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Gifre L, Massó E, Fusaro M, Haarhaus M, Ureña P, Cozzolino M, Mazzaferro S, Calabia J, Peris P, Bover J. Vertebral fractures in patients with CKD and the general population: a call for diagnosis and action. Clin Kidney J 2024; 17:sfae191. [PMID: 39099567 PMCID: PMC11294886 DOI: 10.1093/ckj/sfae191] [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: 12/11/2023] [Indexed: 08/06/2024] Open
Abstract
Vertebral fractures (VFs) are the most common osteoporotic fractures in the general population, and they have been associated with high mortality, decreased quality of life, and high risk of subsequent fractures, especially when recent, multiple, or severe. Currently, VF diagnosis and classification determine fracture risk and the most appropriate anti-osteoporotic treatment. However, VFs are clearly underdiagnosed, especially in patients with chronic kidney disease (CKD), and CKD-associated osteoporosis has been disregarded until recently. VFs are associated with higher morbidity and mortality, and their prevalence and incidence differ depending on the grade of renal dysfunction (CKD G1-G5) and/or the type of renal replacement therapy (dialysis or transplantation). In addition to classical risk factors [such as higher age, female sex, reduced bone mineral density, diabetes and steroid use], various other factors have been associated with an increased risk of VFs in CKD, including CKD grade, haemodialysis vintage, time since renal transplantation, low or high intact parathyroid hormone and phosphate levels, and/or vitamin D and K1 deficiencies. Importantly, several clinical societies have recently modified their algorithms according to the fracture risk classification (including the presence of VFs) and determined the most appropriate anti-osteoporotic treatment for the general population. However, there are no specific guidelines addressing this topic in patients with CKD despite an important paradigm shift regarding the prognostic value of bone mineral density in 2017 after the publication of the CKD-Mineral and Bone Disorder Kidney Disease: Improving Global Outcomes guidelines. A proactive attitude towards diagnosis, treatment, and research is proposed to avoid therapeutic nihilism.
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Affiliation(s)
- Laia Gifre
- Rheumatology Department, Hospital Germans Trias i Pujol, Research Institute Germans Trias i Pujol (IGTP), Universitat Autònoma de Barcelona, Badalona (Barcelona), Catalonia, Spain
| | - Elisabet Massó
- Nephrology Department, University Hospital Germans Trias i Pujol, REMAR-IGTP Group, Research Institute Germans Trias i Pujol (IGTP), Universitat Autònoma de Barcelona, Badalona (Barcelona), Catalonia, Spain
| | - Maria Fusaro
- National Research Council (CNR), Institute of Clinical Physiology, Pisa (Italy). Department of Medicine, University of Padua, Padua, Italy
| | - Mathias Haarhaus
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm, Sweden
- Diaverum AB, Hyllie Boulevard 53, Malmö, Sweden
| | - Pablo Ureña
- Department of Nephrology and Dialysis, AURA Nord Saint-Ouen, Saint-Ouen, Paris, France
- Department of Renal Physiology, Necker Hospital, University of Paris Descartes, Paris, France
| | - Mario Cozzolino
- Renal Division, Department of Health Sciences, University of Milan, Milan, Italy
| | - Sandro Mazzaferro
- Department of Translation and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Jordi Calabia
- Nephrology Department, University Hospital Josep Trueta. IdIBGi Research Institute. Universitat de Girona, Catalonia, Spain
| | - Pilar Peris
- Rheumatology Department, Hospital Clinic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Catalonia, Spain
| | - Jordi Bover
- Nephrology Department, University Hospital Germans Trias i Pujol, REMAR-IGTP Group, Research Institute Germans Trias i Pujol (IGTP), Universitat Autònoma de Barcelona, Badalona (Barcelona), Catalonia, Spain
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Herreros-Carretero Á, Berlanga-Macías C, Martínez-Vizcaíno V, Torres-Costoso A, Pascual-Morena C, Hernández-Castillejo LE, Sequí-Domínguez I, Garrido-Miguel M. Prevalence of Musculoskeletal and Metabolic Disorders in Kidney Transplant Recipients: A Systematic Review and Meta-Analysis. Transpl Int 2024; 37:12312. [PMID: 38720821 PMCID: PMC11076774 DOI: 10.3389/ti.2024.12312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 04/08/2024] [Indexed: 05/12/2024]
Abstract
Introduction Musculoskeletal disorders could be associated with metabolic disorders that are common after kidney transplantation, which could reduce the quality of life of patients. The aim of this study was to assess the prevalence of both musculoskeletal and metabolic disorders in kidney transplant patients. Methods MEDLINE, CINAHL, Cochrane Library, EMBASE and Web of Science were searched from their inception up to June 2023. DerSimonian and Laird random-effects method was used to calculate pooled prevalence estimates and their 95% confidence intervals (CIs). Results 21,879 kidney transplant recipients from 38 studies were analysed. The overall proportion of kidney transplant patients with musculoskeletal disorders was 27.2% (95% CI: 18.4-36.0), with low muscle strength (64.5%; 95% CI: 43.1-81.3) being the most common disorder. Otherwise, the overall proportion of kidney transplant patients with metabolic disorders was 37.6% (95% CI: 21.9-53.2), with hypovitaminosis D (81.8%; 95% CI: 67.2-90.8) being the most prevalent disorder. Conclusion The most common musculoskeletal disorders were low muscle strength, femoral osteopenia, and low muscle mass. Hypovitaminosis D, hyperparathyroidism, and hyperuricemia were also the most common metabolic disorders. These disorders could be associated with poorer quality of life in kidney transplant recipients. Systematic Review Registration https://www.crd.york.ac.uk/prospero/, identifier [CRD42023449171].
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Affiliation(s)
| | - Carlos Berlanga-Macías
- Facultad de Enfermería, Universidad de Castilla-La Mancha, Albacete, Spain
- Health and Social Research Center, Universidad de Castilla-La Mancha, Cuenca, Spain
- Investigación en Cuidados de la Salud Cardiovascular (CARVASCARE), Centro de Estudio Sociosanitarios, Universidad de Castilla-La Mancha, Cuenca, Spain
| | - Vicente Martínez-Vizcaíno
- Health and Social Research Center, Universidad de Castilla-La Mancha, Cuenca, Spain
- Facultad de Ciencias de la Salud, Universidad Autónoma de Chile, Talca, Chile
- Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS), Cuenca, Spain
| | - Ana Torres-Costoso
- Health and Social Research Center, Universidad de Castilla-La Mancha, Cuenca, Spain
- Facultad de Fisioterapia y Enfermería, Universidad de Castilla-La Mancha, Toledo, Spain
| | - Carlos Pascual-Morena
- Facultad de Enfermería, Universidad de Castilla-La Mancha, Albacete, Spain
- Health and Social Research Center, Universidad de Castilla-La Mancha, Cuenca, Spain
- Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS), Cuenca, Spain
| | - Luis Enrique Hernández-Castillejo
- Health and Social Research Center, Universidad de Castilla-La Mancha, Cuenca, Spain
- Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - Irene Sequí-Domínguez
- Facultad de Enfermería, Universidad de Castilla-La Mancha, Albacete, Spain
- Health and Social Research Center, Universidad de Castilla-La Mancha, Cuenca, Spain
- Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS), Cuenca, Spain
| | - Miriam Garrido-Miguel
- Facultad de Enfermería, Universidad de Castilla-La Mancha, Albacete, Spain
- Health and Social Research Center, Universidad de Castilla-La Mancha, Cuenca, Spain
- Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS), Cuenca, Spain
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Velioglu A, Kaya B, Aykent B, Ozkan B, Karapinar MS, Arikan H, Asicioglu E, Bugdaycı O, Yavuz DG, Tuglular S. Low bone density, vertebral fracture and FRAX score in kidney transplant recipients: A cross-sectional cohort study. PLoS One 2021; 16:e0251035. [PMID: 33930070 PMCID: PMC8087085 DOI: 10.1371/journal.pone.0251035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 04/17/2021] [Indexed: 11/25/2022] Open
Abstract
Background Kidney transplantation (KT) recipients are at increased risk of low bone density (LBD) and fractures. In this retrospective study, we investigated bone mineral density (BMD), vertebral fractures, calculated risk for major osteoporotic fractures (MOF), and hip fractures in the KT recipients. Patients-method Patients who completed at least one year after KT were included in the analysis. Demographic, clinical, and laboratory data were recorded. Measurements of BMD were performed by dual-energy X-ray absorptiometry. Vertebral fractures were assessed using semi-quantitative criteria with conventional radiography. The ten-year risk for MOF and hip fracture were calculated using the FRAX@ tool with BMD. Results One hundred fifty-three KT recipients were included in the study. The population included 77 women. The mean age at evaluation was 46,5±11,9 years. Seventy-eight (50.9%) patients had normal femoral neck BMD while osteoporosis and osteopenia at the femoral neck were present in 12 (7.8%) and 63 (41.1%) of the patients, respectively. Age at evaluation was the risk factor for LBD (OR 1.057; 95% CI 1.024–1.091; p = 0.001). In female KT recipients, LBD was principally affected by menopausal status whereas in males, mammalian target of rapamycin (mTOR) inhibitor use and lower BMI levels were the risk factors. The prevalent vertebral fracture was found in 43.4% of patients. In multivariate analysis, only steroid use (OR 0.121; 95% CI 0.015–0.988; p = 0.049) was found to be associated with prevalent fracture. Among all KT recipients, 1.9% had a high MOF probability (≥20% risk of fracture), and 23.5% had high hip fracture probability (≥3% risk of hip fracture) according to FRAX. Conclusion Exploring the prevalence of LBD and vertebral fracture and the risk factors would help clinicians to modify long-term follow-up strategies. Furthermore, the high hip fracture risk probability in our cohort suggested that there is a need for longitudinal studies to confirm the validity of the FRAX tool in the transplant population.
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Affiliation(s)
- Arzu Velioglu
- Division of Nephrology, Department of Internal Medicine, Marmara University School of Medicine, Istanbul, Turkey
| | - Burcu Kaya
- Division of Nephrology, Department of Internal Medicine, Marmara University School of Medicine, Istanbul, Turkey
| | - Basar Aykent
- Division of Nephrology, Department of Internal Medicine, Marmara University School of Medicine, Istanbul, Turkey
| | - Bige Ozkan
- Division of Nephrology, Department of Internal Medicine, Marmara University School of Medicine, Istanbul, Turkey
| | - Melis Sevil Karapinar
- Division of Nephrology, Department of Internal Medicine, Marmara University School of Medicine, Istanbul, Turkey
| | - Hakki Arikan
- Division of Nephrology, Department of Internal Medicine, Marmara University School of Medicine, Istanbul, Turkey
| | - Ebru Asicioglu
- Division of Nephrology, Department of Internal Medicine, Marmara University School of Medicine, Istanbul, Turkey
| | - Onur Bugdaycı
- Department of Radiology, Marmara University School of Medicine, Istanbul, Turkey
| | - Dilek Gogas Yavuz
- Division of Endocrinology, Department of Internal Medicine, Marmara University School of Medicine, Istanbul, Turkey
| | - Serhan Tuglular
- Division of Nephrology, Department of Internal Medicine, Marmara University School of Medicine, Istanbul, Turkey
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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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Kwon YE, Choi HY, Oh HJ, Ahn SY, Ryu DR, Kwon YJ. Vertebral fracture is associated with myocardial infarction in incident hemodialysis patients: a Korean nationwide population-based study. Osteoporos Int 2020; 31:1965-1973. [PMID: 32394062 DOI: 10.1007/s00198-020-05423-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 04/14/2020] [Indexed: 10/24/2022]
Abstract
UNLABELLED Chronic kidney disease (CKD)-mineral and bone disorder suggests that fragile bone and vascular disorder might be connected closely in CKD patients. In this study, fracture event was significantly associated with myocardial infarction (MI) in end-stage renal disease patients on hemodialysis (HD), especially for vertebral fractures. INTRODUCTION CKD-mineral and bone disorder is characterized by biochemical abnormalities, bone disorders, and vascular calcification. We aimed to verify the association between fracture and MI in CKD patients. METHODS Records for incident CKD stage 3 to 5 patients and patients who initiated HD between July 2014 and June 2018 were retrieved from the Korean Health Insurance Review & Assessment Service Database. Fractures were defined using diagnostic codes and were classified into vertebral, femoral, and other site fractures. MI was defined using a combination of MI diagnostic codes and related procedure codes. Multiple logistic regressions and 1:1 propensity score matching analysis were conducted. RESULTS A total of 38,935 patients (HD, 11,379; pre-dialysis CKD, 27,556) were included in this study. A total of 5,057 (13.0%) patients experienced fracture, and 1,431 (3.7%) patients had MI. Multiple logistic regression analysis showed that fracture was significantly associated with MI in the HD group (odds ratio (OR) 1.34, P = 0.024), but not in the pre-dialysis CKD group (OR 1.04, P = 0.701). After propensity score matching for age, gender, and diabetes mellitus between patients with and without fracture, fracture still significantly correlated with MI in HD patients (OR 1.47, P = 0.034) but not in patients with pre-dialysis CKD (OR 1.04, P = 0.751). Subgroup analysis by fracture site found that vertebral fracture was associated with MI in HD patients (OR 2.11, P = 0.024), but femoral or other site fractures were not. CONCLUSION In HD patients, fracture was significantly associated with MI, especially for vertebral fractures patients.
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Affiliation(s)
- Y E Kwon
- Department of Internal Medicine, Hanyang University College of Medicine, Myongji Hospital, Goyang-si, South Korea
| | - H Y Choi
- The Korean Society of Nephrology, Seoul, South Korea
| | - H J Oh
- Ewha Institute of Convergence Medicine and Research Institute for Human Health Information, Ewha Womans University, Seoul, South Korea
| | - S Y Ahn
- Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea
| | - D-R Ryu
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, South Korea.
| | - Y J Kwon
- Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea.
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