34:1065-1073. [PMID: 33909300 DOI: 10.1111/tri.13888] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/23/2021] [Accepted: 04/14/2021] [Indexed: 11/28/2022]
Abstract
Bone loss leads to increase risk of fractures in renal transplantation. The aim of this study was to analyse the relationship between bone densitometry (DXA) findings, bone histomorphometry and bone-related molecules 1-year after renal transplantation. We performed a cross-sectional study of de novo renal transplanted patients that agreed to perform a bone biopsy and a DXA examination 1 year after transplantation. All patients underwent a laboratory evaluation, bone biopsy, DXA examination and cardiac CT 1 year after transplantation. 67 patients were included, 16 had a normal examination, and 18 patients were classified as having osteoporosis by DXA. Correlations between bone mineral density and T-scores of total femur and femoral neck were the ones that best correlated with bone volume assessed by a bone biopsy. The sensitivity of DXA for osteoporosis diagnosis was 47.0%, and the specificity was 81.2%. The positive predictive value was 50.0%, and the negative predictive value (NPV) was 80.0%. DXA parameters also correlated with klotho and sclerostin serum levels. In this population, a normal examination excluded the presence of osteoporosis, helping in identifying patients that would not benefit from therapy. Overall, densitometry in total femur and femoral neck correlated well with bone volume measured by bone biopsy.
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Affiliation(s)
- Ana Carina Ferreira
- Nephrology Department, Hospital Curry Cabral, CHULC, Lisbon, Portugal.,Nova Medical School, Lisbon, Portugal
| | - Marco Mendes
- Nephrology Department, Hospital Curry Cabral, CHULC, Lisbon, Portugal
| | - Cecília Silva
- Nephrology Department, Hospital Curry Cabral, CHULC, Lisbon, Portugal
| | - Patrícia Cotovio
- Nephrology Department, Hospital Curry Cabral, CHULC, Lisbon, Portugal
| | - Inês Aires
- Nephrology Department, Hospital Curry Cabral, CHULC, Lisbon, Portugal.,Nova Medical School, Lisbon, Portugal
| | - David Navarro
- Nephrology Department, Hospital Curry Cabral, CHULC, Lisbon, Portugal
| | - Fernando Caeiro
- Nephrology Department, Hospital Curry Cabral, CHULC, Lisbon, Portugal
| | - Rute Salvador
- Tissue Repair and Inflammation Lab, CEDOC, Lisbon, Portugal
| | - Bruna Correia
- Tissue Repair and Inflammation Lab, CEDOC, Lisbon, Portugal
| | | | - Fernando Nolasco
- Nephrology Department, Hospital Curry Cabral, CHULC, Lisbon, Portugal.,Nova Medical School, Lisbon, Portugal
| | - Aníbal Ferreira
- Nephrology Department, Hospital Curry Cabral, CHULC, Lisbon, Portugal.,Nova Medical School, Lisbon, Portugal
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Torregrosa JV, Ferreira AC, Cucchiari D, Ferreira A. Bone Mineral Disease After Kidney Transplantation. Calcif Tissue Int 2021; 108:551-560. [PMID: 33765230 DOI: 10.1007/s00223-021-00837-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 03/09/2021] [Indexed: 12/18/2022]
Abstract
Chronic kidney disease-mineral bone disorder (CKD-MBD) after kidney transplantation is a mix of pre-existing disorders and new alterations. The final consequences are reflected fundamentally as abnormal mineral metabolism (hypercalcemia, hypophosphatemia) and bone alterations [high or low bone turnover disease (as fibrous osteitis or adynamic bone disease), an eventual compromise of bone mineralization, decrease bone mineral density and bone fractures]. The major cause of post-transplantation hypercalcemia is the persistence of severe secondary hyperparathyroidism, and treatment options include calcimimetics or parathyroidectomy. On turn, hypophosphatemia is caused by both the persistence of high blood levels of PTH and/or high blood levels of FGF23, with its correction being very difficult to achieve. The most frequent bone morphology alteration is low bone turnover disease, while high-turnover osteopathy decreases in frequency after transplantation. Although the pathogenic mechanisms of these abnormalities have not been fully clarified, the available evidence suggests that there are a number of factors that play a very important role, such as immunosuppressive treatment, persistently high levels of PTH, vitamin D deficiency and hypophosphatemia. Fracture risk is four-fold higher in transplanted patients compared to general population. The most relevant risk factors for fracture in the kidney transplant population are diabetes mellitus, female sex, advanced age (especially > 65 years), dialysis vintage, high PTH levels and low phosphate levels, osteoporosis, pre-transplant stress fracture and high doses or prolonged steroids therapy. Treatment alternatives for CKD-MBD after transplantation include minimization of corticosteroids, use of calcium and vitamin D supplements, antiresorptives (bisphosphonates or Denosumab) and osteoformers (synthetic parathyroid hormone). As both mineral metabolism and bone disorders lead to increased morbidity and mortality, the presence of these changes after transplantation has to be prevented (if possible), minimized, diagnosed, and treated as soon as possible.
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Affiliation(s)
- Josep-Vicent Torregrosa
- Nephrology & Renal Transplant Department - Hospital Clínic, Barcelona, Spain.
- Universidad de Barcelona, Barcelona, Spain.
| | - Ana Carina Ferreira
- Nephrology Department, Centro Hospitalare, Universitário de Lisboa Central, Lisbon, Portugal
- Nova Medical School, Nova University, Lisbon, Portugal
| | - David Cucchiari
- Nephrology & Renal Transplant Department - Hospital Clínic, Barcelona, Spain
| | - Aníbal Ferreira
- Nephrology Department, Centro Hospitalare, Universitário de Lisboa Central, Lisbon, Portugal
- Nova Medical School, Nova University, Lisbon, Portugal
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20
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Iseri K, Carrero JJ, Evans M, Felländer-Tsai L, Berg HE, Runesson B, Stenvinkel P, Lindholm B, Qureshi AR. Incidence of Fractures Before and After Dialysis Initiation. J Bone Miner Res 2020; 35:2372-2380. [PMID: 32717115 PMCID: PMC7757394 DOI: 10.1002/jbmr.4141] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 07/13/2020] [Accepted: 07/19/2020] [Indexed: 12/22/2022]
Abstract
Fractures are common in dialysis patients, but little is known about the trajectory of incidence rates of different types of fractures before and after dialysis initiation. To address this, we investigated the incidence of major fractures before and after dialysis initiation. We performed a retrospective statistical analysis using the Swedish Renal Registry of 9041 incident dialysis patients (median age 67 years, 67% men) starting dialysis 2005 through 2015 to identify major fractures (hip, spine, humerus, and forearm) occurring during the dialysis transition period from 1 year before until 1 year after dialysis initiation. Using flexible parametric hazard models and the Fine-Gray model, we estimated adjusted fracture incidence rates and predictors of major fractures. We identified 361 cases with primary diagnosis of major fracture, of which 196 (54%) were hip fractures. The crude incidence rate of major fractures before dialysis initiation was 17 per 1000 patient-years (n = 157) and after dialysis initiation it was 24 per 1000 patient-years (n = 204). The adjusted incidence rate of major fractures began to increase 6 months before dialysis initiation, and then stabilized at a higher rate after 1 year. The adjusted incidence rate of hip fractures started to increase sharply 3 months before dialysis initiation, peaked at initiation, and declined thereafter. In contrast, the adjusted incidence rate of non-hip fractures was stable during the transition period and gradually increased over time. Higher age, female sex, and history of previous major fractures were associated with increased fracture incidence both before and after dialysis initiation. We conclude that the incidence of major fractures, especially hip fractures, start to rise 6 months before initiation of dialysis therapy, indicating that heightened surveillance with implementation of preventive measures to avoid fractures is warranted during the transition period to dialysis. © 2020 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Ken Iseri
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.,Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Juan Jesús Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Marie Evans
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Li Felländer-Tsai
- Division of Orthopaedics and Biotechnology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Hans E Berg
- Division of Orthopaedics and Biotechnology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Björn Runesson
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Peter Stenvinkel
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Bengt Lindholm
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Abdul Rashid Qureshi
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
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21
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Hsu CY, Chen LR, Chen KH. Osteoporosis in Patients with Chronic Kidney Diseases: A Systemic Review. Int J Mol Sci 2020; 21:ijms21186846. [PMID: 32961953 PMCID: PMC7555655 DOI: 10.3390/ijms21186846] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 09/13/2020] [Accepted: 09/16/2020] [Indexed: 02/06/2023] Open
Abstract
Chronic kidney disease (CKD) is associated with the development of mineral bone disorder (MBD), osteoporosis, and fragility fractures. Among CKD patients, adynamic bone disease or low bone turnover is the most common type of renal osteodystrophy. The consequences of CKD-MBD include increased fracture risk, greater morbidity, and mortality. Thus, the goal is to prevent the occurrences of fractures by means of alleviating CKD-induced MBD and treating subsequent osteoporosis. Changes in mineral and humoral metabolism as well as bone structure develop early in the course of CKD. CKD-MBD includes abnormalities of calcium, phosphorus, PTH, and/or vitamin D; abnormalities in bone turnover, mineralization, volume, linear growth, or strength; and/or vascular or other soft tissue calcification. In patients with CKD-MBD, using either DXA or FRAX to screen fracture risk should be considered. Biomarkers such as bALP and iPTH may assist to assess bone turnover. Before initiating an antiresorptive or anabolic agent to treat osteoporosis in CKD patients, lifestyle modifications, such as exercise, calcium, and vitamin D supplementation, smoking cessation, and avoidance of excessive alcohol intake are important. Managing hyperphosphatemia and SHPT are also crucial. Understanding the complex pathogenesis of CKD-MBD is crucial in improving one’s short- and long-term outcomes. Treatment strategies for CKD-associated osteoporosis should be patient-centered to determine the type of renal osteodystrophy. This review focuses on the mechanism, evaluation and management of patients with CKD-MBD. However, further studies are needed to explore more details regarding the underlying pathophysiology and to assess the safety and efficacy of agents for treating CKD-MBD.
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Affiliation(s)
- Chia-Yu Hsu
- Department of Rehabilitation Medicine, Ten-Chan General Hospital, Zhongli, Taoyuan 320, Taiwan;
- Department of Biomedical Engineering, Chung Yuan Christian University, Taoyuan 320, Taiwan
| | - Li-Ru Chen
- Department of Physical Medicine and Rehabilitation, Mackay Memorial Hospital, Taipei 104, Taiwan;
- Department of Mechanical Engineering, National Chiao-Tung University, Hsinchu 300, Taiwan
| | - Kuo-Hu Chen
- Department of Obstetrics and Gynecology, Taipei Tzu-Chi Hospital, The Buddhist Tzu-Chi Medical Foundation, Taipei 231, Taiwan
- Department of Medicine, School of Medicine, Tzu-Chi University, Hualien 970, Taiwan
- Correspondence: ; Tel.: +886-2662-89779
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22
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Gómez-Islas VE, García-Fong KR, Aguilar-Fuentes RE, Hernández-Castellanos S, Pherez-Farah A, Méndez-Bribiesca SA, López-Navarro JM, Osorio-Landa HK, Carbajal-Morelos SL, Zúñiga-Guzmán AM, Pérez-Díaz I. Evaluation of bone densitometry by dual-energy x-ray absorptiometry as a fracture prediction tool in women with chronic kidney disease. Bone Rep 2020; 13:100298. [PMID: 32743028 PMCID: PMC7387779 DOI: 10.1016/j.bonr.2020.100298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/27/2020] [Accepted: 07/13/2020] [Indexed: 11/22/2022] Open
Abstract
Background The 2017 KDIGO guidelines establish a 2B grade recommendation in favor of testing Bone Mineral Density (BMD) by DXA to assess osteoporotic fracture (OPF) risk in patients with CKD G3a-G5D. Still, controversy remains because large studies evaluating it for this particular population are lacking. Aim To establish the clinical performance of BMD measured by DXA in the evaluation of fracture risk in women with CKD. Methods We conducted a 43 year retrospective cohort study with 218 women ≥18 years-old with CKD and BMD measurement by DXA of total hip and lumbar spine. Clinical (age, year of CKD onset, comorbidities, BMI, transplant status, treatment), and biochemical (PTH, corrected calcium, phosphate, vitamin D [25 (OH) D3], creatinine, and albumin), parameters were collected from hospital records. All osteoporotic fractures (as defined by the WHO) found in the clinical and radiologic files were registered. Results 218 women with a median age of 60 years (40–73 IQ range) and a CKD evolution time of 12 years (7–18 IQ range) were evaluated. Forty-eight (28.23%) presented an OPF. These women were older (57 vs 69 years, p =0.0072) and had a lower BMD. CKD stage did not influence fracture incidence. In the multivariate analysis we found that for each standard deviation decrease in hip and lumbar spine T-Score, the overall fracture risk was 2.7 and 2.04 times higher, respectively. More than 50% of fractures took place within the first ten years of follow-up, especially with GFR <30 mL/min/m2 and osteoporosis. Diabetes and hypothyroidism accelerated fracture onset, while renal transplant delayed it. In the ROC analysis, the AUC was largest with the total hip (0.7098, p =0.000) and lumbar spine (0.6916, p = 0.000). Conclusions BMD measured by DXA is a useful fracture prediction tool for women with CKD, having a sensibility and specificity similar to that in the general population. It seems to be appropriate for the diagnosis, treatment decisions, and follow-up of patients with renal failure.
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Affiliation(s)
- Valeria E. Gómez-Islas
- Department of Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Mexico City Campus, Mexico
| | - Kevin R. García-Fong
- Department of Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Rosa E. Aguilar-Fuentes
- Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Mexico City Campus, Mexico
| | | | - Alfredo Pherez-Farah
- Department of Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Mexico City Campus, Mexico
| | - Sofía A. Méndez-Bribiesca
- Department of Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Mexico City Campus, Mexico
| | - Juan M. López-Navarro
- Department of Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Hillary K. Osorio-Landa
- Department of Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Mexico City Campus, Mexico
| | - Sergio L. Carbajal-Morelos
- Department of Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Mexico City Campus, Mexico
| | - Areli M. Zúñiga-Guzmán
- Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Mexico City Campus, Mexico
| | - Iván Pérez-Díaz
- Department of Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Mexico City Campus, Mexico
- Corresponding author at: Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, Avenida Vasco de Quiroga 15, Colonia Belisario Domínguez Sección XVI, PC. 14080, Tlalpan, Mexico City, Mexico.
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23
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Iliac crest bone biopsy by interventional radiologists to improve access to bone biopsy in chronic kidney disease populations: technical note and a case series. J Nephrol 2020; 34:901-906. [PMID: 32656748 DOI: 10.1007/s40620-020-00798-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 07/04/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Chronic kidney disease-mineral and bone disorder (CKD-MBD) leads to increased fracture risk. Iliac crest biopsy remains the gold standard for diagnosing bone disease in CKD. Unfortunately, bone biopsy is rarely performed which is mainly due to the inability of clinicians to perform the procedure. In this paper, we propose a fluoroscopy-guided procedure performed by interventional radiologists as a novel approach to iliac crest biopsy in adult population. We describe the implementation of the procedure and present the first 11 cases of CKD patients who underwent iliac crest biopsy with this new approach. METHODS A nephrologist already trained in performing iliac crest biopsy initiated the creation of a fluoroscopy-based iliac crest biopsy program. Two interventional radiologists underwent a short training. Patients' demographical, clinical and biochemical data were collected on the day of the biopsy. Complications within the first three months after the procedure were collected from electronical records. RESULTS IR rapidly mastered the procedure. The use of fluoroscopy allowed a precise localisation of the biopsy site and standardization of the intervention, which ensured specimen quality. The new approach allowed CKD patients to access iliac crest biopsy, which resulted in precise bone disease diagnosis (levels of bone turnover and mineralization) and targeted therapy for each case. There were no complications during, nor within 3 months after the intervention. CONCLUSIONS We believe this approach will increase the access to iliac crest biopsy for diagnosing bone disease in CKD population. Studies are now needed to evaluate whether CKD patients will benefit from anti-osteoporotic therapy based on the results of iliac crest biopsy.
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Vilaca T, Salam S, Schini M, Harnan S, Sutton A, Poku E, Allen IE, Cummings SR, Eastell R. Risks of Hip and Nonvertebral Fractures in Patients With CKD G3a-G5D: A Systematic Review and Meta-analysis. Am J Kidney Dis 2020; 76:521-532. [PMID: 32654892 DOI: 10.1053/j.ajkd.2020.02.450] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 02/25/2020] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Disordered mineral metabolism complicates chronic kidney disease (CKD), but the effect of reduced kidney function on fracture risk has not been fully established. We conducted a systematic review and meta-analysis of the risks for hip and nonvertebral fractures in people with CKD. We also investigated the effects of age, sex, and CKD stage. STUDY DESIGN Systematic review and meta-analysis. STUDY POPULATION Adults with CKD glomerular filtration rate (GFR) categories 3a-5D (G3a-G5D) compared with adults without CKD G3a-G5D. SELECTION CRITERIA FOR STUDIES Observational studies. DATA EXTRACTION Data extraction was conducted by 1 reviewer and checked by a second reviewer. ANALYTICAL APPROACH MEDLINE, EMBASE, and Cochrane databases were searched in March 2018 and an update was conducted in November 2019. We used random-effects models to calculate pooled risk estimates and 95% CIs. RESULTS 17 studies met the inclusion criteria. We included 13 studies in the hip fracture systematic review and 10 studies in the meta-analysis. Studies reported data from 250,440,035 participants; 5,798,566 with CKD G3a-G5D and 363,410 with hip fractures. 4 studies were included in the nonvertebral fracture analysis, reporting data from 1,396,976 participants; 464,978 with CKD G3a-G5D and 115,284 fractures. Studies reported data from participants aged 18 to older than 90 years. We found a significant increase in fracture risk both for hip (relative risk [RR], 2.36; 95% CI, 1.64-3.39) and nonvertebral fractures (RR, 1.47; 95% CI, 1.15-1.88). For hip fractures, younger patients (<65 years) had higher relative risk (RR, 7.66; 95% CI, 2.76-21.26) than older patients (>65 years; RR, 2.11; 95% CI, 1.41-3.16). Greater GFR loss was associated with higher relative risk for fractures. LIMITATIONS We could not assess the effects of bone mineral density, biochemical abnormalities, renal osteodystrophy, frailty, falls, or medications on risk for fractures. CONCLUSIONS Risks for hip and nonvertebral fractures are increased in CKD G3a-G5D. The relative risk of hip fracture is greater in the younger than the older population and increases progressively with loss of GFR. We suggest that fracture prevention should be a consideration in CKD at any age.
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Affiliation(s)
- Tatiane Vilaca
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, United Kingdom.
| | - Syazrah Salam
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, United Kingdom
| | - Marian Schini
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, United Kingdom
| | - Susan Harnan
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Anthea Sutton
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Edith Poku
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | | | | | - Richard Eastell
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, United Kingdom
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25
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Dusceac R, Niculescu DA, Dobre R, Sorohan MC, Caragheorgheopol A, Tacu C, David C, Poiana C. Bone turnover correlates with bone quantity but not bone microarchitecture in chronic hemodialysis. J Bone Miner Metab 2020; 38:597-604. [PMID: 32144577 DOI: 10.1007/s00774-020-01094-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 02/11/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION In chronic hemodialysis, high-turnover bone disease was associated with decreased bone mineral density (BMD), poor bone quality (chemical and structural), and increased fracture risk. Our aim was to correlate bone turnover markers (BTMs) with bone microarchitecture measured by trabecular bone score (TBS) before and after correction for BMD. MATERIALS AND METHODS We measured lumbar spine (LS), femoral neck, and 1/3 radius BMD and LS TBS by dual X-ray absorptiometry in 81 patients on permanent hemodialysis. Bone turnover was assessed using serum parathyroid hormone, osteocalcin, C-terminal crosslaps of type 1 collagen, procollagen 1 N-terminal propeptide (P1NP), and alkaline phosphatase (ALP). No patient had any partial or total parathyroidectomy and no previous or current treatment with anti-osteoporotic drugs. RESULTS All BTMs correlated significantly with each other. Univariate regressions showed significant negative correlations between BTMs and BMD (best r = - 0.53, between P1NP and 1/3 radius Z-score) or BTMs and TBS (best r = - 0.27, p < 0.05 between ALP and TBS T-score). TBS correlated significantly with BMD at all three sites (best r = 0.5, between LS BMD and TBS T-score). Multivariate regression showed that TBS, crude or adjusted, correlated with LS BMD. No model retained any of the BTMs as independent variables due to the better prediction of BMD and multicollinearity. CONCLUSION We showed a progressively impaired bone microarchitecture with increasing bone turnover in chronic hemodialysis. However, this correlation is no longer present when controlling for bone mass. This suggests that impaired bone microarchitecture and increased fracture risk are dependent upon factors other than high bone turnover.
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Affiliation(s)
- Roxana Dusceac
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, 34-38 Aviatorilor blvd, 011863, Bucharest, Romania
| | - Dan Alexandru Niculescu
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, 34-38 Aviatorilor blvd, 011863, Bucharest, Romania.
| | - Ramona Dobre
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, 34-38 Aviatorilor blvd, 011863, Bucharest, Romania
| | - Madalina Cristina Sorohan
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, 34-38 Aviatorilor blvd, 011863, Bucharest, Romania
| | - Andra Caragheorgheopol
- Research Laboratory, C. I. Parhon National Institute of Endocrinology, 34-38 Aviatorilor blvd, 011863, Bucharest, Romania
| | - Catalin Tacu
- Diaverum Dialysis Center, 2N Industiilor blvd, 032895, Bucharest, Romania
| | - Cristiana David
- Department of Nephrology, Carol Davila University of Medicine and Pharmacy, 13 Vitan-Barzesti rd, 042122, Bucharest, Romania
| | - Catalina Poiana
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, 34-38 Aviatorilor blvd, 011863, Bucharest, Romania
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26
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Desbiens LC, Sidibé A, Beaudoin C, Jean S, Mac-Way F. Comparison of Fracture Prediction Tools in Individuals Without and With Early Chronic Kidney Disease: A Population-Based Analysis of CARTaGENE. J Bone Miner Res 2020; 35:1048-1057. [PMID: 32022942 DOI: 10.1002/jbmr.3977] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 01/11/2020] [Accepted: 01/29/2020] [Indexed: 12/17/2022]
Abstract
Whether fracture prediction tools developed for the management of osteoporosis can be used in chronic kidney disease (CKD) is poorly known. We aimed to compare the performance of fracture prediction tools in non-CKD and CKD. We analyzed CARTaGENE, a population-based survey of 40-year-old to 69-year-old individuals recruited between 2009 and 2010. Renal function was assessed using baseline creatinine and categorized according to Kidney Disease Improving Global Outcomes (KDIGO) guidelines (non-CKD, stage 2, stage 3). Individuals without creatinine measurements or with advanced CKD (stage 4 or 5; prevalence <0.25%) were excluded. Predicted 5-year fracture probabilities (using Fracture Risk Assessment Tool [FRAX], QFracture, and Garvan) were computed at baseline. Fracture incidence (major fracture [MOF] or any fracture) was evaluated in administrative databases from recruitment to March 2016. Discrimination (hazard ratios [HRs] per standard deviation [SD] increase in Cox models; c-statistics) and calibration (standardized incidence ratios [SIRs] before and after recalibration) were assessed in each CKD strata. We included 19,393 individuals (9522 non-CKD; 9114 stage 2; 757 stage 3). A total of 830 patients had any fracture during follow-up, including 352 MOF. FRAX (HR = 1.89 [1.63-2.20] non-CKD; 1.64 [1.41-1.91] stage 2; 1.76 [1.10-2.82] stage 3) and QFracture (HR = 1.90 [1.62-2.22] non-CKD; 1.57 [1.35-1.82] stage 2; 1.86 [1.19-2.91] stage 3) discriminated MOF similarly in non-CKD and CKD. In contrast, the discrimination of Garvan for any fracture tended to be lower in CKD stage 3 compared to non-CKD and CKD stage 2 (HR = 1.36 [1.22-1.52] non-CKD; 1.34 [1.20-1.50] stage 2; 1.11 [0.79-1.55] stage 3). Before recalibration, FRAX globally overestimated fracture risk while QFracture and Garvan globally underestimated fracture risk. After recalibration, FRAX and QFracture were adequately calibrated for MOF in all CKD strata whereas Garvan tended to underestimate any fracture risk in CKD stage 3 (SIR = 1.31 [0.95-1.81]). In conclusion, the discrimination and calibration of FRAX and QFracture is similar in non-CKD and CKD. Garvan may have a lower discrimination in CKD stage 3 and underestimate fracture risk in these patients. © 2020 American Society for Bone and Mineral Research.
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Affiliation(s)
- Louis-Charles Desbiens
- CHU de Québec Research Center, L'Hôtel-Dieu-de-Québec Hospital, Endocrinology and Nephrology Axis, Quebec City, Canada.,Department and Faculty of Medicine, Université Laval, Quebec City, Canada
| | - Aboubacar Sidibé
- CHU de Québec Research Center, L'Hôtel-Dieu-de-Québec Hospital, Endocrinology and Nephrology Axis, Quebec City, Canada.,Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Quebec City, Canada
| | - Claudia Beaudoin
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Quebec City, Canada.,Institut National de Santé Publique du Québec, Quebec City, Canada
| | - Sonia Jean
- Department and Faculty of Medicine, Université Laval, Quebec City, Canada.,Institut National de Santé Publique du Québec, Quebec City, Canada
| | - Fabrice Mac-Way
- CHU de Québec Research Center, L'Hôtel-Dieu-de-Québec Hospital, Endocrinology and Nephrology Axis, Quebec City, Canada.,Department and Faculty of Medicine, Université Laval, Quebec City, Canada
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Jansz TT, Goto NA, van Ballegooijen AJ, Willems HC, Verhaar MC, van Jaarsveld BC. The prevalence and incidence of vertebral fractures in end-stage renal disease and the role of parathyroid hormone. Osteoporos Int 2020; 31:515-524. [PMID: 31728605 PMCID: PMC7076061 DOI: 10.1007/s00198-019-05187-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 10/09/2019] [Indexed: 11/17/2022]
Abstract
UNLABELLED The risk of vertebral fracture is unclear in end-stage renal disease. We report a high vertebral fracture prevalence and incidence in transplantation-eligible patients on dialysis, suggesting that these patients may benefit from radiographic screening for vertebral fractures. Parathyroid hormone had a U-shaped association with vertebral fracture risk. INTRODUCTION Vertebral fractures are often overlooked, but even undiagnosed vertebral fractures negatively impact physical functioning, quality of life, and mortality. The risk of vertebral fractures in end-stage renal disease (ESRD) patients is unclear, and parathyroid hormone (PTH) might play a role in the development of vertebral fractures. We therefore determined vertebral fracture prevalence and incidence in ESRD patients and assessed associations of vertebral trabecular bone mineral density (BMD) and PTH with vertebral fracture. METHODS In 146 transplantation-eligible patients on dialysis, we determined vertebral fractures on lateral chest radiographs, which image the thoracic and upper lumbar spine. We determined incident vertebral fractures in 70 patients with follow-up radiographs (23 received a kidney transplant) after median 1.8 years. Vertebral trabecular BMD was measured with computed tomography, and PTH measured with 2-site immunoassays, categorized in tertiles with the middle tertile as reference. We used Poisson regression to assess associations of vertebral trabecular BMD and PTH with vertebral fracture. RESULTS Mean age of the study population was 52 ± 13 years, and 98 (67%) were male. Median dialysis duration was 26 (IQR 13-55) months. Vertebral fractures were present in 50/146 patients (34%) and incident vertebral fractures occurred in 20/70 patients (29%). Vertebral trabecular BMD was not associated with vertebral fracture prevalence (relative risk 0.97, 95% CI 0.89 to 1.04). For the lowest PTH tertile (< 11 pmol/L), the relative risk of vertebral fracture was greater although not significant (2.28, 95% CI 0.97 to 5.97) and was significantly greater for the highest PTH tertile (≥ 30 pmol/L; 2.82, 95% CI 1.22 to 7.27) after adjustment for potential confounders. CONCLUSIONS The prevalence and incidence of vertebral fractures is high even in relatively young and healthy ESRD patients. Vertebral trabecular BMD is not associated with vertebral fracture, and the association of PTH with vertebral fracture risk appears U-shaped. Nevertheless, our study did not measure vertebral BMD using DXA and assessed vertebral fractures using lateral chest radiographs and not spine radiographs.
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Affiliation(s)
- T T Jansz
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Dianet Dialysis Centers, Utrecht, the Netherlands
| | - N A Goto
- Dianet Dialysis Centers, Utrecht, the Netherlands
- Department of Geriatrics, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - A J van Ballegooijen
- Department of Nephrology and Cardiovascular Sciences (ACS), Amsterdam UMC, Vrije Universiteit Amsterdam, P.O. box 7507, 1007 MB, Amsterdam, the Netherlands
- Department of Epidemiology and Biostatistics, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - H C Willems
- Department of Geriatrics, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - M C Verhaar
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - B C van Jaarsveld
- Dianet Dialysis Centers, Utrecht, the Netherlands.
- Department of Nephrology and Cardiovascular Sciences (ACS), Amsterdam UMC, Vrije Universiteit Amsterdam, P.O. box 7507, 1007 MB, Amsterdam, the Netherlands.
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Desbiens LC, Goupil R, Mac-Way F. Predictive value of quantitative ultrasound parameters in individuals with chronic kidney disease: A population-based analysis of CARTaGENE. Bone 2020; 130:115120. [PMID: 31676408 DOI: 10.1016/j.bone.2019.115120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 09/11/2019] [Accepted: 10/22/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND The use of calcaneal quantitative ultrasound (QUS) to predict fractures has not been well studied in early CKD populations. We compared the association of QUS with incidental fractures and its predictive properties in non-CKD and CKD individuals. METHODS Analysis of a prospective population-based survey of 40- to 69-year-old individuals recruited between 2009 and 2010. QUS parameters (stiffness index [SI], speed of sound [SOS], broadband attenuation [BUA]) were measured at baseline. Renal function was measured using baseline creatinine and was classified into CKD stages (non-CKD, stage 2, stage 3). Fracture incidence at any site or at major osteoporotic fracture sites for up to 7 years of follow-up was identified in administrative databases using a validated algorithm. The association (age-adjusted hazard ratio per standard deviation decrease in Cox models), discrimination (c-statistic) and calibration (standardized incidence ratio [SIR]) of QUS parameters with fracture outcomes was computed in each CKD stratum. RESULTS We included 18,306 individuals (9,011 non-CKD; 8,595 CKD stage 2; 700 CKD stage 3). During a median follow-up of 70 months, we identified 782 fractures at any site and 326 major osteoporotic fractures. Although all QUS parameters (SI, SOS and BUA) were associated with any or major fracture incidence in non-CKD and CKD patients, the magnitude of these associations was lower for any fracture and for BUA. QUS parameters moderately discriminated incidental fractures across CKD strata but underestimated fracture incidence in CKD stage 3 even after adjustment for demographics and clinical risk factors. At a given QUS value, CKD stage 3 patients had higher fracture risk than non-CKD and CKD stage 2 patients. CONCLUSIONS QUS parameters are associated with fracture incidence in both non-CKD and CKD but underestimate fracture incidence in individuals with early CKD.
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Affiliation(s)
- Louis-Charles Desbiens
- CHU de Québec Research Center, L'Hôtel-Dieu-de-Québec 10 McMahon, Quebec City, QC, G1R 2J6, Canada; Department and Faculty of Medicine, Université Laval. 1050, avenue de la Médecine, local 4211, Quebec City, QC, G1V 0A6, Canada.
| | - Rémi Goupil
- Hôpital du Sacré-Coeur de Montréal, Nephrology Division, 5400 Boul Gouin O, Montreal, QC, H4J 1C5, Canada; Department and Faculty of Medicine, Université de Montréal, 2900, boul. Édouard-Montpetit, local S-759, Montreal, QC, H3T 1J4, Canada.
| | - Fabrice Mac-Way
- CHU de Québec Research Center, L'Hôtel-Dieu-de-Québec 10 McMahon, Quebec City, QC, G1R 2J6, Canada; Department and Faculty of Medicine, Université Laval. 1050, avenue de la Médecine, local 4211, Quebec City, QC, G1V 0A6, Canada.
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USTA M, ERSOY A, ERSOY C, GÖKSEL G. Chronic kidney disease presenting with bilateral spontaneous femoral neck fracture: A case report. TURKISH JOURNAL OF INTERNAL MEDICINE 2019. [DOI: 10.46310/tjim.632048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Alvi MA, Zreik J, Wahood W, Goyal A, Freedman BA, Sebastian AS, Bydon M. Impact of Dialysis on 30-Day Outcomes After Spinal Fusion Surgery for Pathologic Fractures: Insights from a National Quality Registry. World Neurosurg 2019; 130:e862-e873. [PMID: 31295605 DOI: 10.1016/j.wneu.2019.07.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 06/30/2019] [Accepted: 07/01/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Patients with chronic renal failure undergoing hemodialysis have been shown to have poor overall health, osteoporosis, and altered bone metabolism. However, the impact of hemodialysis on patient outcomes after spinal fusion remains unknown. We sought to assess the effect of dialysis on 30-day perioperative and postoperative outcomes after cervical and lumbar fusion for pathologic compression fractures. METHODS We queried the National Surgical Quality Improvement Program from 2009 to 2016 for patients undergoing cervical or lumbar fusion for compression fractures. Three-to-one propensity score matching using sex, age, body mass index, and number of operated levels was used to match patients not undergoing dialysis with those undergoing dialysis. Multivariable conditional regression was used to identify the association between dialysis and 30-day clinical outcomes, after adjusting for confounders. RESULTS A total of 48,492 patients undergoing cervical fusion were identified; 156 (0.32%) of these were on dialysis. On multivariable regression, dialysis dependency was associated with increased operative time (regression coefficient [coef.], 15.93; 95% CI, 0.4-31.5; P = 0.045), length of stay (coef. 6.06; 95% CI, 4.64-7.48; P < 0.001), 30-day readmissions (odds ratio [OR], 1.07; 95% CI, 1.02-1.12; P = 0.009), any complications (OR 1.08; 95% CI, 1.03-1.13; P = 0.002), and serious complications (OR, 1.08; 95% CI, 1.02-1.14; P = 0.012). A total of 25,417 patients undergoing lumbar fusion were identified; 51 of these (0.2%) were on dialysis. On multivariable regression, dialysis dependency was associated with significantly higher length of stay (coef. 2.98; 95% CI, 1.28-4.68; P < 0.001). CONCLUSIONS Our analyses indicated that dialysis dependency is associated with poor perioperative and postoperative outcomes after cervical/lumbar fusion for pathologic compression fractures.
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Affiliation(s)
- Mohammed Ali Alvi
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jad Zreik
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Waseem Wahood
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Anshit Goyal
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Brett A Freedman
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Arjun S Sebastian
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohamad Bydon
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
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Cazzolla AP, Lacaita MG, Lacarbonara V, Zhurakivska K, Franco A, Gissi I, Testa NF, Marzo G, Muzio L. Orthopedic and orthodontic management in a patient with DiGeorge Syndrome and Familial Mediterranean Fever: A case report. SPECIAL CARE IN DENTISTRY 2019; 39:340-347. [DOI: 10.1111/scd.12381] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 03/10/2019] [Accepted: 04/08/2019] [Indexed: 11/29/2022]
Affiliation(s)
| | | | | | | | - Annarosa Franco
- Department of Odontostomatology and SurgeryUniversity of Bari Bari Italy
| | - Irene Gissi
- Department of Odontostomatology and SurgeryUniversity of Bari Bari Italy
| | | | - Giuseppe Marzo
- Department of Life, Health and Environmental SciencesDental ClinicUniversity of L'Aquila L'Aquila Italy
| | - Lorenzo Muzio
- Department of Clinical and Experimental MedicineUniversity of Foggia Foggia Italy
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