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Aaltonen L, Hellman T, Lankinen R, Hakamäki M, Metsärinne K, Järvisalo M. Cardiac Biomarkers are Associated with Incident Fracture Risk in Advanced Chronic Kidney Disease. Calcif Tissue Int 2024:10.1007/s00223-024-01275-4. [PMID: 39164372 DOI: 10.1007/s00223-024-01275-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Accepted: 08/12/2024] [Indexed: 08/22/2024]
Abstract
Cardiovascular disease is associated with increased fracture risk in the general population. Few data exist on the association between cardiovascular health and incident fracture risk in patients with advanced CKD, a high-risk population for fractures. We aimed to assess the link between fracture risk and cardiovascular health in a prospective cohort of 210 patients with CKD stage G4-5. Incident fractures were recorded during a prospective follow-up of 5 years. Laboratory parameters, abdominal aortic calcification score, echocardiography, ultrasound assessment of brachial artery flow-mediated dilatation and carotid intima-media thickness, and maximal stress ergometry were obtained at baseline. A total of 51 fractures were observed in 40 (19%) patients during follow-up. In separate multivariable Cox proportional hazards models adjusted for age, gender, and baseline eGFR, TnT (HR 1.007, CI 95% 1.003-1.010, p < 0.001) and ProBNP (HR 1.000, CI 95% 1.000-1.000, p = 0.017) were associated with incident fractures and the association persisted after adjusting for coronary artery disease (CAD). The patients unable to perform the ergometry test had a higher risk of incident fractures compared to others (36.1% vs 15.5%, p = 0.009). A cardiovascular composite risk score summarizing TnT, ProBNP, and ergometry data was independently associated with incident fractures in a multivariable Cox model (HR 1.373, CI 95% 1.180-1.599, p < 0.001). Patients with the lowest score were observed with no fractures, while patients with the highest score were observed with a fracture risk of 40.5% during follow-up. Risk of incident fractures is associated with biomarkers of cardiovascular health and a composite cardiovascular risk score in patients with advanced CKD.
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Affiliation(s)
- Louise Aaltonen
- Kidney Center, Department of Medicine, Turku University Hospital, PL 52, Kiinamyllynkatu 4-8, 20521, Turku, Finland.
| | - Tapio Hellman
- Kidney Center, Department of Medicine, Turku University Hospital, PL 52, Kiinamyllynkatu 4-8, 20521, Turku, Finland
| | - Roosa Lankinen
- Kidney Center, Department of Medicine, Turku University Hospital, PL 52, Kiinamyllynkatu 4-8, 20521, Turku, Finland
| | - Markus Hakamäki
- Kidney Center, Department of Medicine, Turku University Hospital, PL 52, Kiinamyllynkatu 4-8, 20521, Turku, Finland
| | - Kaj Metsärinne
- Kidney Center, Department of Medicine, Turku University Hospital, PL 52, Kiinamyllynkatu 4-8, 20521, Turku, Finland
| | - Mikko Järvisalo
- Department of Medicine, Satakunta Central Hospital, Sairaalantie 3, 28500, Pori, Finland
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2
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Tasnim N, Dutta P, Nayeem J, Masud P, Ferdousi A, Ghosh AS, Hossain M, Rajia S, Kubra KT, Sakibuzzaman M, Khan AT. Osteoporosis, an Inevitable Circumstance of Chronic Kidney Disease: A Systematic Review. Cureus 2021; 13:e18488. [PMID: 34692259 PMCID: PMC8526087 DOI: 10.7759/cureus.18488] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2021] [Indexed: 12/15/2022] Open
Abstract
Nowadays, chronic kidney disease (CKD) and osteoporosis have become crucial health-related issues globally. CKD-induced osteoporosis is a systemic disease characterized by the disruption of mineral, hormone, and vitamin homeostasis that elevates the likelihood of fracture. Here, we review recent studies on the association of CKD and osteoporosis. In particular, we focus on the pathogenesis of CKD-associated osteoporosis, including the homeostasis and pathways of several components such as parathyroid hormone, calcium, phosphate, vitamin D, fibroblast growth factor, and klotho, as well as abnormal bone mineralization, remodeling, and turnover. In addition, we explore the diagnostic tools and possible therapeutic approaches for the management and prevention of CKD-associated osteoporosis. Patients with CKD show higher osteoporosis prevalence, greater fracture rate, increased morbidity and mortality, and an elevated occurrence of hip fracture. We also rule out that increased severity of CKD is related to a more severe condition of osteoporosis. Furthermore, supplements such as calcium and vitamin D as well as lifestyle modifications such as exercise and cessation of smoking and alcohol help in fracture prevention. However, new approaches and advancements in treatment are needed to reduce the fracture risk in patients with CKD. Therefore, further collaborative multidisciplinary research is needed in this regard.
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Affiliation(s)
- Nishat Tasnim
- Internal Medicine, Sacramento Veterans Affairs Medical Center, Mather, USA
| | - Priyata Dutta
- Internal Medicine, Mymensingh Medical College, Mymensingh, BGD
| | - Jannatun Nayeem
- Internal Medicine, Cumilla Medical College and Hospital, Cumilla, BGD
| | - Parisha Masud
- Internal Medicine, Columbia University Medical Center, New York, USA
| | - Afsana Ferdousi
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ammy S Ghosh
- Internal Medicine, Institute of Applied Health Sciences, Chittagong, BGD
| | - Maksuda Hossain
- Biodesign Institute Center for Immunotherapy, Vaccines and Virotherapy, Arizona State University, Tempe, USA
| | - Sultana Rajia
- Internal Medicine, Sher-E Bangla Medical College, Barishal, BGD
| | - Khadija T Kubra
- Internal Medicine, Bangladesh Medical College and Hospital, Dhaka, BGD
| | - Md Sakibuzzaman
- Internal Medicine, University of Mississippi Medical Center, Jackson, USA.,Experimental Pathology (Cancer Biology), Mayo Clinic, Rochester, USA.,Internal Medicine, Sir Salimullah Medical College, Dhaka, BGD.,Neuroscience, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Asma T Khan
- Division of Research & Academic Affairs, Larkin Community Hospital, South Miami, USA
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Jafari M, Anwar S, Kour K, Sanjoy S, Goyal K, Prasad B. T Scores, FRAX, Frailty Phenotype, Falls, and Its Relationship to Fractures in Patients on Maintenance Hemodialysis. Can J Kidney Health Dis 2021; 8:20543581211041184. [PMID: 34457317 PMCID: PMC8392815 DOI: 10.1177/20543581211041184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 07/18/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Despite the magnitude of fracture and the consequences in patients receiving hemodialysis, optimal risk assessment tools in this population are not well explored. Frailty and falls-known risk factors for fracture in chronic kidney disease (CKD) and non-CKD populations-are common in patients receiving hemodialysis (HD) therapy. While the relationship between T scores in relation to fractures in patients receiving HD is recognized, there is a paucity of data to the additional contributions of fracture assessment tool (FRAX), frailty status, and falls in its relationship with fracture. OBJECTIVES To evaluate the clinical utility of adding FRAX, frailty status, and falls to T scores at the femoral neck to determine whether it enhances fracture discrimination in patients on maintenance HD. DESIGN A cross-sectional observational study. SETTING Two main dialysis units in Regina, Saskatchewan, Canada. PATIENTS A total of 109 patients on maintenance HD at two dialysis units from January 1, 2017, to December 31, 2018, were included in the study. MEASUREMENTS Fracture (the main outcome) was documented based on the review of medical charts, self-recall, and additionally vertebral fractures were identified by an x-ray. Areal bone mineral density (BMD) was measured by dual-energy x-ray absorptiometry (DXA). FRAX score was calculated using an online algorithm based on 11 clinical risk factors. We calculated the FRAX score for hip fracture and major osteoprotoic fracture with and without the inclusion of BMD. Frailty was assessed using the Fried criteria, which included assessments of unintentional weight loss, weakness (handgrip strength), slowness (walking speed), and questionnaires for physical activity and self-perceived exhaustion. Patients were enquired about the history and frequency of falls. METHODS A total of 131 patients underwent frailty assessments at the two dialysis units during the dialysis treatment. Following frailty assessments, they were referred for DXA scans and upon receipt of the results undertook FRAX questionnaires. They were additionally sent for lumbar x-rays and contacted for a history of falls. Association between the BMD-T score, FRAX, frailty status, falls, with fracture were examined with sequential multivariable logistic regression models. Differences were considered statistically significant at P values <.05. RESULTS A total of 109 patients were included in the data analysis. The composite of fracture occurred in 37.6% of patients. About 59.3% were identified as frail, and 29% of the participants had at least one fall in the last year. On multivariate regression analysis, each lower standard deviation (SD) in femoral neck T score was associated with 48% higher odds of fracture (odds ratio [OR] = 1.48; 95% confidence interval [CI] 1.20-1.68, P = .005). With the inclusion for FRAX scores (hip), the OR for fracture remained significant at 1.38 (OR = 1.38, 95% CI 1.04-1.63, P = .043). The addition of frailty status and history of falls did not further improve the model. Low T score and FRAX were both independent risk factors in patients on HD therapy. LIMITATIONS This is a single-center study with a small sample size which limits the generalizability of the findings. Due to the cross-sectional study, associations identified may be difficult to interpret. CONCLUSIONS Both BMD measurements by DXA and FRAX are useful tools to assess fracture in patients receiving HD. The addition of frailty status and history of falls is not associated with fractures in this population. Larger prospective studies are needed to determine whether the inclusion of frailty and falls to the conventional models will improve fracture assessment in the population receiving HD. TRIAL REGISTRATION The study was not registered on a publicly accessible registry as it did not involve health care intervention on human participants.
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Affiliation(s)
- Maryam Jafari
- Dr. T. Bhanu Prasad Medical Professional Corporation, Regina, SK, Canada
| | - Salman Anwar
- College of Medicine, University of Saskatchewan, Regina, Canada
| | - Kaval Kour
- Dr. T. Bhanu Prasad Medical Professional Corporation, Regina, SK, Canada
| | - Shubrandu Sanjoy
- Research Department, Saskatchewan Health Authority, Regina, Canada
| | - Kunal Goyal
- Department of Radiology, Regina General Hospital, Regina, SK, Canada
| | - Bhanu Prasad
- Section of Nephrology, Department of Medicine, Regina General Hospital, Regina, SK, Canada
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Jørgensen HS, David K, Salam S, Evenepoel P. Traditional and Non-traditional Risk Factors for Osteoporosis in CKD. Calcif Tissue Int 2021; 108:496-511. [PMID: 33586002 DOI: 10.1007/s00223-020-00786-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 12/02/2020] [Indexed: 12/11/2022]
Abstract
Osteoporosis is a state of bone fragility with reduced skeletal resistance to trauma, and consequently increased risk of fracture. A wide range of conditions, including traditional risk factors, lifestyle choices, diseases and their treatments may contribute to bone fragility. It is therefore not surprising that the multi-morbid patient with chronic kidney disease (CKD) is at a particularly high risk. CKD is associated with reduced bone quantity, as well as impaired bone quality. Bone fragility in CKD is a composite of primary osteoporosis, accumulation of traditional and uremia-related risk factors, assaults brought on by systemic disease, and detrimental effects of drugs. Some risk factors are modifiable and represent potential targets for intervention. This review provides an overview of the heterogeneity of bone fragility in CKD.
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Affiliation(s)
- Hanne Skou Jørgensen
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Karel David
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Laboratory of Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Syazrah Salam
- Sheffield Kidney Institute, Sheffield Teaching Hospitals National Health Service Foundation Trust, Sheffield, UK
- Academic Unit of Bone Metabolism and 3 Mellanby Centre for Bone Research, Medical School, University of Sheffield, Sheffield, UK
| | - Pieter Evenepoel
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium.
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5
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Evenepoel P, Cunningham J, Ferrari S, Haarhaus M, Javaid MK, Lafage-Proust MH, Prieto-Alhambra D, Torres PU, Cannata-Andia J. European Consensus Statement on the diagnosis and management of osteoporosis in chronic kidney disease stages G4-G5D. Nephrol Dial Transplant 2021; 36:42-59. [PMID: 33098421 DOI: 10.1093/ndt/gfaa192] [Citation(s) in RCA: 89] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Indexed: 12/16/2022] Open
Abstract
Controlling the excessive fracture burden in patients with chronic kidney disease (CKD) Stages G4-G5D remains an impressive challenge. The reasons are 2-fold. First, the pathophysiology of bone fragility in patients with CKD G4-G5D is complex and multifaceted, comprising a mixture of age-related (primary male/postmenopausal), drug-induced and CKD-related bone abnormalities. Second, our current armamentarium of osteoporosis medications has not been developed for, or adequately studied in patients with CKD G4-G5D, partly related to difficulties in diagnosing osteoporosis in this specific setting and fear of complications. Doubts about the optimal diagnostic and therapeutic approach fuel inertia in daily clinical practice. The scope of the present consensus paper is to review and update the assessment and diagnosis of osteoporosis in patients with CKD G4-G5D and to discuss the therapeutic interventions available and the manner in which these can be used to develop management strategies for the prevention of fragility fracture. As such, it aims to stimulate a cohesive approach to the management of osteoporosis in patients with CKD G4-G5D to replace current variations in care and treatment nihilism.
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Affiliation(s)
- Pieter Evenepoel
- Department of Nephrology, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - John Cunningham
- Centre for Nephrology, UCL Medical School, Royal Free Campus, London, UK
| | - Serge Ferrari
- Service of Bone Diseases, Geneva University Hospital, Switzerland
| | - Mathias Haarhaus
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Diaverum Sweden, Stockholm, Sweden
| | | | | | | | - Pablo Ureña Torres
- Department of Dialysis, AURA Nord Saint Ouen, Saint Ouen, France.,Department of Renal Physiology, Necker Hospital, University of Paris Descartes, Paris, France
| | - Jorge Cannata-Andia
- Bone and Mineral Research Unit (ISPA) (REDinREN), Hospital Universitario Central Asturias, Oviedo University, Spain
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6
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Accelerated decline in quadriceps area and Timed Up and Go test performance are associated with hip fracture risk in older adults with impaired kidney function. Exp Gerontol 2021; 149:111314. [PMID: 33741458 DOI: 10.1016/j.exger.2021.111314] [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: 12/31/2020] [Revised: 02/27/2021] [Accepted: 03/15/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE This study aimed to examine whether an accelerated decline in quadriceps cross-sectional area (CSA), attenuation (a surrogate of quality), and strength, as well as lower limb muscular function, are associated with hip fractures in older adults with impaired kidney function. DESIGN Prospective population-based study. SETTING Community-dwelling old population in Reykjavik, Iceland. SUBJECTS A total of 875 older adults (mean baseline age 76 years) from the Age, Gene/Environment Susceptibility (AGES)-Reykjavik Study with impaired kidney function. METHODS Quadriceps CSA and density were determined using computed tomography (CT), knee extension strength was measured with an isometric dynamometer chair, and muscular function was assessed using the Timed Up and Go (TUG) test. All muscle-related measurements were assessed twice over a mean follow-up of 5.2 years. Data on hip fracture incidence was obtained from medical records during a maximum of 8.4 years of follow-up time. RESULTS Fully adjusted cox-proportional hazard regression models showed that a faster decline in quadriceps CSA and TUG test performance were significantly associated with increased hip fracture risk (HR = 1.55, 95% CI = 1.02-2.36, and HR = 1.80, 95% CI = 1.19-2.72, respectively). A faster decrease in quadriceps density and isometric knee extension strength were not associated with fracture risk. CONCLUSIONS Accelerated decline in CT-derived quadriceps CSA and muscular function, as measured by the TUG test's performance, are predictive of hip fracture risk in older adults with impaired kidney function. TUG test is a simple measure and easily included in routine medical examinations, compared to CT scans, which seems to be useful for identifying a subgroup of individuals with high risk of fracture.
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7
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Elder GJ. Radiographic absorptiometry: a step in solving the CKD fracture puzzle. Kidney Int 2020; 98:826-828. [PMID: 32998811 DOI: 10.1016/j.kint.2020.05.023] [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: 05/03/2020] [Accepted: 05/06/2020] [Indexed: 11/20/2022]
Abstract
Patients on dialysis are highly prone to fracture, and radiographic absorptiometry can be used to measure their bone mineral density and assess fracture risk. However, to determine its place in management, radiographic absorptiometry should be compared with dual-energy X-ray absorptiometry, and with fracture risk assessment tools such as FRAX, tests of muscle strength, biomarkers, and newer dual-energy X-ray absorptiometry techniques. The convenience, accessibility, and cost of radiographic absorptiometry may contribute to its utility in a number of clinical settings.
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Affiliation(s)
- Grahame J Elder
- Osteoporosis and Bone Biology Division, Garvan Institute of Medical Research, Darlinghurst, New South Wales, Australia; Faculty of Medicine, University of Notre Dame, Sydney, New South Wales, Australia; Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia.
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8
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Hsu CY, Chen LR, Chen KH. Osteoporosis in Patients with Chronic Kidney Diseases: A Systemic Review. Int J Mol Sci 2020; 21:E6846. [PMID: 32961953 PMCID: PMC7555655 DOI: 10.3390/ijms21186846] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 09/13/2020] [Accepted: 09/16/2020] [Indexed: 02/06/2023] Open
Abstract
Chronic kidney disease (CKD) is associated with the development of mineral bone disorder (MBD), osteoporosis, and fragility fractures. Among CKD patients, adynamic bone disease or low bone turnover is the most common type of renal osteodystrophy. The consequences of CKD-MBD include increased fracture risk, greater morbidity, and mortality. Thus, the goal is to prevent the occurrences of fractures by means of alleviating CKD-induced MBD and treating subsequent osteoporosis. Changes in mineral and humoral metabolism as well as bone structure develop early in the course of CKD. CKD-MBD includes abnormalities of calcium, phosphorus, PTH, and/or vitamin D; abnormalities in bone turnover, mineralization, volume, linear growth, or strength; and/or vascular or other soft tissue calcification. In patients with CKD-MBD, using either DXA or FRAX to screen fracture risk should be considered. Biomarkers such as bALP and iPTH may assist to assess bone turnover. Before initiating an antiresorptive or anabolic agent to treat osteoporosis in CKD patients, lifestyle modifications, such as exercise, calcium, and vitamin D supplementation, smoking cessation, and avoidance of excessive alcohol intake are important. Managing hyperphosphatemia and SHPT are also crucial. Understanding the complex pathogenesis of CKD-MBD is crucial in improving one's short- and long-term outcomes. Treatment strategies for CKD-associated osteoporosis should be patient-centered to determine the type of renal osteodystrophy. This review focuses on the mechanism, evaluation and management of patients with CKD-MBD. However, further studies are needed to explore more details regarding the underlying pathophysiology and to assess the safety and efficacy of agents for treating CKD-MBD.
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Affiliation(s)
- Chia-Yu Hsu
- Department of Rehabilitation Medicine, Ten-Chan General Hospital, Zhongli, Taoyuan 320, Taiwan;
- Department of Biomedical Engineering, Chung Yuan Christian University, Taoyuan 320, Taiwan
| | - Li-Ru Chen
- Department of Physical Medicine and Rehabilitation, Mackay Memorial Hospital, Taipei 104, Taiwan;
- Department of Mechanical Engineering, National Chiao-Tung University, Hsinchu 300, Taiwan
| | - Kuo-Hu Chen
- Department of Obstetrics and Gynecology, Taipei Tzu-Chi Hospital, The Buddhist Tzu-Chi Medical Foundation, Taipei 231, Taiwan
- Department of Medicine, School of Medicine, Tzu-Chi University, Hualien 970, Taiwan
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9
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Leonard MB, Wehrli FW, Ziolkowski SL, Billig E, Long J, Nickolas TL, Magland JF, Nihtianova S, Zemel BS, Herskovitz R, Rajapakse CS. A multi-imaging modality study of bone density, bone structure and the muscle - bone unit in end-stage renal disease. Bone 2019; 127:271-279. [PMID: 31158505 DOI: 10.1016/j.bone.2019.05.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 05/16/2019] [Accepted: 05/16/2019] [Indexed: 01/10/2023]
Abstract
End stage renal disease (ESRD) is associated with sarcopenia and skeletal fragility. The objectives of this cross-sectional study were to (1) characterize body composition, bone mineral density (BMD) and bone structure in hemodialysis patients compared with controls, (2) assess whether DXA areal BMD (aBMD) correlates with peripheral quantitative CT (pQCT) measures of volumetric BMD (vBMD), cortical dimensions and MRI measures of trabecular microarchitecture, and (3) determine the magnitude of bone deficits in ESRD after adjustment for muscle mass. Thirty ESRD participants, ages 25 to 64 years, were compared with 403 controls for DXA and pQCT outcomes and 104 controls for MRI outcomes; results were expressed as race- and sex- specific Z-scores relative to age. DXA appendicular lean mass index (ALMI kg/m2) and total hip, femoral neck, ultradistal and 1/3rd radius aBMD were significantly lower in ESRD, vs. controls (all p < 0.01). pQCT trabecular vBMD (p < 0.01), cortical vBMD (p < 0.001) and cortical thickness (due to a greater endosteal circumference, p < 0.02) and MRI measures of trabecular number, trabecular thickness, and whole bone stiffness were lower (all p < 0.01) in ESRD, vs. controls. ALMI was positively associated with total hip, femoral neck, ultradistal radius and 1/3rd radius aBMD and with tibia cortical thickness (R = 0.46 to 0.64). Adjustment for ALMI significantly attenuated bone deficits at these sites: e.g. mean femoral neck aBMD was 0.79 SD lower in ESRD, compared with controls and this was attenuated to 0.33 with adjustment for ALMI. In multivariate models within the dialysis participants, pQCT trabecular vBMD and cortical area Z-scores were significant and independently (all p < 0.02) associated with DXA femoral neck, total hip, and ultradistal radius aBMD Z-scores. Cortical vBMD (p = 0.01) and cortical area (p < 0.001) Z-scores were significantly and independently associated with 1/3rd radius areal aBMD Z-scores (R2 = 0.62). These data demonstrate that DXA aBMD captures deficits in trabecular and cortical vBMD and cortical area. The strong associations with ALMI, as an index of skeletal muscle, highlight the importance of considering the role of sarcopenia in skeletal fragility in patients with ESRD.
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Affiliation(s)
- Mary B Leonard
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States of America; Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States of America.
| | - Felix W Wehrli
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Susan L Ziolkowski
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Erica Billig
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Jin Long
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Thomas L Nickolas
- Department of Medicine, Columbia University, New York, NY, United States of America
| | - Jeremy F Magland
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Snejana Nihtianova
- Susanne M. Glasscock School of Continuing Studies, Rice University, Houston, TX, United States of America
| | - Babette S Zemel
- Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Rita Herskovitz
- Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Chamith S Rajapakse
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, United States of America; Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, United States of America
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10
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Denburg M, Nickolas TL. Declining Hip Fracture Rates in Dialysis Patients: Is This Winning the War? Am J Kidney Dis 2019; 71:154-156. [PMID: 29389383 DOI: 10.1053/j.ajkd.2017.10.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 10/11/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Michelle Denburg
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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11
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Kurajoh M, Inaba M, Nagata Y, Yamada S, Imanishi Y, Emoto M. Association of cystatin C- and creatinine-based eGFR with osteoporotic fracture in Japanese postmenopausal women with osteoporosis: sarcopenia as risk for fracture. J Bone Miner Metab 2019; 37:282-291. [PMID: 29464358 DOI: 10.1007/s00774-018-0913-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 02/06/2018] [Indexed: 10/18/2022]
Abstract
Coexistence of chronic kidney disease (CKD) is regarded as a risk for osteoporotic fracture particularly in postmenopausal women, not only because of increased parathyroid hormone level but also uremic sarcopenia. We examined the relationships of cystatin C-based glomerular filtration rate (eGFRcys) and creatinine-based GFR (eGFRcr), as well as their ratio with occurrence of osteoporotic fracture in postmenopausal osteoporotic women. This cross-sectional study included 555 postmenopausal women with osteoporosis. eGFRcr and eGFRcys were simultaneously measured, while occurrence of osteoporotic fracture was obtained by a medical chart review. Patients with osteoporotic fractures (n = 211) exhibited significantly lower levels of physical activity, eGFRcr, eGFRcys, and eGFRcys/eGFRcr ratios, while a higher percentage was CKD stage 3 or more, estimated by eGFRcr or eGFRcys (CKDcys), than those without (n = 344). Lower eGFRcys, but not lower eGFRcr, was independently associated with osteoporotic fracture in the entire cohort and that association was retained in CKDcys patients. Of great interest, higher eGFRcr was associated with osteoporotic fracture independent of eGFRcys in CKDcys patients. Furthermore, lower eGFRcys/eGFRcr ratio was independently associated with osteoporotic fracture in both CKDcys patients and the entire cohort. eGFRcys reduction might be associated with osteoporotic fracture in postmenopausal osteoporotic women, indicating the involvement of renal osteopathy in its occurrence. Furthermore, the association of higher, but not lower, eGFRcr with osteoporotic fracture in CKDcys cases might be explained by underestimation of renal dysfunction by eGFRcr resulting from decreased muscle mass and quality in those patients.
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Affiliation(s)
- Masafumi Kurajoh
- Department of Metabolism, Endocrinology, and Molecular Medicine, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan.
| | - Masaaki Inaba
- Department of Metabolism, Endocrinology, and Molecular Medicine, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Yuki Nagata
- Department of Metabolism, Endocrinology, and Molecular Medicine, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Shinsuke Yamada
- Department of Metabolism, Endocrinology, and Molecular Medicine, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Yasuo Imanishi
- Department of Metabolism, Endocrinology, and Molecular Medicine, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Masanori Emoto
- Department of Metabolism, Endocrinology, and Molecular Medicine, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
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12
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Wickstrom JF, Sayles HR, Graeff-Armas LA, Yentes JM. The Likelihood of Self-reporting Balance Problems in Those With Advanced Chronic Kidney Disease, Slow Gait Speed, or Low Vitamin D. J Ren Nutr 2018; 29:490-497. [PMID: 30581062 DOI: 10.1053/j.jrn.2018.10.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 09/24/2018] [Accepted: 10/14/2018] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE The purpose of this study was to determine the prevalence of vitamin D (25(OH)D) and balance deficits in persons with chronic kidney disease (CKD) and the likelihood of self-reporting balance and falling problems, measured gait speed in persons with kidney disease, and low levels of vitamin D and albumin. DESIGN Analysis of the National Health and Nutrition Examination Survey 1999-2004 data set. SUBJECTS The study included 8,554 subjects aged >40 years who were categorized into CKD stages based on the glomerular filtration rate (normal kidney function and stages 1 and 2 served as the control group, and stages 3 and 4/5 served as the CKD groups). MAIN OUTCOME MEASURES Measured 25(OH)D levels, timed 20-feet walk, Romberg standing balance task, and self-reported balance and falling issues. RESULTS The prevalence of balance deficits was found to be high in this CKD sample, with fail rates increasing with kidney disease severity. Similarly, when examining the relationship between CKD stage and the measurement of balance, fail rates (impaired balance) increased and gait speed decreased with kidney disease severity. In addition, the likelihood of self-reporting a balance and falling problem in the past year was higher in persons who had advanced CKD, were of older age, were of female sex, were with former or current smoking status, had lower 25(OH)D levels, and had lower albumin levels. Similarly, the likelihood of having a 20-feet walk time of more than 8 seconds was associated with those who were older, had higher body mass index, and had lower levels of 25(OH)D and albumin. CONCLUSION The unique finding of this study is that increased reporting of balance and falling issues (both perceived and measured) and slower gait were found in persons with increased CKD severity and lower 25(OH)D status.
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Affiliation(s)
- Jordan F Wickstrom
- Department of Biomechanics, University of Nebraska at Omaha, Omaha, Nebraska
| | - Harlan R Sayles
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, Nebraska
| | - Laura A Graeff-Armas
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, Nebraska; Internal Medicine Division of Diabetes, Endocrinology, and Metabolism, University of Nebraska Medical Center, Omaha, Nebraska
| | - Jennifer M Yentes
- Department of Biomechanics, University of Nebraska at Omaha, Omaha, Nebraska.
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13
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Damasiewicz MJ, Nickolas TL. Rethinking Bone Disease in Kidney Disease. JBMR Plus 2018; 2:309-322. [PMID: 30460334 PMCID: PMC6237213 DOI: 10.1002/jbm4.10117] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 09/05/2018] [Accepted: 10/03/2018] [Indexed: 12/17/2022] Open
Abstract
Renal osteodystrophy (ROD) is the bone component of chronic kidney disease mineral and bone disorder (CKD-MBD). ROD affects bone quality and strength through the numerous hormonal and metabolic disturbances that occur in patients with kidney disease. Collectively these disorders in bone quality increase fracture risk in CKD patients compared with the general population. Fractures are a serious complication of kidney disease and are associated with higher morbidity and mortality compared with the general population. Furthermore, at a population level, fractures are at historically high levels in patients with end-stage kidney disease (ESKD), whereas in contrast the general population has experienced a steady decline in fracture incidence rates. Based on these findings, it is clear that a paradigm shift is needed in our approach to diagnosing and managing ROD. In clinical practice, our ability to diagnose ROD and initiate antifracture treatments is impeded by the lack of accurate noninvasive methods that identify ROD type. The past decade has seen advances in the noninvasive measurement of bone quality and strength that have been studied in kidney disease patients. Below we review the current literature pertaining to the epidemiology, pathology, diagnosis, and management of ROD. We aim to highlight the pressing need for a greater awareness of this condition and the need for the implementation of strategies that prevent fractures in kidney disease patients. Research is needed for more accurate noninvasive assessment of ROD type, clinical studies of existing osteoporosis therapies in patients across the spectrum of kidney disease, and the development of CKD-specific treatments. © 2018 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of the American Society for Bone and Mineral Research.
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Affiliation(s)
- Matthew J Damasiewicz
- Department of NephrologyMonash HealthClaytonAustralia
- Department of MedicineMonash UniversityClaytonAustralia
| | - Thomas L Nickolas
- Columbia University Medical CenterDepartment of MedicineDivision of NephrologyNew YorkNYUSA
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14
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Chen H, Lips P, Vervloet MG, van Schoor NM, de Jongh RT. Association of renal function with bone mineral density and fracture risk in the Longitudinal Aging Study Amsterdam. Osteoporos Int 2018; 29:2129-2138. [PMID: 29947873 PMCID: PMC6105137 DOI: 10.1007/s00198-018-4592-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Accepted: 05/28/2018] [Indexed: 11/24/2022]
Abstract
Early renal dysfunction is associated with a 38% increased fracture risk in individuals aged 65 years and older. In men but not women, early renal dysfunction is associated with decreased femoral neck bone mineral density (BMD) which can be partially explained by increased parathyroid hormone (PTH) concentrations. INTRODUCTION It is uncertain whether early renal dysfunction is associated with osteoporosis and increased fracture risk. The aim of this study was to determine the relationship of decreased renal function with BMD and fracture risk and the role of PTH therein. METHODS We analyzed data of participants aged 65 years and older from the Longitudinal Aging Study Amsterdam. A 6-year fracture follow-up was obtained in 1477 participants. BMD was measured by dual-energy x-ray absorptiometry (n = 535) and vertebral fractures by lateral spinal radiograph (n = 527) in a subsample at baseline. Glomerular filtration rate (eGFR) was estimated according to the modification of diet in renal disease equation and assessed by the five stages of chronic kidney disease (CKD). RESULTS In men and women, eGFR < 57 ml/min/1.73 m2 (lowest quartile) compared to eGFR > 74 ml/min/1.73 m2 (highest quartile) was associated with a 38% increase in fracture risk after adjustment for relevant confounders [hazard ratio (95%CI): 1.38 (1.17 to 1.61)]. Also, CKD stages 3a and 3b were associated to a 28 and 46% increase in fracture risk, respectively, as compared to CKD stages 1 and 2 together (eGFR > 60 ml/min/1.73 m2) after adjustment for confounders. Renal function was not associated with prevalent vertebral fractures. In men, but not women, lowest quartile of eGFR was related to lower femoral neck BMD as compared to the highest quartile eGFR [unstandardized B (95%CI) - 0.052 g/cm2 (- 0.098 to - 0.006)], after adjustment for relevant confounders. Further adjustment for PTH attenuated this relationship by 27%. CONCLUSIONS In men and women, early decreased renal function (eGFR < 60 ml/min/1.73 m2) was related to increased incident any fracture risk but not with increased prevalence of vertebral fractures. In men, but not women, early renal dysfunction was related to lower femoral neck BMD which could statistically be partially explained by increased PTH concentrations.
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Affiliation(s)
- H Chen
- Department of Endocrinology, Beijing Jishuitan Hospital, Beijing, China
- Department of Internal Medicine, Endocrine section, VU University Medical Center, 1007 MB, Amsterdam, The Netherlands
| | - P Lips
- Department of Internal Medicine, Endocrine section, VU University Medical Center, 1007 MB, Amsterdam, The Netherlands
| | - M G Vervloet
- Department of Nephrology and Institute of Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands
| | - N M van Schoor
- Amsterdam Public Health Research Institute, Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands
| | - R T de Jongh
- Department of Internal Medicine, Endocrine section, VU University Medical Center, 1007 MB, Amsterdam, The Netherlands.
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15
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Abstract
CKD mineral and bone disease is a common complication of kidney disease, and it affects the majority of patients with moderate to severe CKD. Recently, prospective studies have shown that measurement of bone mineral density by dual energy x-ray absorptiometry predicts incident fracture, providing nephrologists the ability to risk classify patients for skeletal fragility and targeted antifracture strategies for the first time. Furthermore, an expanding body of literature and anecdotal evidence suggest that pharmacologic agents used to treat osteoporosis in the general population can be safely used in patients with CKD. This review highlights the effects of the Kidney Disease Improving Global Outcomes updates on the management of CKD-associated osteoporosis, discusses recent investigations on the effects of antiosteoporotic agents in patients with CKD, and provides an overview of novel antiosteoporosis agents and the potential challenges related to their use in CKD.
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Affiliation(s)
- Pascale Khairallah
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York
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16
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Hung LW, Hwang YT, Huang GS, Liang CC, Lin J. The influence of renal dialysis and hip fracture sites on the 10-year mortality of elderly hip fracture patients: A nationwide population-based observational study. Medicine (Baltimore) 2017; 96:e7618. [PMID: 28906354 PMCID: PMC5604623 DOI: 10.1097/md.0000000000007618] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Hip fractures in older people requiring dialysis are associated with high mortality. Our study primarily aimed to evaluate the specific burden of dialysis on the mortality rate following hip fracture. The secondary aim was to clarify the effect of the fracture site on mortality. A retrospective cohort study was conducted using Taiwan's National Health Insurance Research Database to analyze nationwide health data regarding dialysis and non-dialysis patients ≥65 years who sustained a first fragility-related hip fracture during the period from 2001 to 2005. Each dialysis hip fracture patient was age- and sex-matched to 5 non-dialysis hip fracture patients to construct the matched cohort. Survival status of patients was followed-up until death or the end of 2011. Survival analyses using multivariate Cox proportional hazards models and the Kaplan-Meier estimator were performed to compare between-group survival and impact of hip fracture sites on mortality. A total of 61,346 hip fracture patients were included nationwide. Among them, 997 dialysis hip fracture patients were identified and matched to 4985 non-dialysis hip fracture patients. Mortality events were 155, 188, 464, and 103 in the dialysis group, and 314, 382, 1505, and 284 in the non-dialysis group, with adjusted hazard ratios (associated 95% confidence intervals) of 2.58 (2.13-3.13), 2.95 (2.48-3.51), 2.84 (2.55-3.15), and 2.39 (1.94-2.93) at 0 to 3 months, 3 months to 1 year, 1 to 6 years, and 6 to 10 years after the fracture, respectively. In the non-dialysis group, survival was consistently better for patients who sustained femoral neck fractures compared to trochanteric fractures (0-10 years' log-rank test, P < .001). In the dialysis group, survival of patients with femoral neck fractures was better than that of patients with trochanteric fractures only within the first 6 years post-fracture (0-6 years' log-rank, P < .001). Dialysis was a significant risk factor of mortality in geriatric hip fracture patients. Survival outcome was better for non-dialysis patients with femoral neck fractures compared to those with trochanteric fractures throughout 10 years. However, the survival advantage of femoral neck fractures was limited to the first 6 years postinjury among dialysis patients.
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Affiliation(s)
- Li-Wei Hung
- Department of Orthopedic Surgery, National Taiwan University Hospital, Taipei
| | - Yi-Ting Hwang
- Department of Statistics, National Taipei University, Taipei
| | - Guey-Shiun Huang
- Department of Nursing, National Taiwan University College of Medicine, Taipei
| | - Cheng-Chih Liang
- Department of Statistics, National Taipei University, New Taipei City
| | - Jinn Lin
- Department of Orthopedic Surgery, National Taiwan University Hospital, Taipei, Taiwan
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17
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Abstract
PURPOSE OF REVIEW Chronic kidney disease (CKD) affects nearly 10% of the population. The incidence of fractures in population studies demonstrate an increase with worsening stages of kidney disease suggesting specific CKD related causes of fracture. RECENT FINDINGS The increase in fractures with CKD most likely represents disordered bone quality due to the abnormal bone remodeling from renal osteodystrophy. There is also an increase in fractures with age in patients with CKD, suggesting that patients with CKD also have many fracture risk factors common to patients without known CKD. Osteoporosis is defined by the National Institutes of Health as "A skeletal disorder characterized by compromised bone strength predisposing to an increased risk of fracture. Bone strength reflects the integration of two main features: bone quantity and bone quality." Thus, CKD-related fractures can be considered a type of osteoporosis-where the bone quality is additionally impaired above that of age/hormonal-related osteoporosis. Perhaps using the term CKD-induced osteoporosis, similar to steroid-induced osteoporosis, will allow patients with CKD to be studied in trials investigating therapeutic agents. In this series, we will examine how CKD-induced osteoporosis may be diagnosed and treated.
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Affiliation(s)
- Sharon M Moe
- Division of Nephrology, Indiana University School of Medicine, 950 W. Walnut Street, R2-202, Indianapolis, IN, 46202, USA.
- Department of Medicine, Roudebush Veterans Affairs Medical Center, Indianapolis, IN, USA.
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18
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Alfano LN, Yin H, Dvorchik I, Maus EG, Flanigan KM, Mendell JR, Lowes LP. Modeling functional decline over time in sporadic inclusion body myositis. Muscle Nerve 2016; 55:526-531. [DOI: 10.1002/mus.25373] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 07/26/2016] [Accepted: 08/08/2016] [Indexed: 11/08/2022]
Affiliation(s)
- Lindsay N. Alfano
- The Research Institute at Nationwide Children's Hospital, Center for Gene Therapy, 700 Children's Drive, Room AB1042; Columbus Ohio 43205 USA
| | - Han Yin
- The Research Institute at Nationwide Children's Hospital, Biostatistics Core; Columbus Ohio USA
| | - Igor Dvorchik
- The Research Institute at Nationwide Children's Hospital, Biostatistics Core; Columbus Ohio USA
| | - Elizabeth G. Maus
- The Research Institute at Nationwide Children's Hospital, Center for Gene Therapy, 700 Children's Drive, Room AB1042; Columbus Ohio 43205 USA
| | - Kevin M. Flanigan
- The Research Institute at Nationwide Children's Hospital, Center for Gene Therapy, 700 Children's Drive, Room AB1042; Columbus Ohio 43205 USA
| | - Jerry R. Mendell
- The Research Institute at Nationwide Children's Hospital, Center for Gene Therapy, 700 Children's Drive, Room AB1042; Columbus Ohio 43205 USA
| | - Linda P. Lowes
- The Research Institute at Nationwide Children's Hospital, Center for Gene Therapy, 700 Children's Drive, Room AB1042; Columbus Ohio 43205 USA
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19
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Naylor KL, Prior J, Garg AX, Berger C, Langsetmo L, Adachi JD, Goltzman D, Kovacs CS, Josse RG, Leslie WD. Trabecular Bone Score and Incident Fragility Fracture Risk in Adults with Reduced Kidney Function. Clin J Am Soc Nephrol 2016; 11:2032-2040. [PMID: 27797885 PMCID: PMC5108183 DOI: 10.2215/cjn.00720116] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 07/28/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVES Trabecular bone score is a gray-level textural measure obtained from dual energy x-ray absorptiometry lumbar spine images that provides information independent of areal bone mineral density. The association between trabecular bone score and incident fractures in adults with reduced kidney function and whether this association differs from that of adults with normal kidney function are unknown. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We included 1426 participants ages ≥40 years old (mean age of 67 years) in the community-based Canadian Multicentre Osteoporosis Study. We stratified participants at cohort entry (2005-2008) by eGFR (eGFR<60 ml/min per 1.73 m2 [n=199; 72.4% stage 3a, 25.1% stage 3b, and 2.5% stage 4] versus ≥60 ml/min per 1.73 m2 [n=1227]). Trabecular bone score was obtained from lumbar spine (L1-L4) dual energy x-ray absorptiometry images, with a lower trabecular bone score representing worse bone structure. Over an average of 4.7 years follow-up (maximum follow-up of 5 years), we documented incident fragility (low-trauma) fracture events (excluding craniofacial, foot, and hand sites). We used a modified Kaplan-Meier estimator to determine the 5-year probability of fracture. Cox proportional hazard regression per SD lower trabecular bone score expressed the gradient of fracture risk. RESULTS Individuals with an eGFR<60 ml/min per 1.73 m2 who had a trabecular bone score value below the median (<1.277) had a significantly higher 5-year fracture probability than those above the median (18.1% versus 6.2%; P=0.01). The association between trabecular bone score and fracture was independent of bone mineral density and other clinical risk factors in adults with reduced and normal kidney function (adjusted hazard ratio per SD lower trabecular bone score: eGFR<60 ml/min per 1.73 m2: adjusted hazard ratio, 1.62; 95% confidence interval, 1.04 to 2.51; eGFR≥60 ml/min per 1.73 m2: adjusted hazard ratio, 1.44; 95% confidence interval, 1.13 to 1.83). CONCLUSIONS Lower lumbar spine trabecular bone score is independently associated with a higher fracture risk in adults with reduced kidney function. Additional study is needed to examine the association between trabecular bone score and fractures in individuals with diagnosed CKD-mineral and bone disorder.
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Affiliation(s)
- Kyla L Naylor
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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20
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Kim SM, Long J, Montez-Rath M, Leonard M, Chertow GM. Hip Fracture in Patients With Non-Dialysis-Requiring Chronic Kidney Disease. J Bone Miner Res 2016; 31:1803-1809. [PMID: 27145189 DOI: 10.1002/jbmr.2862] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Revised: 04/23/2016] [Accepted: 04/26/2016] [Indexed: 11/07/2022]
Abstract
Patients with end-stage renal disease (ESRD) are at a high risk for hip fracture. Little is known about the risk for, and consequences of, hip fracture among patients with non-dialysis-requiring chronic kidney disease (CKD). We examined the incidence of hip fracture, in-hospital mortality, length of stay, and costs among patients with ESRD, non-dialysis-requiring CKD, and normal or near normal kidney function. Using the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample, a nationally representative database, we identified hospitalizations for hip fracture in 2010. We incorporated data from the United States Renal Data System (USRDS) and the US census to calculate population-specific rates. Age-standardized incidence of hip fracture was highest among patients with ESRD (3.89/1000 person-years), followed by non-dialysis-requiring CKD (1.81/1000 persons) and patients with normal or near normal kidney function (1.18/1000 persons). In-hospital mo rtality (odds ratio [OR] = 1.69, 95% confidence interval [CI] 1.46 to 1.96), lengths of stay (median [10th, 90th percentiles] 5 [3 to 11] versus 5 [3 to 10] days) and costs (median $14,807 versus $13,314) were significantly higher in patients with non-dialysis-requiring CKD relative to patients with normal or near normal kidney function. In summary, non-dialysis-requiring CKD is associated with higher age-standardized rates of hip fracture and post-hip fracture mortality and higher resource utilization. © 2016 American Society for Bone and Mineral Research.
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Affiliation(s)
- Sun Moon Kim
- Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Jin Long
- Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Maria Montez-Rath
- Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Mary Leonard
- Departments of Medicine and Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Glenn M Chertow
- Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA.
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21
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Heaf JG. Chronic Kidney Disease-Mineral Bone Disorder in the Elderly Peritoneal Dialysis Patient. Perit Dial Int 2016; 35:640-4. [PMID: 26702005 DOI: 10.3747/pdi.2014.00339] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE The purpose of this paper was to review the literature concerning the treatment of chronic kidney disease-mineral bone disorder (CKD-MBD) in the elderly peritoneal dialysis (PD) patient. RESULTS Chronic kidney disease-mineral bone disorder is a major problem in the elderly PD patient, with its associated increased fracture risk, vascular calcification, and accelerated mortality fracture risk. Peritoneal dialysis, however, bears a lower risk than hemodialysis (HD). The approach to CKD-MBD prophylaxis and treatment in the elderly PD patient is similar to other CKD patients, with some important differences. Avoidance of hypercalcemia, hyperphosphatemia, and hyperparathyroidism is important, as in other CKD groups, and is generally easier to attain. Calcium-free phosphate binders are recommended for normocalcemic and hypercalcemic patients. Normalization of vitamin D levels to > 75 nmol/L (> 30 pg/L) and low-dose active vitamin D therapy is recommended for all patients. Hyperparathryoidism is to be avoided by using active vitamin D and cinacalcet. Particular attention should be paid to treating protein malnutrition. Fracture prophylaxis (exercise, use of walkers, dwelling modifications) are important. Hypomagnesemia is common in PD and can be treated with magnesium supplements. Vitamin K deficiency is also common and has been identified as a cause of vascular calcification. Accordingly, warfarin treatment for this age group is problematic. CONCLUSION While treatment principles are similar to other dialysis patient groups, physicians should be aware of the special problems of the elderly group.
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Affiliation(s)
- James Goya Heaf
- Department of Medicine, Roskilde Hospital, University of Copenhagen, Copenhagen, Denmark
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22
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Yu D, Li HX, Liu Y, Ying ZW, Guo JJ, Cao CY, Wang J, Li YF, Yang HR. The Reference Intervals for Serum C-Terminal Agrin Fragment in Healthy Individuals and as a Biomarker for Renal Function in Kidney Transplant Recipients. J Clin Lab Anal 2016; 31. [PMID: 27638235 DOI: 10.1002/jcla.22059] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 07/31/2016] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND C-terminal agrin fragment (CAF) has been shown to be a promising new biomarker for kidney function. The aim of this study was to verify the reference intervals for CAF in Chinese healthy adults and to assess the efficiency of CAF for monitoring renal function after transplantation. METHODS Serum samples were collected from 200 healthy adult subjects and 60 living donor kidney recipients before and on day 1, day 2 and at 6 months after transplantation. We measured serum CAF, creatinine, cystatin C and NGAL concentrations at each time. Estimated glomerular filtration rate (eGFR) was evaluated by Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Reference intervals for CAF were determined at 2.5th and 97.5th percentiles. RESULTS Serum CAF concentrations were observed to be higher in females of old age groups while no significant differences were discovered in males between age groups. There were significant gender-related differences in CAF in old age groups (50-64 and ≥65 years). Serum CAF correlated positively with serum creatinine, cystatin C and negatively with eGFR on day 1, day 2 and at 6 months after kidney transplantation. CAF and NGAL fell rapidly into the normal range on the second postoperative day, prior to creatinine and cystatin C. CONCLUSIONS This study verified the reference intervals for serum CAF. CAF could be a potential new biomarker for kidney function monitoring.
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Affiliation(s)
- Dan Yu
- Department of Clinical Laboratory, Peking University First Hospital, Beijing, China
| | - Hai-Xia Li
- Department of Clinical Laboratory, Peking University First Hospital, Beijing, China
| | - Yi Liu
- Department of Clinical Laboratory, Peking University First Hospital, Beijing, China
| | - Ze-Wei Ying
- Department of Urology, Peking University First Hospital, Beijing, China
| | - Jing-Jing Guo
- Department of Clinical Laboratory, Peking University First Hospital, Beijing, China
| | - Chen-Ying Cao
- Department of Clinical Laboratory, Peking University First Hospital, Beijing, China
| | - Jia Wang
- Department of Clinical Laboratory, Peking University First Hospital, Beijing, China
| | - Yuan-Fang Li
- Department of Clinical Laboratory, Peking University First Hospital, Beijing, China
| | - Hui-Rong Yang
- Department of Clinical Laboratory, Peking University First Hospital, Beijing, China
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23
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Moorthi RN, Fadel W, Eckert GJ, Ponsler-Sipes K, Moe SM, Lin C. Bone marrow fat is increased in chronic kidney disease by magnetic resonance spectroscopy. Osteoporos Int 2015; 26:1801-7. [PMID: 25701052 PMCID: PMC4582653 DOI: 10.1007/s00198-015-3064-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 02/02/2015] [Indexed: 11/30/2022]
Abstract
UNLABELLED In aging, the bone marrow fills with fat and this may lead to higher fracture risk. We show that a bone marrow fat measurement by magnetic resonance spectroscopy (MRS), a newer technique not previously studied in chronic kidney disease (CKD), is useful and reproducible. CKD patients have significantly higher bone marrow fat than healthy adults. INTRODUCTION Renal osteodystrophy leads to increased morbidity and mortality in patients with CKD. Traditional bone biopsy histomorphometry is used to study abnormalities in CKD, but the bone marrow, the source of osteoblasts, has not been well characterized in patients with CKD. METHODS To determine the repeatability of bone marrow fat fraction assessment by MRS and water-fat imaging (WFI) at four sites in patients with CKD, testing was performed to determine the coefficients of reproducibility and intraclass coefficients (ICCs). We further determined if this noninvasive technique could be used to determine if there are differences in the percent bone marrow fat in patients with CKD compared to matched controls using paired t tests. RESULTS The mean age of subjects with CKD was 59.8 ± 7.2 years, and the mean eGFR was 24 ± 8 ml/min. MRS showed good reproducibility at all sites in subjects with CKD and controls, with a coefficient of reproducibilities ranging from 2.4 to 13 %. MRS and WFI assessment of bone marrow fat showed moderate to strong agreement (ICC 0.6-0.7) at the lumbar spine, with poorer agreement at the iliac crest and no agreement at the tibia. The mean percent bone marrow fat at L2-L4 was 13.8 % (95 % CI 8.3-19.7) higher in CKD versus controls (p < 0.05). CONCLUSIONS MRS is a useful and reproducible technique to study bone marrow fat in CKD. Patients with CKD have significantly higher bone marrow fat than healthy adults; the relationship with bone changes requires further analyses.
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Affiliation(s)
- R N Moorthi
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, 46202, USA.
| | - W Fadel
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
- Richard M. Fairbanks School of Public Health, Indianapolis, IN, 46202, USA
| | - G J Eckert
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
- Richard M. Fairbanks School of Public Health, Indianapolis, IN, 46202, USA
| | - K Ponsler-Sipes
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - S M Moe
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
- Roudebush Veterans Administration Medical Center, Indianapolis, IN, 46202, USA
| | - C Lin
- Department of Radiology, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
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24
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Abstract
Chronic kidney disease (CKD) is associated with a decline in muscle mass, strength, and function, collectively called "sarcopenia." Sarcopenia is associated with hospitalizations and mortality in CKD and is therefore important to understand and characterize. While the focus of skeletal health in CKD has traditionally focused on bone and mineral aberrations, it is now recognized that sarcopenia must also play a role in poor musculoskeletal health in this population. In this paper, we present an overview of skeletal muscle changes in CKD, including defects in skeletal muscle catabolism and anabolism in uremic tissue. There are many gaps in knowledge in this field that should be the focus for future research to unravel pathogenesis and therapies for musculoskeletal health in CKD.
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Affiliation(s)
- Keith G. Avin
- Indiana University School of Health and Rehabilitation Sciences, Indianapolis, IN 46202, USA
| | - Ranjani N. Moorthi
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, 950 W. Walnut St, R2-202, Indianapolis, IN 46202, USA
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25
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Abstract
Fractures are more common and are associated with greater morbidity and morality in patients with kidney disease than in members of the general population. Thus, it is troubling that in chronic kidney disease (CKD) patients there has been a paradoxical increase in fracture rates over the past 20 years compared to the general population. Increased fracture incidence in CKD patients may be driven in part by the lack of screening for fracture risk. In the general population, dual energy X-ray absorptiometry (DXA) is the clinical standard to stratify fracture risk, and its use has contributed to decreases in fracture incidence. In contrast, in CKD, fracture risk screening with DXA has been uncommon due to its unclear efficacy in predicting fracture and its inability to predict type of renal osteodystrophy. Recently, several prospective studies conducted in patients across the spectrum of kidney disease have demonstrated that bone mineral density measured by DXA predicts future fracture risk and that clinically relevant information regarding fracture risk is provided by application of the World Health Organization cutoffs for osteopenia and osteoporosis to DXA measures. Furthermore, novel high-resolution imaging tools, such as high-resolution peripheral quantitative computed tomography (HR-pQCT), have been used to elucidate the effects of kidney disease on cortical and trabecular microarchitecture and bone strength and to identify potential targets for strategies that protect against fractures. This review will discuss the updated epidemiology of fractures in CKD, fracture risk screening by DXA, and the utility of state-of-the art imaging methods to uncover the effects of kidney disease on the skeleton.
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Affiliation(s)
- Sophie A Jamal
- Women's College Research Institute, University of Toronto, Toronto, Canada
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26
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Moe SM, Abdalla S, Chertow GM, Parfrey PS, Block GA, Correa-Rotter R, Floege J, Herzog CA, London GM, Mahaffey KW, Wheeler DC, Dehmel B, Goodman WG, Drüeke TB. Effects of Cinacalcet on Fracture Events in Patients Receiving Hemodialysis: The EVOLVE Trial. J Am Soc Nephrol 2015; 26:1466-75. [PMID: 25505257 PMCID: PMC4446874 DOI: 10.1681/asn.2014040414] [Citation(s) in RCA: 132] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 09/07/2014] [Indexed: 11/03/2022] Open
Abstract
Fractures are frequent in patients receiving hemodialysis. We tested the hypothesis that cinacalcet would reduce the rate of clinical fractures in patients receiving hemodialysis using data from the Evaluation of Cinacalcet HCl Therapy to Lower Cardiovascular Events trial, a placebo-controlled trial that randomized 3883 hemodialysis patients with secondary hyperparathyroidism to receive cinacalcet or placebo for ≤64 months. This study was a prespecified secondary analysis of the trial whose primary end point was all-cause mortality and non-fatal cardiovascular events, and one of the secondary end points was first clinical fracture event. Clinical fractures were observed in 255 of 1935 (13.2%) patients randomized to placebo and 238 of 1948 (12.2%) patients randomized to cinacalcet. In an unadjusted intention-to-treat analysis, the relative hazard for fracture (cinacalcet versus placebo) was 0.89 (95% confidence interval [95% CI], 0.75 to 1.07). After adjustment for baseline characteristics and multiple fractures, the relative hazard was 0.83 (95% CI, 0.72 to 0.98). Using a prespecified lag-censoring analysis (a measure of actual drug exposure), the relative hazard for fracture was 0.72 (95% CI, 0.58 to 0.90). When participants were censored at the time of cointerventions (parathyroidectomy, transplant, or provision of commercial cinacalcet), the relative hazard was 0.71 (95% CI, 0.58 to 0.87). Fracture rates were higher in older compared with younger patients and the effect of cinacalcet appeared more pronounced in older patients. In conclusion, using an unadjusted intention-to-treat analysis, cinacalcet did not reduce the rate of clinical fracture. However, when accounting for differences in baseline characteristics, multiple fractures, and/or events prompting discontinuation of study drug, cinacalcet reduced the rate of clinical fracture by 16%-29%.
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Affiliation(s)
- Sharon M Moe
- Indiana University School of Medicine and Roudebush Veterans Administration Medical Center, Indianapolis, Indiana;
| | - Safa Abdalla
- Stanford University School of Medicine, Palo Alto, California
| | - Glenn M Chertow
- Stanford University School of Medicine, Palo Alto, California
| | | | | | - Ricardo Correa-Rotter
- Salvador Zubirán National Institute of Medical Sciences and Nutrition, Mexico City, Mexico
| | | | | | | | | | | | | | | | - Tilman B Drüeke
- French Institute of Health and Medical Research (INSERM) Unit 1088, Faculty of Medicine/Pharmacy, University of Picardie, Amiens, France
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27
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Fractures in chronic kidney disease: neglected, common, and associated with sickness and death. Kidney Int 2014; 85:20-2. [PMID: 24380905 DOI: 10.1038/ki.2013.302] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Bone fractures in dialysis patients have been poorly studied in the past. Tentori et al. partially fill this gap, assessing the incidence of post-fracture morbidity and mortality in patients of the Dialysis Outcomes and Practice Patterns Study (DOPPS). A high frequency of fractures and increased adverse outcomes following a fracture were observed. The nephrology community should pay more attention to bone fractures in dialysis patients.
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28
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Salam SN, Eastell R, Khwaja A. Fragility fractures and osteoporosis in CKD: pathophysiology and diagnostic methods. Am J Kidney Dis 2014; 63:1049-59. [PMID: 24631043 DOI: 10.1053/j.ajkd.2013.12.016] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 12/19/2013] [Indexed: 11/11/2022]
Abstract
Both chronic kidney disease (CKD) and osteoporosis are major public health problems associated with an aging population. Osteoporosis is characterized by reduced bone mineral density, while CKD results in qualitative changes in bone structure; both conditions increase the predisposition to fragility fractures. There is a significant coprevalence of osteoporotic fractures and CKD, particularly in the elderly population. Not only is the risk of fracture higher in the CKD population, but clinical outcomes are significantly worse, with substantial health care costs. Management of osteoporosis in the CKD population is particularly complex given the impact of renal osteodystrophy on bone quality and the limited safety and hard outcome data for current therapy in patients with severe CKD or on dialysis therapy. In this review, we discuss the pathophysiology of osteoporosis, the impact of CKD on bone strength, and the role of novel imaging techniques and biomarkers in predicting underlying renal osteodystrophy on bone histomorphometry in the context of CKD.
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Affiliation(s)
- Syazrah N Salam
- Sheffield Kidney Institute, Northern General Hospital, Sheffield, United Kingdom.
| | - Richard Eastell
- Academic Unit of Bone Metabolism, Metabolic Bone Centre, Northern General Hospital, Sheffield, United Kingdom
| | - Arif Khwaja
- Sheffield Kidney Institute, Northern General Hospital, Sheffield, United Kingdom
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29
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Ma MKM, Yap DYH, Yip TPS, Lui SL, Lo WK. Charlson co-morbidity index and albumin significantly associated with fracture risk in peritoneal dialysis patients. Nephrology (Carlton) 2013; 18:365-8. [PMID: 23600370 DOI: 10.1111/nep.12056] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2013] [Indexed: 11/29/2022]
Abstract
Published literature on fracture in dialysis patients seldom addressed the effect of co-morbidity and malnutrition. In this study, we reported the incidence and risk factors for fracture in peritoneal dialysis patients. Peritoneal dialysis patients who had fractures between 2006 and 2011 were recruited. Demographic data, details of fracture, Charlson Co-morbidity Index (CCI) and biochemical parameters were also collected. Non-fracture controls, matched for age, gender and duration of dialysis, were also recruited at ratio 1:1 for fracture risk analysis. The incidence of fracture was 1 in 37 patient-years. The commonest site of fracture was neck of femur (n = 16, 55.2%). Twenty-four patients (82.8%) developed fracture after slip and fall injury. Eight out of 17 self-ambulatory patients (47.1%) became non-ambulatory after fracture. Infection was the commonest complication during hospitalization. Univariant analysis demonstrated high CCI (P = 0.001), hypoalbuminaemia (P < 0.001), loss of self autonomy (P = 0.006) and non-ambulatory state (P = 0.011) significantly associated with increased fracture risk. However, only CCI (odds ratio (OR) 1.373, P = 0.028) and albumin (OR 0.893, P = 0.025) increased fracture risk significantly on multivariant analysis. Bone profile and parathyroid hormone were not significant risk factors. To conclude, fracture associated with adverse outcome in peritoneal dialysis patients. High CCI score and hypoalbuminaemia significantly increase risk of fracture.
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Affiliation(s)
- Maggie K M Ma
- Division of Nephrology, Tung Wah Hospital, University of Hong Kong, Hong Kong.
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30
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31
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Cesini J, Cheriet S, Breuil V, Lafage-Proust MH. Osteoporosis: chronic kidney disease in rheumatology practice. Joint Bone Spine 2013; 79 Suppl 2:S104-9. [PMID: 23098842 DOI: 10.1016/s1297-319x(12)70017-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Johann Cesini
- Service de Rhumatologie, CHU Caen, Avenue de la Côte-de-Nacre, 14033 Caen, France
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32
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Jamal SA, West SL, Miller PD. Bone and kidney disease: diagnostic and therapeutic implications. Curr Rheumatol Rep 2012; 14:217-23. [PMID: 22350608 DOI: 10.1007/s11926-012-0243-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Fractures are common in patients with chronic kidney disease (CKD), but the diagnosis and treatment of bone disease in CKD are difficult due to the multiple etiologies of bone disease in these patients. Noninvasive imaging, including bone mineral density by dual energy x-ray absorptiometry, can be useful in diagnosing osteoporosis in predialysis CKD; however, consensus on the diagnosis of osteoporosis among those with advanced CKD-particularly stage 5 CKD patients on dialysis-is lacking. Treatments approved for osteoporosis in postmenopausal women may be used in patients with stage 1 to 3 CKD. Furthermore, post-hoc analyses show efficacy and safety of oral bisphosphonates, raloxifene, and denosumab in stage 4 CKD for short-term treatment. However, treatment decisions are more difficult in stage 5 CKD. Bone biopsy may be required, and most treatments, if used, would be off label. Overall, the diagnosis and treatment of bone disease in patients with CKD require further research.
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Affiliation(s)
- Sophie A Jamal
- University of Toronto, Women's College Hospital, Ontario, Canada.
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33
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West SL, Jamal SA. Treatment of osteoporosis in patients with chronic kidney disease. ACTA ACUST UNITED AC 2012. [DOI: 10.2217/ijr.12.39] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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34
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Nickolas TL. BMD and Fracture Risk in CKD: Where Should We Go from Here? Clin J Am Soc Nephrol 2012; 7:1058-60. [DOI: 10.2215/cjn.05320512] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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