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Suzuki K, Mizoguchi Y, Hasebe Y, Kimura F, Saita K, Ogihara S. Association of Preoperative Osteoporotic Vertebral Compression Fractures with Muscle Atrophy in Lumbar Spinal Stenosis: A Retrospective Cohort Study. Prog Rehabil Med 2024; 9:20240011. [PMID: 38567018 PMCID: PMC10984831 DOI: 10.2490/prm.20240011] [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: 02/07/2024] [Accepted: 03/13/2024] [Indexed: 04/04/2024] Open
Abstract
Objectives Osteoporotic vertebral compression fractures (OVCFs) are common in older individuals and lead to pain, spinal deformities, and limited mobility. Paraspinal muscle function correlates with fracture severity, and this association may be more significant in patients with lumbar spinal stenosis (LSS). However, studies on the effects of OVCFs are lacking. This study aimed to investigate the relationship between OVCFs, fat infiltration, and muscle atrophy in patients with LSS. Methods This study included 177 patients with preoperative LSS, of whom 16 had OVCFs and 161 did not. Lumbar lordosis angle, fat infiltration, and paraspinal muscle atrophy were evaluated in these patients. Information on patient characteristics such as smoking, diabetes, hemodialysis, steroid use, American Society of Anesthesiologists score, and bladder or bowel dysfunction were obtained from medical records. Logistic regression analysis was conducted to identify factors independently associated with OVCF. Results Patients in the OVCF group were significantly older (P=0.006) than those without fractures, and a higher proportion of the OVCF group showed muscle atrophy (P=0.034). Significant variables and those with moderate effect sizes were included in the logistic regression analysis. Muscle atrophy (P=0.028) was independently associated with OVCF. Conclusions Muscle atrophy was associated with preoperative OVCFs in patients with LSS. Identifying OVCFs in these patients may underscore the importance of tailored treatment and rehabilitation strategies for the paraspinal muscles.
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Affiliation(s)
- Kenta Suzuki
- Department of Rehabilitation, Kimura Orthopedic Clinic,
Kumagaya, Japan
| | - Yasuaki Mizoguchi
- Department of Rehabilitation, Kimura Orthopedic Clinic,
Kumagaya, Japan
- Saitama Medical University Graduate School of Medicine,
Moroyama, Japan
| | - Yuki Hasebe
- Department of Rehabilitation, Saitama Medical Center,
Saitama Medical University, Kawagoe, Japan
| | - Fumihiko Kimura
- Department of Rehabilitation, Kimura Orthopedic Clinic,
Kumagaya, Japan
| | - Kazuo Saita
- Department of Orthopedic Surgery, Saitama Medical Center,
Saitama Medical University, Kawagoe, Japan
| | - Satoshi Ogihara
- Department of Orthopedic Surgery, Saitama Medical Center,
Saitama Medical University, Kawagoe, Japan
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Wang YP, Khelifi N, Halleux CD, Ung RV, Samson F, Gagnon C, Mac-Way F. Bone Marrow Adiposity, Bone Mineral Density and Wnt/β-catenin Pathway Inhibitors Levels in Hemodialysis Patients. J Bone Metab 2022; 29:113-122. [PMID: 35718928 PMCID: PMC9208902 DOI: 10.11005/jbm.2022.29.2.113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 05/16/2022] [Indexed: 11/25/2022] Open
Abstract
Background Marrow adipose tissue (MAT) is known to accumulate in patients with chronic kidney disease. This pilot study aimed to evaluate bone mineral density (BMD), MAT, visceral adipose tissue (VAT), and subcutaneous adipose tissue (SAT) using computed tomography (CT) scans and to explore correlations between bone parameters, circulating Wnt/β-catenin pathway inhibitor levels, and adipose tissue parameters. Methods Single-center cross-sectional pilot study conducted in hemodialysis patients at the Centre Universitaire de Québec, Hôtel-Dieu de Québec hospital, Canada. CT-scan slices were acquired at the levels of the hip, L3 vertebra, and tibia. Volumetric and areal BMD, tibia cortical thickness, VAT and SAT area, and fat marrow index (FMI) were analyzed using the Mindways QCT Pro software. Blood levels of sclerostin, dickkopf-related protein 1 (DKK1), fibroblast growth factor 23, and α-Klotho were assessed. Spearman’s rho test was used to evaluate correlations. Results Fifteen hemodialysis patients (median age, 75 [66–82] years; 80% male; dialysis vintage, 39.3 [27.4–71.0] months) were included. While inverse correlations were obtained between L3 FMI and BMD, positive correlations were found between proximal tibial FMI and vertebral and tibial BMD, as well as with tibial (proximal and distal) cortical thickness. VAT had a positive correlation with α-Klotho levels, whereas L3 FMI had a negative correlation with DKK1 levels. Conclusions CT-scan allows simultaneous evaluation of bone and marrow adiposity in dialysis patients. Correlations between MAT and BMD vary depending on the bone site evaluated. DKK1 and α-Klotho levels correlate with adipose tissue accumulation in dialysis patients.
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Affiliation(s)
- Yue-Pei Wang
- Faculty and Department of Medicine, CHU de Québec Research Center, L'Hôtel-Dieu de Québec Hospital, Endocrinology and Nephrology Axis, Université Laval, Quebec, Canada
| | - Nada Khelifi
- Faculty and Department of Medicine, CHU de Québec Research Center, L'Hôtel-Dieu de Québec Hospital, Endocrinology and Nephrology Axis, Université Laval, Quebec, Canada
| | - Cyrille de Halleux
- Faculty and Department of Medicine, CHU de Québec Research Center, L'Hôtel-Dieu de Québec Hospital, Endocrinology and Nephrology Axis, Université Laval, Quebec, Canada
| | - Roth-Visal Ung
- Faculty and Department of Medicine, CHU de Québec Research Center, L'Hôtel-Dieu de Québec Hospital, Endocrinology and Nephrology Axis, Université Laval, Quebec, Canada
| | - France Samson
- Faculty and Department of Medicine, CHU de Québec Research Center, L'Hôtel-Dieu de Québec Hospital, Endocrinology and Nephrology Axis, Université Laval, Quebec, Canada
| | - Claudia Gagnon
- Faculty and Department of Medicine, CHU de Québec Research Center, L'Hôtel-Dieu de Québec Hospital, Endocrinology and Nephrology Axis, Université Laval, Quebec, Canada
| | - Fabrice Mac-Way
- Faculty and Department of Medicine, CHU de Québec Research Center, L'Hôtel-Dieu de Québec Hospital, Endocrinology and Nephrology Axis, Université Laval, Quebec, 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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Goto NA, Koelé MC, van Loon IN, Boereboom FTJ, Verhaar MC, Emmelot-Vonk MH, Hamaker ME, Willems HC. Thoracic vertebral fractures and hyperkyphosis in elderly patients with end-stage kidney disease; do these patients have different clinical outcomes? Bone 2019; 127:181-187. [PMID: 31200077 DOI: 10.1016/j.bone.2019.06.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 05/29/2019] [Accepted: 06/07/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND OBJECTIVES Elderly patients with end-stage kidney disease (ESKD) are at high risk for fractures. However, the prevalence of vertebral fractures and hyperkyphosis is not studied well. This is relevant, because in the general population, both vertebral fractures and hyperkyphosis are associated with poor outcome. Therefore, the primary aim of our study was to assess the prevalence of vertebral fractures and hyperkyphosis in the ESKD population. The secondary aim was to assess if patients with vertebral fractures and/or hyperkyphosis more often have poor outcome after starting dialysis, such as accidental falling, functional decline and mortality compared to the patients without vertebral fractures and/or hyperkyphosis. DESIGN, SETTING, PARTICIPANTS & MEASUREMENTS This study included patients ≥65 years with ESKD who were enrolled in the Geriatric assessment in Older patients starting Dialysis (GOLD) study of whom a lateral chest radiograph was available. Chest radiographs were scored independently by two observers for vertebral fractures (Genant ≥1) and hyperkyphosis (≥50 degrees). The relation between vertebral fractures and hyperkyphosis with clinical outcomes (falls, decline in ADL and IADL, mortality) was studied using the Chi-square test. RESULTS Of the 196 enrolled patients, chest radiographs were available for 160 patients. Mean age was 75.3 (SD ±6.9), and 35% were female. The prevalence of vertebral fractures was 43% and of hyperkyphosis 22%. Patients with hyperkyphosis had a higher one-year mortality compared to patients without hyperkyphosis (20% vs. 8%, p = 0.04). No differences were observed between patients with and without hyperkyphosis, vertebral fractures and the remaining outcomes after six months of follow-up. CONCLUSIONS In patients ≥65 years old with ESKD starting dialysis, vertebral fractures are highly prevalent. In contrast to the general population, patients with vertebral fractures did experience poor outcome as often as patients without vertebral fractures. Remarkably, patients with hyperkyphosis did have a higher one-year mortality. However, these patients did not experience more functional decline or accidental falls.
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Affiliation(s)
- N A Goto
- Dianet Dialysis Center, Utrecht, the Netherlands; Department of Geriatrics, University Medical Center Utrecht, Utrecht University, the Netherlands.
| | - M C Koelé
- Department of Internal Medicine, Division of Geriatrics, Amsterdam UMC, Academic Medical Center Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - I N van Loon
- Dianet Dialysis Center, Utrecht, the Netherlands; Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - F T J Boereboom
- Dianet Dialysis Center, Utrecht, the Netherlands; Department of Internal Medicine, Diakonessenhuis Utrecht, Utrecht, the Netherlands
| | - M C Verhaar
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - M H Emmelot-Vonk
- Department of Geriatrics, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - M E Hamaker
- Department of Geriatrics, Diakonessenhuis Utrecht, Utrecht, the Netherlands
| | - H C Willems
- Department of Internal Medicine, Division of Geriatrics, Amsterdam UMC, Academic Medical Center Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
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Sidibé A, Auguste D, Desbiens L, Fortier C, Wang YP, Jean S, Moore L, Mac‐Way F. Fracture Risk in Dialysis and Kidney Transplanted Patients: A Systematic Review. JBMR Plus 2019; 3:45-55. [PMID: 30680363 PMCID: PMC6339558 DOI: 10.1002/jbm4.10067] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 06/07/2018] [Accepted: 06/14/2018] [Indexed: 12/14/2022] Open
Abstract
Chronic kidney disease is associated with an increased risk of fracture and cardiovascular mortality. The risk of fracture in hemodialysis (HD), peritoneal dialysis (PD) and kidney transplant (KT) patients is higher when compared with the general population. However, there exists a knowledge gap concerning which group has the highest risk of fracture. We aimed to compare the risk of fracture in HD, PD, and KT populations. We conducted a systematic review of observational studies evaluating the risk of fracture in HD, PD, or KT patients. Eligible studies were searched using MEDLINE, Embase, Web of Science, and Cochrane Library from their inception to January 2016, and in grey literature. Incidences (cumulative and rate) of fracture were described together using the median, according to fracture sites, the data source (administrative database or cohort and clinical registry), and fracture diagnosis method. Prevalence estimates were described separately. We included 47 studies evaluating the risk of fracture in HD, PD, and KT populations. In administrative database studies, incidence of hip fracture in HD (median 11.45 per 1000 person-years [p-y]), range: 9.3 to 13.6 was higher than in KT (median 2.6 per 1000 p-y; range 1.5 to 3.8) or in PD (median 5.2 per 1000 p-y; range 4.1 to 6.3). In dialysis (HD+PD), three studies reported a higher incidence of hip fracture than in KT. Prevalent vertebral fracture (assessed by X-rays or questionnaire) reported in HD was in a similar range as that reported in KT. Incidence of overall fracture was similar in HD and KT, from administrative databases studies, but lower in HD compared with KT, from cohorts or clinical registry studies. This systematic review suggests an important difference in fracture risk between HD, PD, and KT population, which vary according to the diagnosis method for fracture identification. © 2018 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Aboubacar Sidibé
- Centre de Recherche du CHU de QuébecHôpital Hôtel‐Dieu de QuébecDivision of Nephrology, Endocrinology, and Nephrology AxisFaculty of MedicineDepartment of Social and Preventive MedicineLaval UniversityQuebecCanada
| | - David Auguste
- Centre de Recherche du CHU de QuébecHôpital Saint‐SacrementFaculty of MedicineDepartment of Social and Preventive MedicineLaval UniversityQuebecCanada
| | - Louis‐Charles Desbiens
- Centre de Recherche du CHU de QuébecHôpital Hôtel‐Dieu de QuébecDivision of Nephrology, Endocrinology, and Nephrology AxisFaculty and Department of MedicineLaval UniversityQuebecCanada
| | - Catherine Fortier
- Centre de Recherche du CHU de QuébecHôpital Hôtel‐Dieu de QuébecDivision of Nephrology, Endocrinology, and Nephrology AxisFaculty and Department of MedicineLaval UniversityQuebecCanada
| | - Yue Pei Wang
- Centre de Recherche du CHU de QuébecHôpital Hôtel‐Dieu de QuébecDivision of Nephrology, Endocrinology, and Nephrology AxisFaculty and Department of MedicineLaval UniversityQuebecCanada
| | - Sonia Jean
- Institut National de Santé Publique du QuébecMedicine FacultyDepartment of Social and Preventive MedicineLaval UniversityQuebecCanada
| | - Lynne Moore
- Centre de Recherche du CHU de QuébecHôpital de l'Enfant‐JésusTraumatology AxisMedicine FacultyDepartment of Social and Preventive MedicineLaval UniversityQuebecCanada
| | - Fabrice Mac‐Way
- Centre de Recherche du CHU de QuébecHôpital Hôtel‐Dieu de QuébecDivision of Nephrology, Endocrinology, and Nephrology AxisFaculty and Department of MedicineLaval UniversityQuebecCanada
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Bover J, Ureña-Torres P, Torregrosa JV, Rodríguez-García M, Castro-Alonso C, Górriz JL, Laiz Alonso AM, Cigarrán S, Benito S, López-Báez V, Lloret Cora MJ, daSilva I, Cannata-Andía J. Osteoporosis, bone mineral density and CKD-MBD complex (I): Diagnostic considerations. Nefrologia 2018; 38:476-490. [PMID: 29703451 DOI: 10.1016/j.nefro.2017.12.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 12/21/2017] [Accepted: 12/31/2017] [Indexed: 01/10/2023] Open
Abstract
Osteoporosis (OP) and chronic kidney disease (CKD) independently influence bone and cardiovascular health. A considerable number of patients with CKD, especially those with stages 3a to 5D, have a significantly reduced bone mineral density leading to a high risk of fracture and a significant increase in associated morbidity and mortality. Independently of classic OP related to age and/or gender, the mechanical properties of bone are also affected by inherent risk factors for CKD ("uraemic OP"). In the first part of this review, we will analyse the general concepts regarding bone mineral density, OP and fractures, which have been largely undervalued until now by nephrologists due to the lack of evidence and diagnostic difficulties in the context of CKD. It has now been proven that a reduced bone mineral density is highly predictive of fracture risk in CKD patients, although it does not allow a distinction to be made between the causes which generate it (hyperparathyroidism, adynamic bone disease and/or senile osteoporosis, etc.). Therefore, in the second part, we will analyse the therapeutic indications in different CKD stages. In any case, the individual assessment of factors which represent a higher or lower risk of fracture, the quantification of this risk (i.e. using tools such as FRAX®) and the potential indications for densitometry in patients with CKD could represent an important first step pending new clinical guidelines based on randomised studies which do not exclude CKD patients, all the while avoiding therapeutic nihilism in an area of growing importance.
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Affiliation(s)
- Jordi Bover
- Fundació Puigvert, Servicio de Nefrología, IIB Sant Pau, REDinREN, Barcelona, España.
| | - Pablo Ureña-Torres
- Ramsay-Générale de Santé, Clinique du Landy, Department of Nephrology and Dialysis and Department of Renal Physiology, Necker Hospital, University of Paris Descartes, París, Francia
| | - Josep-Vicent Torregrosa
- Servicio de Nefrología, Hospital Clinic, IDIBAPS, Universidad de Barcelona, Barcelona, España
| | - Minerva Rodríguez-García
- Servicio de Nefrología, Hospital Universitario Central de Asturias, REDinREN, Universidad de Oviedo, Oviedo, España
| | | | - José Luis Górriz
- Servicio de Nefrología, Hospital Clínico Universitario de Valencia, INCLIVA, Universidad de Valencia, Valencia, España
| | | | | | - Silvia Benito
- Fundació Puigvert, Servicio de Nefrología, IIB Sant Pau, REDinREN, Barcelona, España
| | - Víctor López-Báez
- Fundació Puigvert, Servicio de Nefrología, IIB Sant Pau, REDinREN, Barcelona, España
| | | | - Iara daSilva
- Fundació Puigvert, Servicio de Nefrología, IIB Sant Pau, REDinREN, Barcelona, España
| | - Jorge Cannata-Andía
- Unidad de Gestión Clínica de Servicio de Metabolismo Óseo, Hospital Universitario Central de Asturias, Instituto de Investigación del Principado de Asturias, REDinREN, Universidad de Oviedo, Oviedo, España
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7
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Jørgensen HS, Winther S, Bøttcher M, Hauge EM, Rejnmark L, Svensson M, Ivarsen P. Bone turnover markers are associated with bone density, but not with fracture in end stage kidney disease: a cross-sectional study. BMC Nephrol 2017; 18:284. [PMID: 28874132 PMCID: PMC5586067 DOI: 10.1186/s12882-017-0692-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 08/18/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Fracture risk is increased in chronic kidney disease (CKD), but assessment of bone fragility remains controversial in these patients. This study investigated the associations between bone turnover markers, bone mineral density (BMD), and prevalent fragility fracture in a cohort of kidney transplantation candidates. METHODS Volumetric BMD of spine and hip was measured by quantitative computed tomography. Parathyroid hormone (PTH), bone-specific alkaline phosphatase, procollagen type-1 N-terminal propeptide, tartrate resistant alkaline phosphatase, and C- and N-terminal telopeptides of type 1 collagen were analyzed from fasting morning blood samples. Fragility fractures included prevalent vertebral fractures and previous low-trauma clinical fractures. RESULTS The fracture prevalence was 18% in 157 adult kidney transplant candidates. Fractured patients had reduced BMD and Z-score at both spine and hip. Levels of bone turnover markers were significantly higher in patients on maintenance dialysis than in pre-dialysis patients; but did not differ between patients with and without fracture. There were strong, positive correlations between PTH and all bone turnover markers. PTH was negatively associated with Z-score at lumbar spine and total hip; in contrast, bone turnover markers were only negatively associated with total hip Z-score. CONCLUSIONS Bone turnover markers were negatively associated with bone density, but not associated with prevalent fracture in kidney transplantation candidates. The role of bone turnover markers in assessing bone fragility in CKD will require further investigation. TRIAL REGISTRATION This study was registered at ClinicalTrials.gov with identifier NCT01344434 .
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Affiliation(s)
- Hanne Skou Jørgensen
- Department of Renal Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark. .,Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Simon Winther
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Internal Medicine, Hospital Unit West, Herning, Denmark
| | - Morten Bøttcher
- Department of Internal Medicine, Hospital Unit West, Herning, Denmark
| | - Ellen-Margrethe Hauge
- Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
| | - Lars Rejnmark
- Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - My Svensson
- Department of Nephrology, Division of Medicine, Akershus University Hospital, Oslo, Norway
| | - Per Ivarsen
- Department of Renal Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
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8
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Torres PAU, Cohen-Solal M. Evaluation of fracture risk in chronic kidney disease. J Nephrol 2017; 30:653-661. [PMID: 28386879 DOI: 10.1007/s40620-017-0398-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 03/29/2017] [Indexed: 01/09/2023]
Abstract
Chronic kidney disease (CKD) is associated with mineral and bone disorders (MBD) that are now considered as a syndrome. Bone fragility and a four to tenfold increased rate of skeletal fractures are often reported in CKD patients. The evaluation of the risk of these fractures in CKD patients should explore the same risk factors identified for the general population including low body weight, menopause, personal and familial history of osteoporosis, chronic inflammatory diseases, and corticosteroid therapy. The aim of this article is to provide a critical review of the tools used for the evaluation of bone loss and the risk of fracture in CKD patients, ranging from the measurement of bone mineral density (BMD), fracture risk assessment (Frax™), quantitative computed tomography (QCT), high-resolution peripheral quantitative computed tomography (HRpQTC), to circulating biomarkers of bone metabolism including vitamin D, parathyroid hormone (PTH), bone-specific alkaline phosphatase, osteocalcin, and some collagen type 1-related molecules indicators of bone remodeling.
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Affiliation(s)
- Pablo Antonio Ureña Torres
- Ramsay-Générale de Santé, Clinique du Landy, Saint-Ouen, France. .,Department of Renal Physiology, Necker Hospital, University of Paris Descartes, Paris, France.
| | - Martine Cohen-Solal
- INSERM U1132 and USPC Paris-Diderot, Paris, France.,Department of Rheumatology, Hôpital Lariboisière, Paris, France
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9
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Krishnasamy R, Hawley CM, Johnson DW. An update on bone imaging and markers in chronic kidney disease. Expert Rev Endocrinol Metab 2016; 11:455-466. [PMID: 30058917 DOI: 10.1080/17446651.2016.1239527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Bone disorders in chronic kidney disease (CKD) are associated with heightened risks of fractures, vascular calcification, poor quality of life and mortality compared to the general population. However, diagnosis and management of these disorders in CKD are complex and appreciably limited by current diagnostic modalities. Areas covered: Bone histomorphometry remains the gold standard for diagnosis but is not widely utilised and lacks feasibility as a monitoring tool. In practice, non-invasive imaging and biochemical markers are preferred to guide therapeutic decisions. Expert commentary: This review aims to summarize the risk factors for, and spectrum of bone disease in CKD, as well as appraise the clinical utility of dual energy X-ray densitometry, peripheral quantitative computed tomography, high-resolution peripheral quantitative computed tomography, and bone turnover markers.
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Affiliation(s)
- Rathika Krishnasamy
- a Department of Nephrology , Nambour General Hospital , Nambour , Australia
- c School of Medicine , The University of Queensland , Brisbane , Australia
| | - Carmel M Hawley
- b Department of Nephrology , Princess Alexandra Hospital , Brisbane , Australia
- c School of Medicine , The University of Queensland , Brisbane , Australia
- d Department of Nephrology , Translation Research Institute , Brisbane , Australia
| | - David W Johnson
- b Department of Nephrology , Princess Alexandra Hospital , Brisbane , Australia
- c School of Medicine , The University of Queensland , Brisbane , Australia
- d Department of Nephrology , Translation Research Institute , Brisbane , Australia
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10
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Wetmore JB, Liu J, Wirtz HS, Gilbertson DT, Cooper K, Nieman KM, Collins AJ, Bradbury BD. Geovariation in Fracture Risk among Patients Receiving Hemodialysis. Clin J Am Soc Nephrol 2016; 11:1413-1421. [PMID: 27269611 PMCID: PMC4974888 DOI: 10.2215/cjn.11651115] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 04/04/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Fractures are a major source of morbidity and mortality in patients receiving dialysis. We sought to determine whether rates of fractures and tendon ruptures vary geographically. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Data from the US Renal Data System were used to create four yearly cohorts, 2007-2010, including all eligible prevalent patients on hemodialysis in the United States on January 1 of each year. A secondary analysis comprising patients in a large dialysis organization conducted over the same period permitted inclusion of patient-level markers of mineral metabolism. Patients were grouped into 10 regions designated by the Centers for Medicare and Medicaid Services and divided by latitude into one of three bands: south, <35°; middle, 35° to <40°; and north, ≥40°. Poisson regression was used to calculate unadjusted and adjusted region-level rate ratios for events. RESULTS Overall, 327,615 patients on hemodialysis were included. Mean (SD) age was 61.8 (15.0) years old, 52.7% were white, and 55.0% were men. During 716,962 person-years of follow-up, 44,014 fractures and tendon ruptures occurred, the latter being only 0.3% of overall events. Event rates ranged from 5.36 to 7.83 per 100 person-years, a 1.5-fold rate difference across regions. Unadjusted region-level rate ratios varied from 0.83 (95% confidence interval, 0.81 to 0.85) to 1.20 (95% confidence interval, 1.18 to 1.23), a 1.45-fold rate difference. After adjustment for a wide range of case mix variables, a 1.33-fold variation in rates remained. Rates were higher in north and middle bands than the south (north rate ratio, 1.18; 95% confidence interval, 1.13 to 1.23; middle rate ratio, 1.13; 95% confidence interval, 1.10 to 1.17). Latitude explained 11% of variation, independent of region. A complementary analysis of 87,013 patients from a large dialysis organization further adjusted for circulating mineral metabolic parameters and protein energy wasting yielded similar results. CONCLUSIONS Rates of fractures vary geographically in the United States dialysis population, even after adjustment for known patient characteristics. Latitude seems to contribute to this phenomenon, but additional analyses exploring whether other factors might influence variation are warranted.
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Affiliation(s)
- James B. Wetmore
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Jiannong Liu
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | | | - David T. Gilbertson
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Kerry Cooper
- Global Medical Organization, Amgen, Inc., Thousand Oaks, California; and
| | - Kimberly M. Nieman
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Allan J. Collins
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
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11
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Zangeneh F, Clarke BL, Hurley DL, Watts NB, Miller PD. Chronic Kidney Disease-Mineral and Bone Disorders (CKD-MBDs): What the Endocrinologist Needs to Know. Endocr Pract 2016; 20:500-16. [PMID: 24325991 DOI: 10.4158/ep12291.ra] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Chronic kidney disease-mineral and bone disorders (CKD-MBDs) are a spectrum of abnormalities involving skeletal hormones, minerals, and bone turnover and mineralization. This paper focuses on what the endocrinologist should know about the assessment and management of skeletal and metabolic disorders in CKD-MBDs. METHODS Relevant literature was reviewed to (1) define disturbances of minerals and hormones in the course of CKD; (2) identify the variable radiographic and histomorphometric changes of CKD-MBDs; (3) review the association among CKD-MBDs, vascular calcification, cardiovascular disease (CVD), and mortality; and (4) clarify issues in CKD-MBDs therapy. RESULTS Assessment and treatment of CKD-MBDs is complicated by progressive changes in bone minerals and skeletal regulatory hormones as kidney function declines. CKD-MBDs are associated with fracture risk, and studies demonstrate that bone mineral density can be used to assess bone loss and fracture risk in these patients. Treatment of CKD-MBDs continues to evolve. Use of calcium, phosphate binders, vitamin D, vitamin D-receptor analogs, and drugs for osteoporosis and CKD-MBDs treatment are discussed in the context of safety and efficacy for patients with CKD. CONCLUSION The association of CKD with bone disease, vascular calcification, CVD, and mortality mandates earlier recognition and treatment of CKD-MBDs. Osteoporosis as a distinct entity can be diagnosed and managed in CKD, although assessment of osteoporosis becomes challenging in late (stage 4 to 5) CKD. Diabetes is common in early (stage 1 to 3) CKD. In addition, 96% of all individuals identified as having CKD have early CKD. The endocrinologist is uniquely positioned to address and treat both diabetes and many of the metabolic and skeletal disorders associated with early CKD-MBDs, including osteoporosis.
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Affiliation(s)
- Farhad Zangeneh
- Endocrine, Diabetes & Osteoporosis Clinic (EDOC), Sterling, VA
| | - Bart L Clarke
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota
| | - Daniel L Hurley
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota
| | - Nelson B Watts
- Mercy Health Osteoporosis and Bone Health Services, Cincinnati, Ohio
| | - Paul D Miller
- Colorado Center for Bone Research, University of Colorado Health Sciences Center
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12
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Sharma AK, Masterson R, Holt SG, Toussaint ND. Emerging role of high-resolution imaging in the detection of renal osteodystrophy. Nephrology (Carlton) 2016; 21:801-11. [PMID: 27042945 DOI: 10.1111/nep.12790] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 03/14/2016] [Accepted: 03/25/2016] [Indexed: 12/17/2022]
Abstract
The term renal osteodystrophy refers to changes in bone morphology induced by chronic kidney disease (CKD) and represents the skeletal component of the entity 'chronic kidney disease - mineral and bone disorder'. Changes in turnover, mineralization, mass and microarchitecture impair bone quality, compromising strength and increasing susceptibility to fractures. Fractures are more common in CKD compared with the general population and result in increased morbidity and mortality. Screening for fracture risk and management of renal osteodystrophy are hindered by the complex, and still only partially understood, pathophysiology and the inadequacy of currently available diagnostic methods. Bone densitometry and bone turnover markers, although potentially helpful, have significant limitations in patients with CKD, and the 'gold standard' test of bone biopsy is infrequently performed in routine clinical practice. However, recent advances in high-resolution bone microarchitecture imaging may offer greater potential for quantification and assessment of bone structure and strength and, when used in conjunction with serum biomarkers, may allow non-invasive testing for a diagnostic virtual bone biopsy.
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Affiliation(s)
- Ashish K Sharma
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Victoria, Australia
| | - Rosemary Masterson
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Victoria, Australia
| | - Stephen G Holt
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Victoria, Australia
| | - Nigel D Toussaint
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Victoria, Australia. .,Department of Medicine (RMH), The University of Melbourne, Melbourne, Victoria, Australia.
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13
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Wong J, Tan MZW, Chandran M. Fifty shades of gray: Bone disease in renal transplantation. PROCEEDINGS OF SINGAPORE HEALTHCARE 2015. [DOI: 10.1177/2010105815611808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Kidney transplantation is the renal replacement therapy of choice for patients with end stage renal disease. Advances in technology, surgical techniques and pharmacotherapy have improved renal allograft survival. Increasingly, we are seeing long term side effects related to renal transplantation, bone disease being a major one amongst them. Renal transplant patients have a higher risk of fragility fractures even when compared to those who remain on dialysis. This is likely to be related to pre-existing underlying bone disease and the emergence of new metabolic bone problems post-transplant. Conditions such as persistent hyperparathyroidism and the use of certain immunosuppressive agents have a deleterious effect on the post renal transplant bone. Remarkable advances in the field of metabolic bone research have been made in the last decade and newer imaging techniques, biomarkers and therapeutic options are now available for osteoporosis in the general population. Interest is being focused on attempting to extrapolate these new discoveries to the management of bone disease post renal transplant. This review will briefly describe the metabolic bone changes that occur after transplantation and will provide an update on the currently available investigative options and therapeutic strategies for the management of post renal transplant bone disease.
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Affiliation(s)
- Jiunn Wong
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | | | - Manju Chandran
- Department of Endocrinology, Singapore General Hospital, Singapore
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14
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Kinsella S, Murphy K, Breen M, O'Neill S, McLaughlin P, Coyle J, Bogue C, O'Neill F, Moore N, McGarrigle A, Molloy MG, Maher MM, Eustace JA. Comparison of single CT scan assessment of bone mineral density, vascular calcification and fat mass with standard clinical measurements in renal transplant subjects: the ABC HeART study. BMC Nephrol 2015; 16:188. [PMID: 26558994 PMCID: PMC4642694 DOI: 10.1186/s12882-015-0182-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 11/02/2015] [Indexed: 12/01/2022] Open
Abstract
Background Despite limitations of routine methods, Clinical Practice Guidelines support the assessment of bone mineral density (BMD) and vascular calcification in renal transplant recipients. Changes in fat mass also occur post-transplantation, although they are traditionally difficult to measure accurately. We report the feasibility, convenience and accuracy of measuring the above 3 parameters using a novel CT protocol. Methods We conducted a cross-sectional study of 64 first renal allograft recipients (eGFR > 30 ml/min/1.73 m2). Quantitative CT (QCT) BMD analysis was conducted using CT lumbar spine (GE Medical Systems Lightspeed VCT & Mindways QCT Pro Bone Mineral Densitometry System Version 4.2.3) to calculate spinal volumetric BMD and compared with standard DXA calculated areal BMD at the spine, hip and distal forearm. Abdominal aortic calcification was assessed by semi-quantitative Aortic Calcification Index (ACI) method and compared with lateral lumbar x-ray Kappuila score and pulse wave velocity (PWV). Visceral and subcutaneous adipose tissue volume (Osirix 16 Ver 3.7.1) was compared with BMI. Results Participants were 61 % male, had a mean age of 47 years, median ESKD duration of 5.4 years and a mean eGFR of 54 ml/min. iDXA median T-score at proximal femur was −1.2 and at lumbar spine was −0.2. Median QCT Trabecular T-score at lumbar spine was −1.2. The percent of subjects with a T-score of <2.5 by site and method was DXA Proximal Femur: 7 %, DXA distal radius: 17 %, DXA spine: 9 %, QCT (American College of Radiology cutoffs): 9 %. CT derived ACI correlated with PWV (r = 0.29, p = 0.02), pulse wave pressure (r = 0.51, p < 0.001), QCT Trabecular (−0.31, p = 0.01) and cortical volumetric BMD and history of cardiovascular events (Mann–Whitney U, p = 0.02). Both visceral and subcutaneous adipose tissue correlated with BMI (r = 0.63 & 0.64, p < 0.001). Conclusions Single CT scan triple assessment of BMD, vascular calcification and body composition is an efficient, accurate and convenient method of risk factor monitoring post renal transplantation.
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Affiliation(s)
- Sinead Kinsella
- Department of Renal Medicine, Cork University Hospital, Cork, Ireland. .,HRB Clinical Research Facility at UCC, 2nd Floor, Mercy University Hospital, Grenville Place, Cork, Ireland.
| | - Kevin Murphy
- Department of Radiology, Cork University Hospital, Cork, Ireland.
| | - Micheal Breen
- Department of Radiology, Cork University Hospital, Cork, Ireland.
| | - Siobhan O'Neill
- Department of Radiology, Cork University Hospital, Cork, Ireland.
| | | | - Joe Coyle
- Department of Radiology, Cork University Hospital, Cork, Ireland.
| | - Conor Bogue
- Department of Radiology, Cork University Hospital, Cork, Ireland.
| | - Fiona O'Neill
- Department of Radiology, Cork University Hospital, Cork, Ireland.
| | - Niamh Moore
- Department of Radiology, Cork University Hospital, Cork, Ireland.
| | | | - Michael G Molloy
- Department of Rheumatology, Cork University Hospital, Cork, Ireland.
| | - Michael M Maher
- Department of Radiology, Cork University Hospital, Cork, Ireland.
| | - Joseph A Eustace
- Department of Renal Medicine, Cork University Hospital, Cork, Ireland. .,HRB Clinical Research Facility at UCC, 2nd Floor, Mercy University Hospital, Grenville Place, Cork, Ireland.
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15
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Moe SM, Abdalla S, Chertow GM, Parfrey PS, Block GA, Correa-Rotter R, Floege J, Herzog CA, London GM, Mahaffey KW, Wheeler DC, Dehmel B, Goodman WG, Drüeke TB. Effects of Cinacalcet on Fracture Events in Patients Receiving Hemodialysis: The EVOLVE Trial. J Am Soc Nephrol 2015; 26:1466-75. [PMID: 25505257 PMCID: PMC4446874 DOI: 10.1681/asn.2014040414] [Citation(s) in RCA: 130] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 09/07/2014] [Indexed: 11/03/2022] Open
Abstract
Fractures are frequent in patients receiving hemodialysis. We tested the hypothesis that cinacalcet would reduce the rate of clinical fractures in patients receiving hemodialysis using data from the Evaluation of Cinacalcet HCl Therapy to Lower Cardiovascular Events trial, a placebo-controlled trial that randomized 3883 hemodialysis patients with secondary hyperparathyroidism to receive cinacalcet or placebo for ≤64 months. This study was a prespecified secondary analysis of the trial whose primary end point was all-cause mortality and non-fatal cardiovascular events, and one of the secondary end points was first clinical fracture event. Clinical fractures were observed in 255 of 1935 (13.2%) patients randomized to placebo and 238 of 1948 (12.2%) patients randomized to cinacalcet. In an unadjusted intention-to-treat analysis, the relative hazard for fracture (cinacalcet versus placebo) was 0.89 (95% confidence interval [95% CI], 0.75 to 1.07). After adjustment for baseline characteristics and multiple fractures, the relative hazard was 0.83 (95% CI, 0.72 to 0.98). Using a prespecified lag-censoring analysis (a measure of actual drug exposure), the relative hazard for fracture was 0.72 (95% CI, 0.58 to 0.90). When participants were censored at the time of cointerventions (parathyroidectomy, transplant, or provision of commercial cinacalcet), the relative hazard was 0.71 (95% CI, 0.58 to 0.87). Fracture rates were higher in older compared with younger patients and the effect of cinacalcet appeared more pronounced in older patients. In conclusion, using an unadjusted intention-to-treat analysis, cinacalcet did not reduce the rate of clinical fracture. However, when accounting for differences in baseline characteristics, multiple fractures, and/or events prompting discontinuation of study drug, cinacalcet reduced the rate of clinical fracture by 16%-29%.
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Affiliation(s)
- Sharon M Moe
- Indiana University School of Medicine and Roudebush Veterans Administration Medical Center, Indianapolis, Indiana;
| | - Safa Abdalla
- Stanford University School of Medicine, Palo Alto, California
| | - Glenn M Chertow
- Stanford University School of Medicine, Palo Alto, California
| | | | | | - Ricardo Correa-Rotter
- Salvador Zubirán National Institute of Medical Sciences and Nutrition, Mexico City, Mexico
| | | | | | | | | | | | | | | | - Tilman B Drüeke
- French Institute of Health and Medical Research (INSERM) Unit 1088, Faculty of Medicine/Pharmacy, University of Picardie, Amiens, France
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16
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West SL, Lok CE, Langsetmo L, Cheung AM, Szabo E, Pearce D, Fusaro M, Wald R, Weinstein J, Jamal SA. Bone mineral density predicts fractures in chronic kidney disease. J Bone Miner Res 2015; 30:913-9. [PMID: 25400209 DOI: 10.1002/jbmr.2406] [Citation(s) in RCA: 148] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 11/08/2014] [Accepted: 11/15/2014] [Indexed: 11/11/2022]
Abstract
Fractures are common in chronic kidney disease (CKD). The optimal methods by which to assess fracture risk are unknown, in part, due to a lack of prospective studies. We determined if bone mineral density (BMD) by dual-energy X-ray absorptiometry (DXA), and/or high-resolution peripheral quantitative computed tomography (HRpQCT) could predict fractures in men and women ≥18 years old with stages 3 to 5 CKD. BMD was measured by DXA (at the total hip, lumbar spine, ultradistal, and 1/3 radius) and by HRpQCT (at the radius), and subjects were followed for 2 years for incident morphometric spine fractures and low-trauma clinical fractures. The mean age of the subjects was 62 years with equal numbers having stages 3, 4, and 5 CKD. Over 2 years there were 51 fractures in 35 subjects. BMD by DXA at baseline was significantly lower at all sites among those with incident fractures versus those without. For example, the mean BMD at the total hip in those with incident fractures was 0.77 g/cm2 (95% confidence interval [CI], 0.73 to 0.80) and in those without fracture was 0.95 g/cm2 (95% CI, 0.92 to 0.98). Almost all baseline HRpQCT measures were lower in those with incident fracture versus those without. For example, volumetric BMD in those with incident fractures was 232 mg HA/cm3 (95% CI, 213 to 251) and in those without fracture was 317.6 mg HA/cm3 (95% CI, 306 to 329.1). Bone loss occurred in all subjects, but was significantly greater among those with incident fractures. Our data demonstrate that low BMD (by DXA and HRpQCT) and a greater annualized percent decrease in BMD are risk factors for subsequent fracture in men and women with predialysis CKD.
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Affiliation(s)
- Sarah L West
- Women's College Research Institute, University of Toronto, Toronto, Ontario, Canada
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17
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Moorthi RN, Moe SM. Recent advances in the noninvasive diagnosis of renal osteodystrophy. Kidney Int 2013; 84:886-94. [PMID: 23802194 PMCID: PMC3805700 DOI: 10.1038/ki.2013.254] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 03/18/2013] [Accepted: 03/28/2013] [Indexed: 02/07/2023]
Abstract
Chronic kidney disease-mineral and bone disorder (CKD-MBD) is the term used to describe a constellation of biochemical abnormalities, bone disturbances that may lead to fractures, and extraskeletal calcification in soft tissues and arteries seen in CKD. This review focuses on the noninvasive diagnosis of renal osteodystrophy, the term used exclusively to define the bone pathology associated with CKD. Transiliac bone biopsy and histomorphometry with double-labeled tetracycline or its derivatives remains the gold standard for diagnosis of renal osteodystrophy. However, histomorphometry provides a 'window' into bone only at a single point in time, and is not clinically practical for studying continuous changes in bone morphology. Furthermore, the etiology of fractures in CKD is multifactorial and not fully explained by histomorphometry findings alone. The propensity of a bone to fracture is determined by bone strength, which is affected by bone mass and bone quality; the latter is a term used to describe the structure and composition of bone. Bone quantity is traditionally assessed by dual X-ray absorptiometry (DXA) and CT-based methods. Bone quality is more difficult to assess noninvasively, but newer techniques are emerging and are described in this review. Ultimately, the optimal diagnostic strategy for renal osteodystrophy may be a combination of multiple imaging techniques and biomarkers that are specific to each gender and race in CKD, with a goal of predicting fracture risk and optimizing therapy.
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Affiliation(s)
- Ranjani N Moorthi
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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18
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Chang NT, Lee YH, Hsu JC, Chan CL, Huang GS, Renn JH, Yang NP. Epidemiological study of orthopedic injuries in hemodialysis patients in Taiwan: a fixed cohort survey, 2004-2008. Clin Interv Aging 2013; 8:301-8. [PMID: 23682209 PMCID: PMC3653676 DOI: 10.2147/cia.s41132] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The burden of chronic kidney disease (CKD) is a growing concern worldwide. The prevalence of hemodialysis in Taiwan is the highest in the world, and this may increase the prevalence of orthopedic fractures. The aim of this study was to explore the incidences of various orthopedic injuries and the related risk factors. METHODS A nationwide prospective study based on the Taiwan National Health Insurance dataset was conducted during 2004-2008. A total of 82,491 CKD patients were selected as the fixed cohort population. The International Classification of Diseases 9-CM diagnosis codes and treatment codes were identified as the inclusion criteria for orthopedic injury. RESULTS A total of 82,491 Taiwanese people with CKD were identified in 2004, and 4915 orthopedic injuries occurred during the 5-year follow-up period. The cumulative incidences of orthopedic injuries were 42.56‰ for lower limb fractures, and 12.93‰, 3.27‰, and 1.64‰ for upper limb fractures, vertebrae fractures, and joint dislocations, respectively. All three types of orthopedic fractures were more common in the oldest age stratum (≥65 years old). In the CKD patients, the risk ratio of osteoporosis was 3.47 (95% confidence interval, 3.10-3.89) for all orthopedic injuries. Patients of advanced age, the female gender, and those with high comorbidity were also at significant risk of sustaining orthopedic fractures. CONCLUSION The results from this Taiwanese CKD cohort support the strong influence of aging and osteoporosis on all kinds of orthopedic injuries. The postponing of osteoporosis may need to be taken into consideration for the prevention of orthopedic injury among CKD patients undergoing hemodialysis.
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Affiliation(s)
- Nien-Tzu Chang
- Community Health Research Center and Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
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19
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Association between high-molecular-weight adiponectin and bone mineral density in hemodialysis patients. Clin Exp Nephrol 2012; 17:411-5. [DOI: 10.1007/s10157-012-0723-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2012] [Accepted: 10/24/2012] [Indexed: 01/05/2023]
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20
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West SL, Jamal SA. Determination of bone architecture and strength in men and women with stage 5 chronic kidney disease. Semin Dial 2012; 25:397-402. [PMID: 22686655 DOI: 10.1111/j.1525-139x.2012.01096.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Fractures are common in men and women with dialysis-dependent chronic kidney disease (stage 5D CKD) and are associated with substantial morbidity and mortality. The clinical utility of dual energy X-ray absorptiometry (DXA) and peripheral quantitative computed tomography (pQCT), noninvasive measures of bone mass and architecture that reflect fracture risk in healthy men and women, is uncertain in patients with stage 5D CKD. This review will outline the epidemiology and etiology of fractures and will summarize the published data that describe the association between fractures, bone mass, and bone strength in stage 5D CKD. Fracture risk assessment in stage 5D CKD is complicated as the etiology of fractures is multifactorial and includes impairments in bone quantity and quality. Cross-sectional data suggest that bone density by DXA is lower among stage 5D CKD patients with fractures compared with those without, and that this may be particularly true at cortical sites. However, DXA does not capture bone microarchitecture and cannot differentiate between cortical and trabecular bone. Some, but not all studies, that measure cortical and trabecular bone by pQCT in stage 5D CKD, demonstrate a preferential decrease in cortical bone; however, these studies are limited by small sample sizes and cross-sectional study design. No studies have reported on longitudinal relationships between bone architecture, strength, and incident fractures in patients with stage 5D CKD. Further research is needed to identify noninvasive measures of bone strength that can be used for fracture risk assessment in stage 5D CKD.
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Affiliation(s)
- Sarah L West
- Department of Exercise Sciences, University of Toronto, Women's College Hospital, Toronto, Ontario, Canada
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21
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Cejka D, Patsch JM, Weber M, Diarra D, Riegersperger M, Kikic Z, Krestan C, Schueller-Weidekamm C, Kainberger F, Haas M. Bone microarchitecture in hemodialysis patients assessed by HR-pQCT. Clin J Am Soc Nephrol 2011; 6:2264-71. [PMID: 21737853 PMCID: PMC3358993 DOI: 10.2215/cjn.09711010] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2010] [Accepted: 05/11/2011] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND OBJECTIVES Dialysis patients are at high risk for low-trauma bone fracture. Bone density measurements using dual-energy x-ray absorptiometry (DXA) do not reliably differentiate between patients with and without fractures. The aim of this study was to identify differences in bone microarchitecture between patients with and without a history of fracture using high-resolution peripheral quantitative computed tomography (HR-pQCT). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Seventy-four prevalent hemodialysis patients were recruited for measurements of areal bone mineral density (aBMD) by DXA and bone microarchitecture by HR-pQCT. Patients with a history of trauma-related fracture were excluded. Forty healthy volunteers served as controls. Blood levels of parathyroid hormone, vitamin D, and markers of bone turnover were determined. RESULTS Dialysis patients, particularly women, had markedly impaired bone microarchitecture. Patients with fractures had significantly reduced cortical and trabecular microarchitecture compared with patients without fractures. aBMD tended to be lower in patients with fractures, but differences were statistically not significant. The strongest determinant of fracture was the HR-pQCT-measured trabecular density of the tibia, which also had the highest discriminatory power to differentiate patients according to fracture status. Radial DXA had a lower discriminatory power than trabecular density. CONCLUSIONS Bone microarchitecture is severely impaired in dialysis patients and even more so in patients with a history of fracture. HR-pQCT can identify dialysis patients with a history of low-trauma fracture.
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Affiliation(s)
- Daniel Cejka
- Department of Internal Medicine III, Division of Nephrology and Dialysis
| | - Janina M. Patsch
- Department of Radiology, Division of Neuroradiology and Musculoskeletal Radiology, and
| | - Michael Weber
- Department of Radiology, Medical University Vienna, Vienna, Austria
| | - Danielle Diarra
- Department of Internal Medicine III, Division of Nephrology and Dialysis
| | | | - Zeljko Kikic
- Department of Internal Medicine III, Division of Nephrology and Dialysis
| | - Christian Krestan
- Department of Radiology, Division of Neuroradiology and Musculoskeletal Radiology, and
| | | | - Franz Kainberger
- Department of Radiology, Division of Neuroradiology and Musculoskeletal Radiology, and
| | - Martin Haas
- Department of Internal Medicine III, Division of Nephrology and Dialysis
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22
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Nickolas TL, Stein E, Cohen A, Thomas V, Staron RB, McMahon DJ, Leonard MB, Shane E. Bone mass and microarchitecture in CKD patients with fracture. J Am Soc Nephrol 2010; 21:1371-80. [PMID: 20395370 PMCID: PMC2938588 DOI: 10.1681/asn.2009121208] [Citation(s) in RCA: 134] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2009] [Accepted: 02/15/2010] [Indexed: 11/03/2022] Open
Abstract
Patients with predialysis chronic kidney disease (CKD) have increased risk for fracture, but the structural mechanisms underlying this increased skeletal fragility are unknown. We measured areal bone mineral density (aBMD) by dual-energy x-ray absorptiometry at the spine, hip, and radius, and we measured volumetric BMD (vBMD), geometry, and microarchitecture by high-resolution peripheral quantitative computed tomography (HR-pQCT) at the radius and tibia in patients with CKD: 32 with fracture and 59 without fracture. Patients with fracture had lower aBMD at the spine, total hip, femoral neck, and the ultradistal radius, the last having the strongest association with fracture. By HR-pQCT of the radius, patients with fracture had lower cortical area and thickness, total and trabecular vBMD, and trabecular number and greater trabecular separation and network heterogeneity. At the tibia, patients with fracture had significantly lower cortical area, thickness, and total and cortical density. Total vBMD at both radius and tibia most strongly associated with fracture. By receiver operator characteristic curve analysis, patients with longer duration of CKD had area under the curve of >0.75 for aBMD at both hip sites and the ultradistal radius, vBMD and geometry at the radius and tibia, and microarchitecture at the tibia. In summary, patients with predialysis CKD and fractures have lower aBMD by dual-energy x-ray absorptiometry and lower vBMD, thinner cortices, and trabecular loss by HR-pQCT. These density and structural differences may underlie the increased susceptibility to fracture among patients with CKD.
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Affiliation(s)
- Thomas L Nickolas
- Department of Medicine, Columbia University Medical Center, New York, NY 10032, USA.
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Toussaint ND, Elder GJ, Kerr PG. A Rational Guide to Reducing Fracture Risk in Dialysis Patients. Semin Dial 2010; 23:43-54. [DOI: 10.1111/j.1525-139x.2009.00650.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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OTT SUSANM. Review article: Bone density in patients with chronic kidney disease stages 4-5. Nephrology (Carlton) 2009; 14:395-403. [DOI: 10.1111/j.1440-1797.2009.01159.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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