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Simonini M, Bologna A, Vezzoli G. Is denosumab an efficient and safe drug for osteoporosis in dialysis patients? Considerations and state of the art about its use in this setting. Int Urol Nephrol 2024:10.1007/s11255-024-04110-9. [PMID: 38856936 DOI: 10.1007/s11255-024-04110-9] [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: 04/09/2024] [Accepted: 06/02/2024] [Indexed: 06/11/2024]
Abstract
PURPOSE In patients with chronic kidney disease (CKD), renal osteodystrophy may be associated with a progressive bone mass loss that increases fracture risk. Denosumab, a monoclonal antibody inhibiting osteoclast activity, is an antiresorptive medication used for the treatment osteoporosis. METHODS Its efficacy and safety were initially established in the FREEDOM study, showing a significant reduction in incident fractures in osteoporotic women treated with denosumab. Subsequent post hoc analyses showed its efficacy in patients stratified by kidney function, but these analyses did not include patients with advanced stages of CKD. The capability of denosumab in improving bone mineral density in uremic patients was evaluated in 12 studies including 461 dialysis patients with low bone mineral density. The improvement of bone mineral density was the final end point in these studies assessed during a follow-up of 6-60 months. Nine of these studies did not have hyperparathyroidism among criteria for patient inclusion and their participants may have low-turnover bone disease. Despite current recommendations, no patients underwent bone biopsy before denosumab therapy. RESULTS Overall, findings in these studies suggest that denosumab is a viable option for promoting bone mass recovery in patients with advanced stages of CKD having either high or low serum levels of PTH. However, the increase of bone mineral density was lower in patients with low serum markers of bone turnover at baseline. These studies also highlighted the need for calcium and vitamin D supplementation to prevent hypocalcemia that remains a serious concern. CONCLUSIONS Denosumab emerges as a potentially safe and effective option for enhancing bone health in CKD patients.
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Affiliation(s)
- Marco Simonini
- IRCCS San Raffaele Scientific Institute, Nephrology and Dialysis Unit, Milan, Italy
| | - Arianna Bologna
- IRCCS San Raffaele Scientific Institute, Nephrology and Dialysis Unit, Milan, Italy
- Università Vita Salute San Raffaele, Milan, Italy
| | - Giuseppe Vezzoli
- IRCCS San Raffaele Scientific Institute, Nephrology and Dialysis Unit, Milan, Italy.
- Università Vita Salute San Raffaele, Milan, Italy.
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2
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Bird ST, Gelperin K, Graham DJ. Denosumab-Associated Severe Hypocalcemia in Dialysis-Dependent Patients-Reply. JAMA 2024; 331:1865-1866. [PMID: 38717783 DOI: 10.1001/jama.2024.6842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Affiliation(s)
- Steven T Bird
- Office of Pharmacovigilance and Epidemiology, US Food and Drug Administration, Silver Spring, Maryland
| | - Kate Gelperin
- Office of Pharmacovigilance and Epidemiology, US Food and Drug Administration, Silver Spring, Maryland
| | - David J Graham
- Office of Pharmacovigilance and Epidemiology, US Food and Drug Administration, Silver Spring, Maryland
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3
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Schoenmakers I, Fraser WD. Denosumab-Associated Severe Hypocalcemia in Dialysis-Dependent Patients. JAMA 2024; 331:1864-1865. [PMID: 38717748 DOI: 10.1001/jama.2024.6839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Affiliation(s)
- Inez Schoenmakers
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, United Kingdom
| | - William D Fraser
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, United Kingdom
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4
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Jørgensen HS, Claes K, Smout D, Naesens M, Kuypers D, D'Haese P, Cavalier E, Evenepoel P. Associations of Changes in Bone Turnover Markers with Change in Bone Mineral Density in Kidney Transplant Patients. Clin J Am Soc Nephrol 2024; 19:483-493. [PMID: 38030558 PMCID: PMC11020431 DOI: 10.2215/cjn.0000000000000368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 11/17/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Bone loss after kidney transplantation is highly variable. We investigated whether changes in bone turnover markers associate with bone loss during the first post-transplant year. METHODS Bone mineral density (BMD) was measured at 0 and 12 months, with biointact parathyroid hormone, bone-specific alkaline phosphatase (BALP), intact procollagen type I N -terminal propeptide (PINP), and tartrate-resistant acid phosphatase isoform 5b (TRAP5b) measured at 0, 3, and 12 months post-transplant ( N =209). Paired transiliac bone biopsies were available in a subset ( n =49). Between-group differences were evaluated by Student's t test, Wilcoxon signed-rank test, or Pearson's chi-squared test. RESULTS Changes in BMD varied from -22% to +17%/yr. Compared with patients with no change (±2.5%/yr), patients who gained BMD had higher levels of parathyroid hormone (236 versus 136 pg/ml), BALP (31.7 versus 18.8 μ g/L), and Intact PINP (121.9 versus 70.4 μ g/L) at time of transplantation; a greater decrease in BALP (-40% versus -21%) and Intact PINP (-43% versus -13%) by 3 months; and lower levels of Intact PINP (36.3 versus 60.0 μ g/L) at 12 months post-transplant. Patients who lost BMD had a less marked decrease, or even increase, in Intact PINP (+22% versus -13%) and TRAP5b (-27% versus -43%) at 3 months and higher Intact PINP (83.7 versus 60.0 μ g/L) and TRAP5b (3.89 versus 3.16 U/L) at 12 months compared with patients with no change. If none of the biomarkers decreased by the least significant change at 3 months, an almost two-fold (69% versus 36%) higher occurrence of bone loss was seen at 12 months post-transplant. CONCLUSIONS Bone loss after kidney transplantation was highly variable. Resolution of high bone turnover, as reflected by decreasing bone turnover markers, associated with BMD gain, while increasing bone turnover markers associated with bone loss.
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Affiliation(s)
- Hanne Skou Jørgensen
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium
- Department of Nephrology, Aalborg University Hospital, Aalborg, Denmark
| | - Kathleen Claes
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium
- Department of Nephrology and Renal Transplantation, University Hospital Leuven, Leuven, Belgium
| | - Dieter Smout
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium
- Department of Nephrology and Renal Transplantation, University Hospital Leuven, Leuven, Belgium
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium
- Department of Nephrology and Renal Transplantation, University Hospital Leuven, Leuven, Belgium
| | - Dirk Kuypers
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium
- Department of Nephrology and Renal Transplantation, University Hospital Leuven, Leuven, Belgium
| | - Patrick D'Haese
- Laboratory of Pathophysiology, University of Antwerp, Wilrijk, Belgium
| | - Etienne Cavalier
- Department of Clinical Chemistry, CIRM, CHU de Liège, University of Liège, Liège, Belgium
| | - Pieter Evenepoel
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium
- Department of Nephrology and Renal Transplantation, University Hospital Leuven, Leuven, Belgium
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5
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Kato K, Yaginuma T, Kobayashi A, Nakashima A, Ohkido I, Yokoo T. Long-term effects of denosumab on bone mineral density and turnover markers in patients undergoing hemodialysis. J Bone Miner Metab 2024; 42:264-270. [PMID: 38512458 PMCID: PMC10982096 DOI: 10.1007/s00774-024-01505-7] [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] [Received: 12/28/2023] [Accepted: 02/15/2024] [Indexed: 03/23/2024]
Abstract
INTRODUCTION Denosumab, a fully human anti-RANKL monoclonal antibody, is a widely used osteoporosis treatment that is increasingly being used in patients undergoing dialysis; however, its long-term efficacy and safety in these patients remain unknown. MATERIALS AND METHODS This observational study comprised individuals aged ≥ 20 years undergoing hemodialysis and receiving denosumab. After denosumab administration, we analyzed the long-term changes in bone mineral density (BMD) and levels of bone turnover markers (BTMs) and calcium. RESULTS The study included 45 patients who have been receiving denosumab for a median duration of 3.8 (interquartile range, 2.5-6.7) years. Tartrate-resistant acid phosphatase 5b (TRACP-5b) levels decreased from a median of 595 (434-778) mU/dL at baseline to 200 (141-430) mU/dL after 6 months of denosumab administration (P < 0.001) and remained low thereafter. Similarly, bone-specific alkaline phosphatase (BAP) levels decreased from a median of 18.2 (15.9-25.8) μg/L at baseline to 12.4 (9.9-15.6) μg/L after 6 months (P < 0.001) and remained low thereafter. Meanwhile, BMD, as assessed with dual energy X-ray absorptiometry and measured at the distal 1/3 of the radius, did not decrease (0.465 ± 0.112 g/cm2 at baseline vs. 0.464 ± 0.112 g/cm2 after administration; P = 0.616). Regarding hypocalcemia, corrected calcium levels reached were the lowest at 7 days after administration and normalized within 30 days. CONCLUSION The study showed long-term suppression of TRACP-5b and BAP levels and sustaining BMD after denosumab administration over an extended period in patients undergoing hemodialysis.
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Affiliation(s)
- Kazuhiko Kato
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
- Division of Molecular Epidemiology, The Jikei University School of Medicine, Tokyo, Japan
| | | | - Arisa Kobayashi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
- Human Health Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Akio Nakashima
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Ichiro Ohkido
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan.
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
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Bird ST, Smith ER, Gelperin K, Jung TH, Thompson A, Kambhampati R, Lyu H, Zhao H, Zhao Y, Zhu Y, Easley O, Niak A, Wernecke M, Chillarige Y, Zemskova M, Kelman JA, Graham DJ. Severe Hypocalcemia With Denosumab Among Older Female Dialysis-Dependent Patients. JAMA 2024; 331:491-499. [PMID: 38241060 PMCID: PMC10799290 DOI: 10.1001/jama.2023.28239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 12/27/2023] [Indexed: 01/22/2024]
Abstract
Importance Dialysis-dependent patients experience high rates of morbidity from fractures, yet little evidence is available on optimal treatment strategies. Chronic kidney disease-mineral and bone disorder is nearly universal in dialysis-dependent patients, complicating diagnosis and treatment of skeletal fragility. Objective To examine the incidence and comparative risk of severe hypocalcemia with denosumab compared with oral bisphosphonates among dialysis-dependent patients treated for osteoporosis. Design, Setting, and Participants Retrospective cohort study of female dialysis-dependent Medicare patients aged 65 years or older who initiated treatment with denosumab or oral bisphosphonates from 2013 to 2020. Clinical performance measures including monthly serum calcium were obtained through linkage to the Consolidated Renal Operations in a Web-Enabled Network database. Exposures Denosumab, 60 mg, or oral bisphosphonates. Main Outcomes and Measures Severe hypocalcemia was defined as total albumin-corrected serum calcium below 7.5 mg/dL (1.88 mmol/L) or a primary hospital or emergency department hypocalcemia diagnosis (emergent care). Very severe hypocalcemia (serum calcium below 6.5 mg/dL [1.63 mmol/L] or emergent care) was also assessed. Inverse probability of treatment-weighted cumulative incidence, weighted risk differences, and weighted risk ratios were calculated during the first 12 treatment weeks. Results In the unweighted cohorts, 607 of 1523 denosumab-treated patients and 23 of 1281 oral bisphosphonate-treated patients developed severe hypocalcemia. The 12-week weighted cumulative incidence of severe hypocalcemia was 41.1% with denosumab vs 2.0% with oral bisphosphonates (weighted risk difference, 39.1% [95% CI, 36.3%-41.9%]; weighted risk ratio, 20.7 [95% CI, 13.2-41.2]). The 12-week weighted cumulative incidence of very severe hypocalcemia was also increased with denosumab (10.9%) vs oral bisphosphonates (0.4%) (weighted risk difference, 10.5% [95% CI, 8.8%-12.0%]; weighted risk ratio, 26.4 [95% CI, 9.7-449.5]). Conclusions and Relevance Denosumab was associated with a markedly higher incidence of severe and very severe hypocalcemia in female dialysis-dependent patients aged 65 years or older compared with oral bisphosphonates. Given the complexity of diagnosing the underlying bone pathophysiology in dialysis-dependent patients, the high risk posed by denosumab in this population, and the complex strategies required to monitor and treat severe hypocalcemia, denosumab should be administered after careful patient selection and with plans for frequent monitoring.
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Affiliation(s)
- Steven T. Bird
- Office of Pharmacovigilance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | | | - Kate Gelperin
- Office of Pharmacovigilance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Tae Hyun Jung
- Division of Biometrics, Office of Biostatistics, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Aliza Thompson
- Division of Cardiology and Nephrology, Office of Cardiology, Hematology, Endocrinology, and Nephrology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Rekha Kambhampati
- Division of Cardiology and Nephrology, Office of Cardiology, Hematology, Endocrinology, and Nephrology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Hai Lyu
- Acumen LLC, Burlingame, California
| | | | - Yueqin Zhao
- Division of Biometrics, Office of Biostatistics, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | | | - Olivia Easley
- Division of General Endocrinology, Office of Cardiology, Hematology, Endocrinology, and Nephrology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Ali Niak
- Office of Pharmacovigilance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | | | | | - Marina Zemskova
- Division of General Endocrinology, Office of Cardiology, Hematology, Endocrinology, and Nephrology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | | | - David J. Graham
- Office of Pharmacovigilance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
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7
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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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Evenepoel P, Jørgensen HS, Bover J, Davenport A, Bacchetta J, Haarhaus M, Hansen D, Gracia-Iguacel C, Ketteler M, McAlister L, White E, Mazzaferro S, Vervloet M, Shroff R. Recommended calcium intake in adults and children with chronic kidney disease-a European consensus statement. Nephrol Dial Transplant 2024; 39:341-366. [PMID: 37697718 DOI: 10.1093/ndt/gfad185] [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: 06/01/2023] [Indexed: 09/13/2023] Open
Abstract
Mineral and bone disorders (MBD) are common in patients with chronic kidney disease (CKD), contributing to significant morbidity and mortality. For several decades, the first-line approach to controlling hyperparathyroidism in CKD was by exogenous calcium loading. Since the turn of the millennium, however, a growing awareness of vascular calcification risk has led to a paradigm shift in management and a move away from calcium-based phosphate binders. As a consequence, contemporary CKD patients may be at risk of a negative calcium balance, which, in turn, may compromise bone health, contributing to renal bone disease and increased fracture risk. A calcium intake below a certain threshold may be as problematic as a high intake, worsening the MBD syndrome of CKD, but is not addressed in current clinical practice guidelines. The CKD-MBD and European Renal Nutrition working groups of the European Renal Association (ERA), together with the CKD-MBD and Dialysis working groups of the European Society for Pediatric Nephrology (ESPN), developed key evidence points and clinical practice points on calcium management in children and adults with CKD across stages of disease. These were reviewed by a Delphi panel consisting of ERA and ESPN working groups members. The main clinical practice points include a suggested total calcium intake from diet and medications of 800-1000 mg/day and not exceeding 1500 mg/day to maintain a neutral calcium balance in adults with CKD. In children with CKD, total calcium intake should be kept within the age-appropriate normal range. These statements provide information and may assist in decision-making, but in the absence of high-level evidence must be carefully considered and adapted to individual patient needs.
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Affiliation(s)
- Pieter Evenepoel
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium
- Department of Medicine, Division of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Hanne Skou Jørgensen
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium
- Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Nephrology, Aalborg University Hospital, Aalborg, Denmark
| | - Jordi Bover
- Department of Nephrology, University Hospital Germans Trias i Pujol, Barcelona, Catalonia, Spain
- REMAR-IGTP Group, Germans Trias i Pujol Research Institute, Can Ruti Campus, Barcelona, Catalonia, Spain
| | - Andrew Davenport
- Department of Renal Medicine, Royal Free Hospital, University College London, London, UK
| | - Justine Bacchetta
- Pediatric Nephrology Rheumatology and Dermatology Unit, Reference Center for Rare Renal Diseases, ORKID and ERK-Net networks, Lyon University Hospital, Bron, France
- Lyon Est Medical School, INSERM1033 Research Unit, Claude Bernard Lyon 1 University, Lyon, France
| | - Mathias Haarhaus
- Division of Renal Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Diaverum Sweden, Malmö, Sweden
| | - Ditte Hansen
- Department of Nephrology, Copenhagen University Hospital-Herlev, Copenhagen
- Institute of Clinical Medicine, University of Copenhagen, Denmark
| | - Carolina Gracia-Iguacel
- Department of Renal Medicine, IIS-Fundación Jiménez Díaz UAM University Hospital, Madrid, Spain
| | - Markus Ketteler
- Department of General Internal Medicine and Nephrology, Robert-Bosch Hospital, Stuttgart, Germany
| | - Louise McAlister
- Dietetic Team, UCL Great Ormond Street Hospital for Children and University College London, London, UK
| | - Emily White
- Dietetic Team, Royal Free Hospital, University College London, London, UK
| | - Sandro Mazzaferro
- Department of Translation and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Marc Vervloet
- Amsterdam Cardiovascular Sciences, Amsterdam UMC, The Netherlands
- Department of Nephrology, Amsterdam UMC, The Netherlands
| | - Rukshana Shroff
- Renal Unit, UCL Great Ormond Street Hospital for Children, London, UK
- Institute of Child Health, University College London, London, UK
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9
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Humphrey MB, Russell L, Danila MI, Fink HA, Guyatt G, Cannon M, Caplan L, Gore S, Grossman J, Hansen KE, Lane NE, Ma NS, Magrey M, McAlindon T, Robinson AB, Saha S, Womack C, Abdulhadi B, Charles JF, Cheah JTL, Chou S, Goyal I, Haseltine K, Jackson L, Mirza R, Moledina I, Punni E, Rinden T, Turgunbaev M, Wysham K, Turner AS, Uhl S. 2022 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis. Arthritis Rheumatol 2023; 75:2088-2102. [PMID: 37845798 DOI: 10.1002/art.42646] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 06/28/2023] [Accepted: 07/03/2023] [Indexed: 10/18/2023]
Abstract
OBJECTIVE The objective is to update recommendations for prevention and treatment of glucocorticoid-induced osteoporosis (GIOP) for patients with rheumatic or nonrheumatic conditions receiving >3 months treatment with glucocorticoids (GCs) ≥2.5 mg daily. METHODS An updated systematic literature review was performed for clinical questions on nonpharmacologic, pharmacologic treatments, discontinuation of medications, and sequential therapy. Grading of Recommendations Assessment, Development and Evaluation approach was used to rate the certainty of evidence. A Voting Panel achieved ≥70% consensus on the direction (for or against) and strength (strong or conditional) of recommendations. RESULTS For adults beginning or continuing >3 months of GC treatment, we strongly recommend as soon as possible after initiation of GCs, initial assessment of fracture risks with clinical fracture assessment, bone mineral density with vertebral fracture assessment or spinal x-ray, and Fracture Risk Assessment Tool if ≥40 years old. For adults at medium, high, or very high fracture risk, we strongly recommend pharmacologic treatment. Choice of oral or intravenous bisphosphonates, denosumab, or parathyroid hormone analogs should be made by shared decision-making. Anabolic agents are conditionally recommended as initial therapy for those with high and very high fracture risk. Recommendations are made for special populations, including children, people with organ transplants, people who may become pregnant, and people receiving very high-dose GC treatment. New recommendations for both discontinuation of osteoporosis therapy and sequential therapies are included. CONCLUSION This guideline provides direction for clinicians and patients making treatment decisions for management of GIOP. These recommendations should not be used to limit or deny access to therapies.
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Affiliation(s)
- Mary Beth Humphrey
- University of Oklahoma Health Sciences Center and U.S. Department of Veterans Affairs, Oklahoma City, Oklahoma
| | | | - Maria I Danila
- University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, Alabama
| | - Howard A Fink
- Geriatric Research Education and Clinical Center, VA Health Care System, Minneapolis, Minnesota
| | | | - Michael Cannon
- Arthritis Consultants of Tidewater, Virginia Beach, Virginia
| | | | | | | | | | | | - Nina S Ma
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora
| | - Marina Magrey
- Case Western Reserve University, MetroHealth, Cleveland, Ohio
| | | | | | | | | | - Basma Abdulhadi
- University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, Alabama
| | | | - Jonathan T L Cheah
- UMass Memorial Health and UMass Chan Medical School, Worcester, Massachusetts
| | - Sharon Chou
- Brigham and Women's Hospital, Boston, Massachusetts
| | - Itivrita Goyal
- University of Oklahoma Health Sciences Center and U.S. Department of Veterans Affairs, Oklahoma City, Oklahoma
| | | | - Lesley Jackson
- University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, Alabama
| | - Reza Mirza
- McMaster University, Hamilton, Ontario, Canada
| | - Iram Moledina
- University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, Alabama
| | - Emma Punni
- University of Oklahoma Health Sciences Center and U.S. Department of Veterans Affairs, Oklahoma City, Oklahoma
| | | | | | - Katherine Wysham
- VA Puget Sound Health Care System and University of Washington School of Medicine, Seattle, Washington
| | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
| | - Stacey Uhl
- ECRI Institute, Plymouth Meeting, Pennsylvania
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10
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Humphrey MB, Russell L, Danila MI, Fink HA, Guyatt G, Cannon M, Caplan L, Gore S, Grossman J, Hansen KE, Lane NE, Ma NS, Magrey M, McAlindon T, Robinson AB, Saha S, Womack C, Abdulhadi B, Charles JF, Cheah JTL, Chou S, Goyal I, Haseltine K, Jackson L, Mirza R, Moledina I, Punni E, Rinden T, Turgunbaev M, Wysham K, Turner AS, Uhl S. 2022 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis. Arthritis Care Res (Hoboken) 2023; 75:2405-2419. [PMID: 37884467 DOI: 10.1002/acr.25240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 06/28/2023] [Accepted: 07/03/2023] [Indexed: 10/28/2023]
Abstract
OBJECTIVE The objective is to update recommendations for prevention and treatment of glucocorticoid-induced osteoporosis (GIOP) for patients with rheumatic or nonrheumatic conditions receiving >3 months treatment with glucocorticoids (GCs) ≥2.5 mg daily. METHODS An updated systematic literature review was performed for clinical questions on nonpharmacologic, pharmacologic treatments, discontinuation of medications, and sequential therapy. Grading of Recommendations Assessment, Development and Evaluation approach was used to rate the certainty of evidence. A Voting Panel achieved ≥70% consensus on the direction (for or against) and strength (strong or conditional) of recommendations. RESULTS For adults beginning or continuing >3 months of GC treatment, we strongly recommend as soon as possible after initiation of GCs, initial assessment of fracture risks with clinical fracture assessment, bone mineral density with vertebral fracture assessment or spinal x-ray, and Fracture Risk Assessment Tool if ≥40 years old. For adults at medium, high, or very high fracture risk, we strongly recommend pharmacologic treatment. Choice of oral or intravenous bisphosphonates, denosumab, or parathyroid hormone analogs should be made by shared decision-making. Anabolic agents are conditionally recommended as initial therapy for those with high and very high fracture risk. Recommendations are made for special populations, including children, people with organ transplants, people who may become pregnant, and people receiving very high-dose GC treatment. New recommendations for both discontinuation of osteoporosis therapy and sequential therapies are included. CONCLUSION This guideline provides direction for clinicians and patients making treatment decisions for management of GIOP. These recommendations should not be used to limit or deny access to therapies.
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Affiliation(s)
- Mary Beth Humphrey
- University of Oklahoma Health Sciences Center and U.S. Department of Veterans Affairs, Oklahoma City, Oklahoma
| | | | - Maria I Danila
- University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, Alabama
| | - Howard A Fink
- Geriatric Research Education and Clinical Center, VA Health Care System, Minneapolis, Minnesota
| | | | - Michael Cannon
- Arthritis Consultants of Tidewater, Virginia Beach, Virginia
| | | | | | | | | | | | - Nina S Ma
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora
| | - Marina Magrey
- Case Western Reserve University, MetroHealth, Cleveland, Ohio
| | | | | | | | | | - Basma Abdulhadi
- University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, Alabama
| | | | - Jonathan T L Cheah
- UMass Memorial Health and UMass Chan Medical School, Worcester, Massachusetts
| | - Sharon Chou
- Brigham and Women's Hospital, Boston, Massachusetts
| | - Itivrita Goyal
- University of Oklahoma Health Sciences Center and U.S. Department of Veterans Affairs, Oklahoma City, Oklahoma
| | | | - Lesley Jackson
- University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, Alabama
| | - Reza Mirza
- McMaster University, Hamilton, Ontario, Canada
| | - Iram Moledina
- University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, Alabama
| | - Emma Punni
- University of Oklahoma Health Sciences Center and U.S. Department of Veterans Affairs, Oklahoma City, Oklahoma
| | | | | | - Katherine Wysham
- VA Puget Sound Health Care System and University of Washington School of Medicine, Seattle, Washington
| | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
| | - Stacey Uhl
- ECRI Institute, Plymouth Meeting, Pennsylvania
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11
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Kanagalingam T, Khan T, Sultan N, Cowan A, Thain J, Hoy C, Ledger S, Clemens KK. Reducing the risk of denosumab-induced hypocalcemia in patients with advanced chronic kidney disease: a quality improvement initiative. Arch Osteoporos 2023; 18:138. [PMID: 37985504 DOI: 10.1007/s11657-023-01341-8] [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] [Received: 04/21/2023] [Accepted: 10/23/2023] [Indexed: 11/22/2023]
Abstract
Denosumab can improve bone health in advanced kidney disease (CKD) but is associated with hypocalcemia. We created a clinical care pathway focused on the safe provision of denosumab in advanced CKD that reduced the risk of hypocalcemia by 37% at our hospital. Similar pathways could be adopted and tested in other centers. PURPOSE There is an increased risk of hypocalcemia with denosumab in advanced chronic kidney disease (CKD). We aimed to reduce the proportion of patients with advanced CKD who experienced denosumab-induced hypocalcemia at our center. METHODS We conducted a quality improvement (QI) project of patients with CKD stage 3b or less (i.e., estimated glomerular filtration rate <45 mL/min/1.73m2 including dialysis) who were part of the Osteoporosis and Bone Disease Program at St. Joseph's Health Care London (Canada) between December 2020 and January 2023. Our intervention was a clinical care pathway which optimized CKD mineral and bone disorder (CKD-MBD) and 25-hydroxyvitamin levels; provided calcium and vitamin D prophylaxis; promoted multidisciplinary communication between bone and kidney specialists; and carefully monitored calcium post-denosumab injection. Our primary outcome measure was the proportion of patients with hypocalcemia (defined by albumin-corrected serum calcium <1.9mmol/L) at 60 days. Process measures included the appropriate provision of calcium and vitamin D prophylaxis. Balance measures included the development of hypercalcemia and hyperphosphatemia following prophylaxis. We used plan-do-see-act cycles to study four tests of change and presented results using descriptive statistics and run charts. RESULTS There were 6 patients with advanced CKD treated with denosumab prior to the implementation of our care pathway (March 2015-October 2020; 83% receiving dialysis). At the time of their denosumab injection, 83% were using 500-1000 mg of calcium, and 83% used 1000-2000 IU of vitamin D3. Fifty percent developed denosumab-induced hypocalcemia. Following the implementation of our care pathway, 15 patients (40% receiving dialysis) were treated with denosumab. Ninety-three percent received calcium at a daily dose of 350 to 2250 mg and 87% received 1000-2000 IU of vitamin D3. Thirteen percent developed denosumab-induced hypocalcemia. There was no hypercalcemia or hyperphosphatemia. CONCLUSIONS A clinical care pathway focused on the safe provision of denosumab in advanced CKD reduced the risk of hypocalcemia in patients treated in our hospital. Similar pathways could be adopted and tested in other centers.
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Affiliation(s)
- Tharsan Kanagalingam
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Tayyab Khan
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Division of Endocrinology and Metabolism, Western University, London, ON, Canada
- St Joseph's Health Care London, London, ON, Canada
- Centre for Diabetes, Endocrinology, and Metabolism, St. Joseph's Hospital, PO BOX 5777, STN B, London, Ontario, N6A 4V2, Canada
| | - Nabil Sultan
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- London Health Sciences Centre, London, ON, Canada
- Division of Nephrology, Western University, London, ON, Canada
| | - Andrea Cowan
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- London Health Sciences Centre, London, ON, Canada
- Division of Nephrology, Western University, London, ON, Canada
| | - Jenny Thain
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- St Joseph's Health Care London, London, ON, Canada
- Division of Geriatrics, Western University, London, ON, Canada
| | - Cindy Hoy
- St Joseph's Health Care London, London, ON, Canada
| | | | - Kristin K Clemens
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.
- Division of Endocrinology and Metabolism, Western University, London, ON, Canada.
- St Joseph's Health Care London, London, ON, Canada.
- Centre for Diabetes, Endocrinology, and Metabolism, St. Joseph's Hospital, PO BOX 5777, STN B, London, Ontario, N6A 4V2, Canada.
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada.
- Lawson Health Research Institute, London, ON, Canada.
- ICES, London, ON, Canada.
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12
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Gu Z, Yang X, Wang Y, Gao J. Effects of denosumab on bone mineral density and bone metabolism in patients with end-stage renal disease: A systematic review and meta-analysis. Hemodial Int 2023; 27:352-363. [PMID: 37264758 DOI: 10.1111/hdi.13098] [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: 11/22/2022] [Revised: 04/25/2023] [Accepted: 05/12/2023] [Indexed: 06/03/2023]
Abstract
INTRODUCTION The effects of denosumab on bone mineral density (BMD) and metabolism in patients with end-stage renal disease (ESRD) remain controversial. Hence, we performed a systematic review and meta-analysis of observational studies. METHODS The MEDLINE, EMBASE, and Cochrane Library databases were searched in June 2022 to identify studies that evaluated the risk of denosumab-associated hypocalcemia and changes in bone metabolism, changes in BMD from baseline to post-treatment in patients with ESRD. FINDINGS Twelve studies with 348 participants were included. The pooled incidence of hypocalcemia during denosumab treatment was 35.0% (95% confidence interval [CI], 25%-46%; I2 = 63.6%). There were no significant changes in either the serum calcium or phosphate levels from the baseline to post-treatment period; the mean differences were 0.04 mg/dL (95% CI, -0.12 to 0.20 mg/dL) and -0.39 mg/dL (95% CI, -0.89 to 0.12 mg/dL). We found significant changes in the alkaline phosphatase and parathyroid hormone levels; the standardized mean differences were -2.98 (95% CI, -5.36 to -0.59) and -3.12 (95% CI: -4.94 to -1.29), respectively. Denosumab may increase BMD, with mean differences of 9.10% (95% CI: 4.07%-14.13%) and 9.00% (95% CI: 5.93%-12.07%) for the femoral neck and lumbar spine, respectively. DISCUSSION Denosumab increased the BMDs of the lumbar spine and femoral neck in patients with ESRD. The onset of hypocalcemia must be carefully monitored during denosumab administration.
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Affiliation(s)
- Zhaoyan Gu
- Department of Endocrinology, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, People's Republic of China
| | - Xuhui Yang
- Department of Oncology, The Fifth Medical Center, Chinese PLA General Hospital and Chinese PLA Medical School, Beijing, People's Republic of China
| | - Yan Wang
- Chaoyang 1st Sanitarium for Retired Cadres of Beijing Garrison of the Chinese PLA, Beijing, People's Republic of China
| | - Jianjun Gao
- Department of Nephrology, The Chinese PLA Strategic Support Force Characteristic Medical Center, Beijing, People's Republic of China
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13
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Iseri K, Mizobuchi M, Winzenrieth R, Humbert L, Saitou T, Kato T, Nakajima Y, Wakasa M, Shishido K, Honda H. Long-Term Effect of Denosumab on Bone Disease in Patients with CKD. Clin J Am Soc Nephrol 2023; 18:1195-1203. [PMID: 37314764 PMCID: PMC10564351 DOI: 10.2215/cjn.0000000000000213] [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: 02/02/2023] [Accepted: 06/06/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND The effect of long-term denosumab therapy and of denosumab discontinuation on the cortical bone of the hip regions in dialysis patients has not been studied. METHODS This retrospective study investigated the cortical and trabecular compartments and estimated strength indices of the hip region, obtained using 3D-SHAPER software, after a maximum of 5 years of denosumab therapy in 124 dialysis patients. A Wilcoxon signed-rank test was used to identify the differences in each parameter before and after denosumab initiation. Similarly, we investigated the changes in these parameters after denosumab discontinuation in 11 dialysis patients. RESULTS Integral and trabecular volumetric bone mineral densities (BMD) were significantly lower at the start of denosumab therapy than those in 1 year before denosumab initiation. After starting denosumab, areal BMD (median change +7.7% [interquartile range (IQR), +4.6 to +10.6]), cortical volumetric BMD (median change +3.4% [IQR, +1.0 to +4.7]), cortical surface BMD (median change +7.1% [IQR, +3.4 to +9.4]), and cortical thickness (median change +3.2% [IQR, +1.8 to +4.9]) showed a significantly higher trend for 3.5 years, which then stabilized at a higher value compared with baseline. A similar trend in the trabecular volumetric BMD (median change +9.8% [IQR, +3.8 to +15.7]) was observed over 2.5 years, with a higher value maintained thereafter. The whole area of the hip region improved after denosumab therapy. Similar trajectories were also found in the estimated strength indices. Conversely, at 1 year after denosumab discontinuation, these 3D parameters and estimated strength indices tended to largely worsen. The lateral aspect of the greater trochanter was the most pronounced location showing volumetric BMD loss. CONCLUSIONS The BMD of both cortical and trabecular components in the hip region was significantly higher after starting denosumab therapy. However, these measurements exhibited a trend of declining substantially after the discontinuation of denosumab.
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Affiliation(s)
- Ken Iseri
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Masahide Mizobuchi
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | | | | | - Tomohiro Saitou
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Tadashi Kato
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yutaka Nakajima
- Internal Medicine, Sekishin-kai Kawasaki Clinic, Kawasaki, Japan
| | - Mikio Wakasa
- Internal Medicine, Sekishin-kai Kawasaki Clinic, Kawasaki, Japan
| | - Kanji Shishido
- Internal Medicine, Sekishin-kai Kawasaki Clinic, Kawasaki, Japan
| | - Hirokazu Honda
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
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14
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Integrated Osteoporosis Care to Reduce Denosumab-Associated Hypocalcemia for Patients with Advanced Chronic Kidney Disease and End-Stage Renal Disease. Healthcare (Basel) 2023; 11:healthcare11030313. [PMID: 36766888 PMCID: PMC9914883 DOI: 10.3390/healthcare11030313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/18/2023] [Accepted: 01/18/2023] [Indexed: 01/21/2023] Open
Abstract
The incidence of hypocalcemia is high in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) undergoing denosumab treatment. Since 2018, we have carried out a "multidisciplinary integrated care program for osteoporosis among patients with CKD and ESRD" in our hospital. The aim of this study was to compare the incidence of denosumab-associated hypocalcemia among patients with advanced CKD and ESRD before and after the integrated care program. We retrospectively reviewed the records of patients on their first dose of denosumab treatment from January 2012 to December 2021. A total of 3208 patients were included in our study. Among the 3208 patients, there were 101 dialysis patients, 150 patients with advanced CKD (stage 4 and 5), and 2957 patients with an estimated glomerular filtration rate (eGFR) higher than or equal to 30. The incidence of post-treatment severe hypocalcemia (corrected calcium level less than 7.0 mg/dl) within 30 days was significantly higher in the dialysis and advanced CKD group than in patients with an eGFR higher than or equal to 30 (6.9% vs. 2.0% vs. 0.1%, respectively, p < 0.001). Based on the results of the multivariate regression model, poor renal function (p < 0.05) and lower baseline corrected calcium level (p < 0.05) were associated with severe hypocalcemia within 30 days following the first dose of denosumab treatment. The incidence of post-treatment severe hypocalcemia within 30 days in advanced CKD and dialysis patients was significantly lower after the integrated care program (6.8% vs. 0.8%, p < 0.05). Our study shows that multidisciplinary integrated care may reduce the incidence rate of denosumab-associated severe hypocalcemia among patients with advanced CKD and ESRD.
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15
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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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16
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Smout D, Jørgensen HS, Cavalier E, Evenepoel P. Clinical utility of bone turnover markers in patients with chronic kidney disease. Curr Opin Nephrol Hypertens 2022; 31:332-338. [PMID: 35703216 DOI: 10.1097/mnh.0000000000000798] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW The burden of fractures is very high in patients with chronic kidney disease (CKD). It is increasingly recognized that knowledge of bone turnover is of paramount importance in guiding mineral metabolism and osteoporosis therapy in CKD. Bone histomorphometry is the gold standard to assess bone turnover, but is seldomly performed in clinical practice. Bone turnover markers (BTMs) may be the long awaited noninvasive diagnostic that may help to close the therapeutic gap in patients with advanced CKD presenting with bone fragility. RECENT FINDINGS Mounting evidence indicates that BTMs may be useful in skeletal and nonskeletal risk stratification, in guiding mineral metabolism and osteoporosis therapy, and in monitoring the therapeutic response. SUMMARY BTMs provide information that is complementary to other clinical tests. It may be envisioned that in the near future, the assessment of nonkidney cleared BTMs may become part of routine clinical evaluation and monitoring of bone health in CKD patients, integrated with clinical risk factors, imaging data and, eventually, bone histomorphometry. Panels of BTMs will likely be more informative than single markers, and the same might hold true for trends as opposed to single time point data.
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Affiliation(s)
- Dieter Smout
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Hanne S Jørgensen
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven
- Department of Kidney Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Etienne Cavalier
- Department of Clinical Chemistry, University of Liege, CHU de Liege, Liege, Belgium
| | - Pieter Evenepoel
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
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17
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Horikawa A, Hongo M, Kasukawa Y, Shimada Y, Kodama H, Sano A, Miyakoshi N. The relationship between chronic kidney disease and denosumab-induced hypocalcemia in high-age osteoporotic patients. J Bone Miner Metab 2022; 40:670-676. [PMID: 35641798 DOI: 10.1007/s00774-022-01331-9] [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: 08/27/2021] [Accepted: 03/31/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE A few studies have reported the safety of the treatment of elderly osteoporotic patients with chronic kidney disease (CKD) and the possibility of hypocalcemia. The aim of the present study was to examine the relationship between the incidence of hypocalcemia and the CKD stage in elderly osteoporotic patients treated with denosumab. MATERIALS AND METHODS This study was designed as a parallel-group comparison study between the denosumab-associated hypocalcemia (DAH) groups: the concentration of serum calcium was under 8.6 mg/dl and the normal calcium (NC) groups: the concentration of serum calcium was over 8.6 mg/dl. Fifty-two subjects over 70 years old were enrolled in this study, with 16 patients classified into the DAH group and 36 patients assigned to the NC group. All patients were further classified into two subgroups according to their age, into an around 75 years group to clarify the relevance of old age and an around 85 years group and also into a mild CKD group and a moderate CKD group by based on estimated glomerular filtration (eGFR). Serum calcium concentration, tartrate-resistant acid phosphatase (TRACP-5b), and type 1 procollagen N terminal propeptide (P1NP) were measured, and adverse drug reactions were evaluated. RESULTS The eGFR and serum calcium were significantly lower in the DAH group than in the NC group in the starting phase. Moreover, TRACP-5b was significantly higher in the DAH group than in the NC group in the starting phase. There were no significant differences in P1NP. The incidence of hypocalcemia was significantly higher in the around 85 groups than in the around 75 groups. The frequency of hypocalcemia was also significantly higher in the severe CKD group than in the mild CKD group. CONCLUSION Advanced age combined with low eGFR and low serum Ca status appear to be associated with the incidence of hypocalcemia when using denosumab for the treatment of osteoporosis.
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Affiliation(s)
- Akira Horikawa
- Shizuoka Tokusyukai Hospital, 1-11 Surugaku-Simokawahara-Minami, Shizuoka, 421-0117, Japan.
| | - Michio Hongo
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Yuji Kasukawa
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Yoichi Shimada
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Hiroyuki Kodama
- South Akita Orthopedic Clinic, Seiwakai, 96-2 Kaidousita, Syowa-Ookubo, Katagami, 018-1401, Japan
| | - Akihisa Sano
- Shizuoka Tokusyukai Hospital, 1-11 Surugaku-Simokawahara-Minami, Shizuoka, 421-0117, Japan
| | - Naohisa Miyakoshi
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
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18
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Effects of bone turnover status on the efficacy and safety of denosumab among haemodialysis patients. Sci Rep 2022; 12:7781. [PMID: 35546172 PMCID: PMC9095701 DOI: 10.1038/s41598-022-12029-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 05/04/2022] [Indexed: 11/08/2022] Open
Abstract
Denosumab is reported to increase bone mineral density (BMD) among haemodialysis patients; however, hypocalcaemia is a serious adverse effect among chronic kidney disease (CKD) patients. Identifying which patients will show greater improvement in BMD is important. We enrolled 84 haemodialysis patients with osteoporosis in our study. 28 patients initiated denosumab treatment between October 2019 and October 2020. We assessed BMD changes and investigated the association between baseline bone turnover marker (BTM) levels and 6-month changes in BMD after denosumab treatment. BMD was increased at 6 months in denosumab-treated patients compared with patients not treated with denosumab (lumbar spine: 5.34% vs. - 0.49%; total hip: 2.43% vs. - 0.47%). Bone-specific alkaline phosphatase (BAP) and tartrate-resistant acid phosphatase-5b (TRACP-5b) at baseline were independently associated with increased BMD in the total hip (BAP: β = 0.472, p value = 0.004; TRACP-5b: β = 0.433, p value = 0.008) and lumbar spine (BAP: β = 0.591, p value = 0.001; TRACP-5b: β = 0.613, p value = 0.0008). BAP and TRACP-5b were also independent predictors of hypocalcaemic events (OR [95% CI] 1.747 [1.084-4.604] and 1.006 [1.000-1.015], respectively). BTMs may be associated with increased BMD and hypocalcaemic events after denosumab treatment. BTM measurement may be useful for assessing the effect of denosumab on BMD; however, careful monitoring of serum calcium levels is needed.
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19
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Halfon M, Schwotzer N, Pruijm M, Bonny O. Letter to the Editor regarding: Granulomatous inflammation and hypercalcemia in patients with severe systemic oxalosis, by Perrin et al, KI Reports, 2021. Kidney Int Rep 2022; 7:930-931. [PMID: 35497791 PMCID: PMC9039470 DOI: 10.1016/j.ekir.2021.12.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/06/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Matthieu Halfon
- Service of Nephrology and Hypertension, Lausanne University Hospital, Lausanne, Switzerland
- Transplantation Center, Lausanne University Hospital, Lausanne, Switzerland
- Correspondence: Matthieu Halfon, Transplantation Center, Lausanne University Hospital, Rue du Bugnon 44, Lausanne, Switzerland
| | - Nora Schwotzer
- Service of Nephrology and Hypertension, Lausanne University Hospital, Lausanne, Switzerland
| | - Menno Pruijm
- Service of Nephrology and Hypertension, Lausanne University Hospital, Lausanne, Switzerland
| | - Olivier Bonny
- Service of Nephrology and Hypertension, Lausanne University Hospital, Lausanne, Switzerland
- Service of Nephrology, Fribourg State Hospital, Fribourg, Switzerland
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20
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Jørgensen HS, Behets G, Viaene L, Bammens B, Claes K, Meijers B, Naesens M, Sprangers B, Kuypers D, Cavalier E, D'Haese P, Evenepoel P. Diagnostic Accuracy of Noninvasive Bone Turnover Markers in Renal Osteodystrophy. Am J Kidney Dis 2021; 79:667-676.e1. [PMID: 34710517 DOI: 10.1053/j.ajkd.2021.07.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 07/23/2021] [Indexed: 01/17/2023]
Abstract
RATIONALE & OBJECTIVE Bone biopsy remains the gold standard for diagnosing renal osteodystrophy as comparable non-invasive alternatives have yet to be established. The aim of this study was to investigate the diagnostic accuracy of biochemical markers of skeletal remodeling to predict bone turnover. STUDY DESIGN Cross-sectional retrospective diagnostic test study. SETTING & PARTICIPANTS Patients with chronic kidney disease stages G4-G5D and kidney transplant recipients with successful transiliac bone biopsies. TESTS COMPARED Bone turnover as determined by bone histomorphometry was compared to the following biochemical markers: Full-length (1-84) parathyroid hormone (PTH), bone-specific alkaline phosphatase (BsAP), intact procollagen type I N-terminal propeptide (PINP), and tartrate-resistant acid phosphatase isoform 5b (TRAP5b). OUTCOME Diagnostic performance was evaluated by area under the receiver operator characteristics curve (AUC), sensitivity, specificity, and negative and positive predictive values. Optimal diagnostic cutoffs were determined in an exploration cohort (n=100) and validated in a separate cohort (n=99). RESULTS All biomarkers differed across categories of low 33 (17%), normal 109 (55%), and high 57 (29%) bone turnover. AUC values were in the range of 0.75 - 0.85. High negative predictive values (≥90%) were found for both high and low bone turnover, indicating the ability to rule out both conditions using the suggested biomarker cutoffs. The highest diagnostic performances were seen with combinations of biomarkers, with overall diagnostic accuracies of 90% for high turnover, and 78% for low turnover. Results were comparable for kidney transplant candidates and recipients in a sensitivity analysis. LIMITATIONS The single-center approach and heterogeneity of the study cohort are main limitations of this study. CONCLUSIONS We conclude that the diagnostic performance of biochemical markers of bone turnover is acceptable, with clinical utility in ruling out both high and low turnover bone disease.
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Affiliation(s)
- Hanne Skou Jørgensen
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU Leuven, Belgium; Department of Kidney Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Geert Behets
- Laboratory of Pathophysiology, University of Antwerp, Wilrijk, Belgium
| | | | - Bert Bammens
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU Leuven, Belgium; Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Belgium
| | - Kathleen Claes
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU Leuven, Belgium; Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Belgium
| | - Bjorn Meijers
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU Leuven, Belgium; Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Belgium
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU Leuven, Belgium; Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Belgium
| | - Ben Sprangers
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU Leuven, Belgium; Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Belgium
| | - Dirk Kuypers
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU Leuven, Belgium; Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Belgium
| | - Etienne Cavalier
- Department of Clinical Chemistry, Université de Liège, Liège, Belgium
| | - Patrick D'Haese
- Laboratory of Pathophysiology, University of Antwerp, Wilrijk, Belgium
| | - Pieter Evenepoel
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU Leuven, Belgium; Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Belgium.
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21
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Gopaul A, Kanagalingam T, Thain J, Khan T, Cowan A, Sultan N, Clemens KK. Denosumab in chronic kidney disease: a narrative review of treatment efficacy and safety. Arch Osteoporos 2021; 16:116. [PMID: 34319515 DOI: 10.1007/s11657-021-00971-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 06/04/2021] [Indexed: 02/03/2023]
Abstract
UNLABELLED People with chronic kidney disease (CKD) are at high risk of bone fractures. In this review, we summarize the complexity of fracture prevention in CKD, describe the usefulness of a medication called denosumab, and review its safety in this population. Our article will help doctors manage brittle bones in CKD and encourage researchers to conduct more studies to improve bone health in CKD. PURPOSE Patients with CKD are at increased risk of fragility fractures and associated consequences. We discuss the complexity of fracture prevention in CKD, summarize the efficacy and safety of denosumab, and provide an approach to denosumab-induced hypocalcemia. METHODS Using predefined terms, we searched PubMed, MEDLINE, and Google Scholar for studies on fracture prevention in CKD and the efficacy and safety of denosumab. We included observational studies, randomized controlled trials (RCTs), meta-analyses, evidence-based reviews, and clinical practice guidelines. RESULTS The diagnosis of osteoporosis and prevention of related fragility fractures is complex in CKD, particularly in those with advanced and end-staged kidney disease (ESKD). Prior to initiating denosumab, it is important to assess for and optimize CKD-mineral and bone disorders (CKD-MBD). In observational studies and small RCTs, denosumab has been shown to improve bone mineral density and reduce bone turnover in CKD, but there have been no studies focused upon its fracture efficacy. Denosumab-induced hypocalcemia has also been reported, which disproportionately impacts those with ESKD. Risk factors for hypocalcemia with denosumab use in CKD include lower baseline serum calcium and 25 hydroxyvitamin D and both low and high bone turnover. Choosing the "right patient" for denosumab, supplementing with calcium and vitamin D, adjusting calcium dialysate, and close clinical monitoring are essential if considering this drug. CONCLUSION With optimization of CKD-MBD, calcium and vitamin D supplementation, and close monitoring, denosumab can be considered in CKD. There are however opportunities to better understand its fracture efficacy and safety in an RCT setting.
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Affiliation(s)
- Aquila Gopaul
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Tharsan Kanagalingam
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Jenny Thain
- Division of Geriatrics, Western University, London, ON, Canada
| | - Tayyab Khan
- Division of Endocrinology and Metabolism, Western University, London, ON, Canada.,St. Joseph's Health Care London, London, ON, Canada
| | - Andrea Cowan
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Nabil Sultan
- Division of Nephrology, Western University, London, ON, Canada.,London Health Sciences Centre, London, ON, Canada
| | - Kristin K Clemens
- Division of Endocrinology and Metabolism, Western University, London, ON, Canada. .,St. Joseph's Health Care London, London, ON, Canada. .,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada. .,Lawson Health Research Institute, London, ON, Canada. .,ICES, Ontario, Canada.
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22
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Differentiating the causes of adynamic bone in advanced chronic kidney disease informs osteoporosis treatment. Kidney Int 2021; 100:546-558. [PMID: 34102219 DOI: 10.1016/j.kint.2021.04.043] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 04/15/2021] [Accepted: 04/20/2021] [Indexed: 12/15/2022]
Abstract
Patients with chronic kidney disease (CKD) have an increased fracture risk because of impaired bone quality and quantity. Low bone mineral density predicts fracture risk in all CKD stages, including advanced CKD (CKD G4-5D). Pharmacological therapy improves bone mineral density and reduces fracture risk in moderate CKD. Its efficacy in advanced CKD remains to be determined, although pilot studies suggest a positive effect on bone mineral density. Currently, antiresorptive agents are the most commonly prescribed drugs for the prevention and therapy of osteoporosis. Their use in advanced CKD has been limited by the lack of large clinical trials and fear of causing kidney dysfunction and adynamic bone disease. In recent decades, adynamic bone disease has evolved as the most predominant form of renal osteodystrophy, commonly associated with poor outcomes, including premature mortality and progression of vascular calcification. Evolving evidence indicates that reduction of bone turnover by parathyroidectomy or pharmacological therapies, such as calcimimetics and antiresorptive agents, are not associated with premature mortality or accelerated vascular calcification in CKD. In contrast, chronic inflammation, oxidative stress, malnutrition, and diabetes can induce low bone turnover and associate with poor prognosis. Thus, the conditions causing suppression of bone turnover rather than the low bone turnover per se may account for the perceived association with outcomes. Anabolic treatment, in contrast, has been suggested to improve turnover and bone mass in patients with advanced CKD and low bone turnover; however, uncertainty about safety even exceeds that of antiresorptive agents. Here, we critically review the pathophysiological concept of adynamic bone disease and discuss the effect of low bone turnover on the safety and efficacy of anti-osteoporosis pharmacotherapy in advanced CKD.
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