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Khairallah P, Nickolas TL. Managing Osteoporosis in Dialysis-A Medical Catch-22. JAMA 2024; 331:477-479. [PMID: 38241040 DOI: 10.1001/jama.2023.24072] [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: 02/15/2024]
Affiliation(s)
| | - Thomas L Nickolas
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
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2
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Jurina A, Kasumović D, Delimar V, Filipec Kanižaj T, Japjec M, Dujmović T, Vučić Lovrenčić M, Starešinić M. Fibroblast growth factor 23 and its role in bone diseases. Growth Factors 2024; 42:1-12. [PMID: 37906060 DOI: 10.1080/08977194.2023.2274579] [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: 12/28/2022] [Accepted: 10/18/2023] [Indexed: 11/02/2023]
Abstract
Fibroblast growth factor 23 (FGF23) has been casually linked to numerous hypophosphatemic bone diseases, however connection with bone loss or fragility fractures is still a matter of debate. The purpose of this review is to explore and summarise the known actions of FGF23 in various pathological bone conditions. Besides implication in bone mineralisation, elevated FGF23 showed a pathological effecton bone remodelling, primarily by inhibiting osteoblast function. Unlike the weak association with bone mineral density, high values of FGF23 have been connected with fragility fracture prevalence. This review shows that its effects on bone are concomitantly present on multiple levels, affecting both qualitative and quantitative part of bone strength, eventually leading to impaired bone strength and increased tendency of fractures. Recognising FGF23 as a risk factor for the development of bone diseases and correcting its levels could lead to the reduction of morbidity and mortality in specific groups of patients.
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Affiliation(s)
- Andrija Jurina
- Department of Surgery, Division of General and Sport Traumatology and Orthopaedics, Merkur University Hospital, Zagreb, Croatia
| | - Dino Kasumović
- Department of Internal Medicine, Division of Nephrology and Dialysis, Dubrava University Hospital, Zagreb, Croatia
| | - Valentina Delimar
- Special Hospital for Medical Rehabilitation KrapinskeToplice, KrapinskeToplice, Croatia
| | - Tajana Filipec Kanižaj
- Department of Internal Medicine, Division of Gastroenterology, Merkur University Hospital, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Mladen Japjec
- Department of Surgery, Division of General and Sport Traumatology and Orthopaedics, Merkur University Hospital, Zagreb, Croatia
| | - Tomislav Dujmović
- Department of Surgery, Division of General and Sport Traumatology and Orthopaedics, Merkur University Hospital, Zagreb, Croatia
| | - Marijana Vučić Lovrenčić
- Department of Clinical Chemistry and Laboratory Medicine, Merkur University Hospital, Zagreb, Croatia
| | - Mario Starešinić
- Department of Surgery, Division of General and Sport Traumatology and Orthopaedics, Merkur University Hospital, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
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Szu LY, Hsieh SI, Shih WM, Tsai MC, Tseng SM. The Scale of Perceptions and Self-Participation in Hemodialysis: Development and Psychometric Evaluation. Healthcare (Basel) 2023; 11:3072. [PMID: 38063640 PMCID: PMC10705966 DOI: 10.3390/healthcare11233072] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 11/24/2023] [Accepted: 11/28/2023] [Indexed: 02/11/2024] Open
Abstract
Hemodialysis patients undergo hemodialysis two to three times a week and must live together with the dialysis machine. The patient's self-participation is to combine the patient's own experience and professional knowledge to influence the care. A successful self-participation experience empowers patients to adapt to living with hemodialysis. However, few studies have been conducted regarding the subjective experiences of such patient participation. There is a lack of a self-participation dialysis life scale for hemodialysis patients. Therefore, this study aims to develop and evaluate a self-participation dialysis life scale for hemodialysis patients. The items for the self-participation dialysis life scale were confirmed through qualitative interviews based on grounded theory. After expert content validity evaluation, 435 hemodialysis patients were purposively sampled from hemodialysis centers in two regional teaching hospitals in Taiwan. Descriptive statistics, principal axis factoring, reliability analysis, Pearson's correlation, and one-way ANOVA were used for data analysis. The results show that the item- and scale-content validity indices are 0.96 and 0.73, respectively. This scale is divided into two scales. The first part is "Scale of Perceptions of Hemodialysis", including two factors. The overall can explain 66.34% of the cumulative variances. The second part is the "Scale of Self-Participation in Hemodialysis", including four factors. The overall can explain 58.91% of the cumulative variances. The Cronbach's α is 0.812 for "Perceptions of Hemodialysis" and 0.959 for "Self-Participation in Hemodialysis", respectively. The self-participation dialysis life scale has good reliability and validity and can be used to evaluate the implementation of a patient's self-participation in their hemodialysis life. Discussing or consulting with patients based on their characteristics, life priorities, and their desired life on dialysis is essential for a high-quality of clinical care among hemodialysis patients.
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Affiliation(s)
- Li-Yun Szu
- Department of Nursing, Taoyuan Chang Gung Memorial Hospital, Taoyuan City 33372, Taiwan; (L.-Y.S.); (M.-C.T.); (S.-M.T.)
- Department of Nursing, Chang Gung University of Science and Technology, Taoyuan City 33302, Taiwan
| | - Suh-Ing Hsieh
- Department of Nursing, Chang Gung University of Science and Technology, Taoyuan City 33302, Taiwan
| | - Whei-Mei Shih
- Graduate Institute of Health Care, Chang Gung University of Science and Technology, Taoyuan City 33302, Taiwan;
| | - Mei-Chu Tsai
- Department of Nursing, Taoyuan Chang Gung Memorial Hospital, Taoyuan City 33372, Taiwan; (L.-Y.S.); (M.-C.T.); (S.-M.T.)
- Department of Nursing, Chang Gung University of Science and Technology, Taoyuan City 33302, Taiwan
| | - Su-Mei Tseng
- Department of Nursing, Taoyuan Chang Gung Memorial Hospital, Taoyuan City 33372, Taiwan; (L.-Y.S.); (M.-C.T.); (S.-M.T.)
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Laster M, Pereira RC, Noche K, Gales B, Salusky IB, Albrecht LV. Sclerostin, Osteocytes, and Wnt Signaling in Pediatric Renal Osteodystrophy. Nutrients 2023; 15:4127. [PMID: 37836411 PMCID: PMC10574198 DOI: 10.3390/nu15194127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 09/07/2023] [Accepted: 09/19/2023] [Indexed: 10/15/2023] Open
Abstract
The pathophysiology of chronic kidney disease-mineral and bone disorder (CKD-MBD) is not well understood. Specific factors secreted by osteocytes are elevated in the serum of adults and pediatric patients with CKD-MBD, including FGF-23 and sclerostin, a known inhibitor of the Wnt signaling pathway. The molecular mechanisms that promote bone disease during the progression of CKD are incompletely understood. In this study, we performed a cross-sectional analysis of 87 pediatric patients with pre-dialysis CKD and post-dialysis (CKD 5D). We assessed the associations between serum and bone sclerostin levels and biomarkers of bone turnover and bone histomorphometry. We report that serum sclerostin levels were elevated in both early and late CKD. Higher circulating and bone sclerostin levels were associated with histomorphometric parameters of bone turnover and mineralization. Immunofluorescence analyses of bone biopsies evaluated osteocyte staining of antibodies towards the canonical Wnt target, β-catenin, in the phosphorylated (inhibited) or unphosphorylated (active) forms. Bone sclerostin was found to be colocalized with phosphorylated β-catenin, which suggests that Wnt signaling was inhibited. In patients with low serum sclerostin levels, increased unphosphorylated "active" β-catenin staining was observed in osteocytes. These data provide new mechanistic insight into the pathogenesis of CKD-MBD and suggest that sclerostin may offer a potential biomarker or therapeutic target in pediatric renal osteodystrophy.
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Affiliation(s)
- Marciana Laster
- Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, CA 90024, USA; (M.L.); (R.C.P.); (K.N.); (B.G.)
| | - Renata C. Pereira
- Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, CA 90024, USA; (M.L.); (R.C.P.); (K.N.); (B.G.)
| | - Kathleen Noche
- Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, CA 90024, USA; (M.L.); (R.C.P.); (K.N.); (B.G.)
| | - Barbara Gales
- Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, CA 90024, USA; (M.L.); (R.C.P.); (K.N.); (B.G.)
| | - Isidro B. Salusky
- Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, CA 90024, USA; (M.L.); (R.C.P.); (K.N.); (B.G.)
| | - Lauren V. Albrecht
- Department of Pharmaceutical Sciences, School of Pharmacy, University of California, Irvine, CA 92697, USA
- Department of Developmental and Cell Biology, School of Biological Sciences, University of California, Irvine, CA 92697, USA
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5
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Szu LY, Chang CH, Hsieh SI, Shih WM, Huang LM, Tsai MC, Tseng SM. Factors Related to Quality of Life of Hemodialysis Patients during the COVID-19 Pandemic. Healthcare (Basel) 2023; 11:healthcare11081155. [PMID: 37107989 PMCID: PMC10137652 DOI: 10.3390/healthcare11081155] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 04/05/2023] [Accepted: 04/13/2023] [Indexed: 04/29/2023] Open
Abstract
Taiwan had the second highest number globally of end-stage renal disease patients undergoing treatment in 2018. A meta-analysis of Chen et al. (2021) showed the incidence and mortality rates of COVID-19 were 7.7% and 22.4%, respectively. Few studies have explored the effects of patients' self-participation and perceptions of hemodialysis on their quality of life. This study aimed to explore the factors related to hemodialysis patients' quality of life during the COVID-19 pandemic. This study was a descriptive correlational study. Patients were recruited (n = 298) from the hemodialysis unit of a medical center in northern Taiwan. Variables included patients' sociodemographic, psychological, spiritual, and clinical characteristics (i.e., perceived health level, comorbidities, hemodialysis duration, weekly frequency, transportation, and accompaniment during hemodialysis), perceptions of hemodialysis, self-participation in hemodialysis, and health-related quality of life (KDQOL-36 scale). Data were analyzed using descriptive and bivariate and multivariate linear regression. Multivariate linear regression, after adjusting for covariates, showed that anxiety, self-perceived health status, two vs. four comorbidities, and self-participation in hemodialysis were significantly associated with quality of life. The overall model was significant and accounted for 52.2% (R2 = 0.522) of the variance in quality of life during hemodialysis (adjusted R2 = 0.480). In conclusion, the quality of life of hemodialysis patients with mild, moderate, or severe anxiety was poorer, whereas that of patients with fewer comorbidities, higher self-perceived health status, and higher self-participation in hemodialysis was better.
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Affiliation(s)
- Li-Yun Szu
- Department of Nursing, Taoyuan Chang Gung Memorial Hospital, Taoyuan City 33372, Taiwan
- Department of Nursing, Chang Gung University of Science and Technology, Taoyuan City 33302, Taiwan
| | - Chih-Hsiang Chang
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan City 33302, Taiwan
| | - Suh-Ing Hsieh
- Department of Nursing, Taoyuan Chang Gung Memorial Hospital, Taoyuan City 33372, Taiwan
- Department of Nursing, Chang Gung University of Science and Technology, Taoyuan City 33302, Taiwan
| | - Whei-Mei Shih
- Graduate Institute of Health Care, Chang Gung University of Science and Technology, Taoyuan City 33302, Taiwan
| | - Lan-Mei Huang
- Hemodialysis Unit, Taoyuan Chang Gung Memorial Hospital, Taoyuan City 33372, Taiwan
| | - Mei-Chu Tsai
- Department of Nursing, Taoyuan Chang Gung Memorial Hospital, Taoyuan City 33372, Taiwan
| | - Su-Mei Tseng
- Department of Nursing, Taoyuan Chang Gung Memorial Hospital, Taoyuan City 33372, Taiwan
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Cowan AC, Clemens KK, Sontrop JM, Dixon SN, Killin L, Anderson S, Acedillo RR, Bagga A, Bohm C, Brown PA, Cote B, Dev V, Harris C, Hiremath S, Kiaii M, Lacson E, Molnar AO, Oliver MJ, Parmar MS, McRae JM, Nathoo B, Quinn K, Shah N, Silver SA, Tascona DJ, Thompson S, Ting RH, Tonelli M, Vorster H, Wadehra DB, Wald R, Wolf M, Garg AX. Magnesium and Fracture Risk in the General Population and Patients Receiving Dialysis: A Narrative Review. Can J Kidney Health Dis 2023; 10:20543581231154183. [PMID: 36814964 PMCID: PMC9940170 DOI: 10.1177/20543581231154183] [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: 08/31/2022] [Accepted: 12/18/2022] [Indexed: 02/19/2023] Open
Abstract
Purpose of Review Magnesium is an essential mineral for bone metabolism, but little is known about how magnesium intake alters fracture risk. We conducted a narrative review to better understand how magnesium intake, through supplementation, diet, or altering the concentration of dialysate magnesium, affects mineral bone disease and the risk of fracture in individuals across the spectrum of kidney disease. Sources of Information Peer-reviewed clinical trials and observational studies. Methods We searched for relevant articles in MEDLINE and EMBASE databases. The methodologic quality of clinical trials was assessed using a modified version of the Downs and Black criteria checklist. Key Findings The role of magnesium intake in fracture prevention is unclear in both the general population and in patients receiving maintenance dialysis. In those with normal kidney function, 2 meta-analyses showed higher bone mineral density in those with higher dietary magnesium, whereas 1 systematic review showed no effect on fracture risk. In patients receiving maintenance hemodialysis or peritoneal dialysis, a higher concentration of dialysate magnesium is associated with a lower concentration of parathyroid hormone, but little is known about other bone-related outcomes. In 2 observational studies of patients receiving hemodialysis, a higher concentration of serum magnesium was associated with a lower risk of hip fracture. Limitations This narrative review included only articles written in English. Observed effects of magnesium intake in the general population may not be applicable to those with chronic kidney disease particularly in those receiving dialysis.
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Affiliation(s)
- Andrea C. Cowan
- Division of Nephrology, Department of Medicine, Victoria Hospital, London Health Sciences Centre, ON, Canada,Andrea C. Cowan, Division of Nephrology, Department of Medicine, Victoria Hospital, London Health Sciences Centre, 800 Commissioners Road, Room ELL-215, London, ON N6A 5W9, Canada.
| | - Kristin K. Clemens
- Division of Endocrinology, Department of Medicine, St. Joseph’s Hospital, London, ON, Canada
| | - Jessica M. Sontrop
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Stephanie N. Dixon
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada,Lawson Health Research Institute, London Health Sciences Centre, ON, Canada
| | | | | | - Rey R. Acedillo
- Department of Medicine, Thunder Bay Regional Health Sciences Centre, ON, Canada
| | | | - Clara Bohm
- Chronic Disease Innovation Centre, Winnipeg, MB, Canada,University of Manitoba, Winnipeg, Canada
| | - Pierre Antoine Brown
- Department of Medicine, The Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| | - Brenden Cote
- Patient Partner, London Health Sciences Centre, ON, Canada
| | - Varun Dev
- Humber River Hospital, Toronto, ON, Canada
| | - Claire Harris
- Division of Nephrology, Department of Medicine, Vancouver General Hospital, The University of British Columbia, Canada
| | | | - Mercedeh Kiaii
- Division of Nephrology, Department of Medicine, St. Paul’s Hospital, Vancouver, BC, Canada
| | - Eduardo Lacson
- Division of Nephrology, Tufts University School of Medicine, Boston, MA, USA
| | - Amber O. Molnar
- Department of Medicine, St Joseph’s Healthcare Hamilton, ON, Canada
| | - Matthew J. Oliver
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada
| | | | - Jennifer M. McRae
- Division of Nephrology, Department of Medicine, University of Calgary, AB, Canada
| | | | | | | | - Samuel A. Silver
- Division of Nephrology, Kingston Health Sciences Center, Queen’s University, ON, Canada
| | | | | | | | | | | | | | - Ron Wald
- Division of Nephrology, St. Michael’s Hospital, University of Toronto, ON, Canada
| | - Myles Wolf
- Division of Nephrology, Department of Medicine, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Amit X. Garg
- Division of Nephrology, Department of Medicine, Victoria Hospital, London Health Sciences Centre, ON, Canada
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Kao CC, Wu PC, Chuang MT, Yeh SC, Lin YC, Chen HH, Fang TC, Chang WC, Wu MS, Chang TH. Effects of osteoporosis medications on bone fracture in patients with chronic kidney disease. Postgrad Med J 2022; 99:postgradmedj-2021-140341. [PMID: 35046111 DOI: 10.1136/postgradmedj-2021-140341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 12/01/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE OF THE STUDY The risk of bone fracture is high in patients with chronic kidney disease (CKD), and aggressive treatment to reduce fragility fracture risk is the major strategy. However, the outcomes of osteoporosis medications in patients with CKD remain unclear. STUDY DESIGN Patients with stage 3-5 CKD during 2011-2019 were enrolled. Patients were divided into two groups based on receiving osteoporosis medications (bisphosphonates, raloxifene, teriparatide or denosumab) or not. Two groups were matched at a 1:1 ratio by using propensity scores. The outcomes of interest were bone fractures, cardiovascular (CV) events and all-cause mortality. Cox proportional hazard regression models were applied to identify the risk factors. Additional stratified analyses by cumulative dose, treatment length and menopause condition were performed. RESULTS AND CONCLUSIONS 67 650 patients were included. After propensity score matching, 1654 patients were included in the study and control group, respectively. The mean age was 70.2±12.4 years, and 32.0% of patients were men. After a mean follow-up of 3.9 years, the incidence rates of bone fracture, CV events and all-cause mortality were 2.0, 1.7 and 6.5 per 1000 person-months, respectively. Multivariate analysis results showed that osteoporosis medications reduced the risk of CV events (HR, 0.35; 95% CI, 0.18 to 0.71; p=0.004), but did not alleviate the risks of bone fracture (HR, 1.48; 95% CI, 0.73 to 2.98; p=0.28) and all-cause mortality (HR, 0.93; 95% CI, 0.67 to 1.28; p=0.65). Stratified analysis showed that bisphosphonates users have most benefits in the reduction of CV events (HR, 0.26; 95% CI, 0.11 to 0.64; p=0.003). In conclusion, osteoporosis medications did not reduce the risk of bone fractures, or mortality, but improved CV outcomes in patients with CKD.
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Affiliation(s)
- Chih-Chin Kao
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan.,Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Taipei Medical University-Research Center of Urology and Kidney (TMU-RCUK), Taipei Medical University, Taipei, Taiwan
| | - Pei-Chen Wu
- Division of Nephrology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Ming-Tsang Chuang
- Clinical Data Center, Office of Data Science, Taipei Medical University, Taipei, Taiwan
| | - Shu-Ching Yeh
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan.,Taipei Medical University-Research Center of Urology and Kidney (TMU-RCUK), Taipei Medical University, Taipei, Taiwan
| | - Yen-Chung Lin
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan.,Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Taipei Medical University-Research Center of Urology and Kidney (TMU-RCUK), Taipei Medical University, Taipei, Taiwan
| | - Hsi-Hsien Chen
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan.,Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Taipei Medical University-Research Center of Urology and Kidney (TMU-RCUK), Taipei Medical University, Taipei, Taiwan
| | - Te-Chao Fang
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan.,Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Taipei Medical University-Research Center of Urology and Kidney (TMU-RCUK), Taipei Medical University, Taipei, Taiwan
| | - Wei-Chiao Chang
- Department of Clinical Pharmacy, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Master Program for Clinical Pharmacogenomics and Pharmacoproteomics, School of Pharmacy, Taipei Medical University, Taipei, Taiwan
| | - Mai-Szu Wu
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan .,Taipei Medical University-Research Center of Urology and Kidney (TMU-RCUK), Taipei Medical University, Taipei, Taiwan.,Division of Nephrology, Department of Internal Medicine, Shuang-Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Tzu-Hao Chang
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan .,Clinical Big Data Research Center, Taipei Medical University Hospital, Taipei, Taiwan
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Wakasugi M, Kazama JJ, Nitta K, Narita I. Smoking and risk of fractures requiring hospitalization in hemodialysis patients: a nationwide cohort study in Japan. Nephrol Dial Transplant 2021; 37:950-959. [PMID: 34718771 DOI: 10.1093/ndt/gfab307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Smoking is a well-established lifestyle risk factor for fractures in the general population, but evidence specific to hemodialysis populations is lacking. This nationwide cohort study used data from the Japanese Society for Dialysis Therapy Renal Data Registry to examine the association between smoking status and fractures. METHODS A total of 154,077 patients (64.2% men; mean age, 68 years) aged ≥20 years undergoing maintenance hemodialysis thrice a week at the end of 2016 were followed for 1 year. Among these, 19,004 (12.3%) patients were current smokers. Standardized incidence rate ratios of hospitalization due to any fracture were calculated and analyzed by multivariable logistic regression analysis, controlling for potential confounders. Propensity score matching and subgroup analyses were also performed as sensitivity analyses. RESULTS During the 1-year follow-up period, 3,337 fractures requiring hospitalization (1,201 hip, 479 vertebral, and 1,657 other fractures) occurred in 3,291 patients. The age- and sex-standardized incidence ratio for current smokers was 1.24 (95% confidence interval, 1.12-1.39) relative to non-smokers. Standardized incidence ratios were similar after stratification by age group and sex. Multivariable logistic regression analysis revealed a 1.25-fold higher risk of any fracture requiring hospitalization (95% confidence interval, 1.10-1.42) in current smokers relative to non-smokers in a fully adjusted model. Propensity score matching showed similar results (odds ratio, 1.25; 95% confidence interval, 1.05-1.48). Subgroup analyses for baseline covariates revealed no significant interactions. CONCLUSIONS Smoking is a significant risk factor for any fracture requiring hospitalization in hemodialysis patients.
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Affiliation(s)
- Minako Wakasugi
- Department of Inter-Organ Communication Research, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Junichiro James Kazama
- Departments of Nephrology and Hypertension, Fukushima Medical University, Fukushima, Japan
| | - Kosaku Nitta
- Committee of Renal Data Registry, Japanese Society for Dialysis Therapy, Tokyo, Japan
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Science, Niigata, Japan
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Rodrigues FG, Ormanji MS, Heilberg IP, Bakker SJL, de Borst MH. Interplay between gut microbiota, bone health and vascular calcification in chronic kidney disease. Eur J Clin Invest 2021; 51:e13588. [PMID: 33948936 PMCID: PMC8459296 DOI: 10.1111/eci.13588] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 04/30/2021] [Accepted: 05/01/2021] [Indexed: 02/06/2023]
Abstract
Deregulations in gut microbiota may play a role in vascular and bone disease in chronic kidney disease (CKD). As glomerular filtration rate declines, the colon becomes more important as a site of excretion of urea and uric acid, and an increased bacterial proteolytic fermentation alters the gut microbial balance. A diet with limited amounts of fibre, as well as certain medications (eg phosphate binders, iron supplementation, antibiotics) further contribute to changes in gut microbiota composition among CKD patients. At the same time, both vascular calcification and bone disease are common in patients with advanced kidney disease. This narrative review describes emerging evidence on gut dysbiosis, vascular calcification, bone demineralization and their interrelationship termed the 'gut-bone-vascular axis' in progressive CKD. The role of diet, gut microbial metabolites (ie indoxyl sulphate, p-cresyl sulphate, trimethylamine N-oxide (TMAO) and short-chain fatty acids (SCFA)), vitamin K deficiency, inflammatory cytokines and their impact on both bone health and vascular calcification are discussed. This framework may open up novel preventive and therapeutic approaches targeting the microbiome in an attempt to improve cardiovascular and bone health in CKD.
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Affiliation(s)
- Fernanda G Rodrigues
- Department of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.,Nutrition Post-Graduation Program, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Milene S Ormanji
- Nephrology Division, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Ita P Heilberg
- Nutrition Post-Graduation Program, Universidade Federal de São Paulo, São Paulo, Brazil.,Nephrology Division, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Stephan J L Bakker
- Department of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Martin H de Borst
- Department of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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10
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Asadipooya K, Abdalbary M, Ahmad Y, Kakani E, Monier-Faugere MC, El-Husseini A. Bone Quality in Chronic Kidney Disease Patients: Current Concepts and Future Directions - Part II. KIDNEY DISEASES (BASEL, SWITZERLAND) 2021; 7:359-371. [PMID: 34604343 PMCID: PMC8443940 DOI: 10.1159/000515542] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 02/26/2021] [Indexed: 12/16/2022]
Abstract
Background Patients with chronic kidney disease (CKD) have an increased risk of osteoporotic fractures, which is due not only to low bone volume and mass but also poor microarchitecture and tissue quality. The pharmacological and nonpharmacological interventions detailed, herein, are potential approaches to improve bone health in CKD patients. Various medications build up bone mass but also affect bone tissue quality. Antiresorptive therapies strikingly reduce bone turnover; however, they can impair bone mineralization and negatively affect the ability to repair bone microdamage and cause an increase in bone brittleness. On the other hand, some osteoporosis therapies may cause a redistribution of bone structure that may improve bone strength without noticeable effect on BMD. This may explain why some drugs can affect fracture risk disproportionately to changes in BMD. Summary An accurate detection of the underlying bone abnormalities in CKD patients, including bone quantity and quality abnormalities, helps in institution of appropriate management strategies. Here in this part II, we are focusing on advancements in bone therapeutics that are anticipated to improve bone health and decrease mortality in CKD patients. Key Messages Therapeutic interventions to improve bone health can potentially advance life span. Emphasis should be given to the impact of various therapeutic interventions on bone quality.
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Affiliation(s)
- Kamyar Asadipooya
- Division of Endocrinology, University of Kentucky, Lexington, Kentucky, USA
| | - Mohamed Abdalbary
- Division of Nephrology & Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA.,Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - Yahya Ahmad
- Division of Nephrology & Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
| | - Elijah Kakani
- Division of Nephrology & Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
| | | | - Amr El-Husseini
- Division of Nephrology & Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
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11
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Suresh S, Wright EC, Wright DG, Abbott KC, Noguchi CT. Erythropoietin treatment and the risk of hip fractures in hemodialysis patients. J Bone Miner Res 2021; 36:1211-1219. [PMID: 33949002 PMCID: PMC8360057 DOI: 10.1002/jbmr.4297] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 03/08/2021] [Accepted: 03/25/2021] [Indexed: 12/19/2022]
Abstract
Erythropoietin (EPO) is the primary regulator of bone marrow erythropoiesis. Mouse models have provided evidence that EPO also promotes bone remodeling and that EPO-stimulated erythropoiesis is accompanied by bone loss independent of increased red blood cell production. EPO has been used clinically for three decades to treat anemia in end-stage renal disease, and notably, although the incidence of hip fractures decreased in the United States generally after 1990, it rose among hemodialysis patients coincident with the introduction and subsequent dose escalation of EPO treatment. Given this clinical paradox and findings from studies in mice that elevated EPO affects bone health, we examined EPO treatment as a risk factor for fractures in hemodialysis patients. Relationships between EPO treatment and hip fractures were analyzed using United States Renal Data System (USRDS) datasets from 1997 to 2013 and Consolidated Renal Operations in a Web-enabled Network (CROWNWeb) datasets for 2013. Fracture risks for patients treated with <50 units of EPO/kg/week were compared to those receiving higher doses by multivariable Cox regression. Hip fracture rates for 747,832 patients in USRDS datasets (1997-2013) increased from 12.0 per 1000 patient years in 1997 to 18.9 in 2004, then decreased to 13.1 by 2013. Concomitantly, average EPO doses increased from 11,900 units/week in 1997 to 18,300 in 2004, then decreased to 8,800 by 2013. During this time, adjusted hazard ratios for hip fractures with EPO doses of 50-149, 150-299, and ≥ 300 units/kg/week compared to <50 units/kg/week were 1.08 (95% confidence interval [CI], 1.01-1.15), 1.22 (95% CI, 1.14-1.31), and 1.41 (95% CI, 1.31-1.52), respectively. Multivariable analyses of 128,941 patients in CROWNWeb datasets (2013) replicated these findings. This study implicates EPO treatment as an independent risk factor for hip fractures in hemodialysis patients and supports the conclusion that EPO treatment may have contributed to changing trends in fracture incidence for these patients during recent decades. Published 2021. This article is a U.S. Government work and is in the public domain in the USA. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Sukanya Suresh
- Molecular Medicine Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Elizabeth C Wright
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Daniel G Wright
- Molecular Medicine Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Kevin C Abbott
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Constance T Noguchi
- Molecular Medicine Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
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12
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Li D, Liu W, Huang H, Guo W, Diao Z, Chen X, Wangs W. Association between the risk of death and serum calcium, phosphate, and intact parathyroid hormone levels in older patients undergoing maintenance hemodialysis: a cohort study in Beijing. Ther Adv Endocrinol Metab 2021; 12:20420188211025161. [PMID: 34262687 PMCID: PMC8246503 DOI: 10.1177/20420188211025161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 05/26/2021] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND The number of patients ⩾65 years who require maintenance hemodialysis (MHD) is increasing. Although reduced bone turnover in older patients receiving hemodialysis, as reflected by lower serum intact parathyroid hormone (iPTH) and phosphate (P) levels, has been reported, focus on the association between abnormal bone metabolism and the risk of death in older patients receiving MHD has been limited. METHODS We retrospectively examined data from the Beijing Hemodialysis Quality Control and Improvement Center for 1410 older patients who underwent hemodialysis from 1 January 2012 to 31 December 2016. Baseline, time-dependent (TD) Cox proportional hazards models and Kaplan-Meier analyses were used to evaluate the association between the markers of mineral and bone disorder (MBD) [calcium (Ca), P, and iPTH] and survival. The Kidney Disease: Improving Global Outcomes (KDIGO) target ranges were included as reference values. RESULTS Serum P levels >2.49 mmol/l increased the risk of all-cause death [hazard ratio (HR): 1.46; 95% confidence interval (CI): 1.04-2.07; p = 0.030] and cardiovascular death (HR: 2.01; 95%CI: 1.21-3.34; p = 0.007); iPTH levels >600 pg/ml increased the risk of cardiovascular death (HR: 1.95; 95%CI: 1.20-3.15; p = 0.007). Baseline results and TD Cox analyses were similar. All three MBD parameters were within the respective target ranges at least once during the follow-up period in 399 (28.3%) patients, and these patients had better survival rates than those who achieved two of the three target ranges (715/1410 patients; 50.7%); those who achieved one or no target range (296/1410; 21.0%) had the lowest survival rate (all-cause death: log-rank chi square = 83.96, p < 0.001; cardiovascular death: log-rank chi square = 47.06, p < 0.001). CONCLUSION Older patients undergoing MHD who achieved the KDIGO target levels for any two or three MBD parameters had lower risks of all-cause and cardiovascular death.
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Affiliation(s)
- Dishan Li
- Department of Nephrology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Wenhu Liu
- Department of Nephrology, Beijing Friendship Hospital, Capital Medical University, 95 Yong’An Road, Beijing 100050, China
| | - Hongdong Huang
- Department of Nephrology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Wang Guo
- Department of Nephrology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zongli Diao
- Department of Nephrology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Xinpan Chen
- Department of Nephrology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Weiwei Wangs
- National Clinical Research Center for Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
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13
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Fusaro M, Holden R, Lok C, Iervasi G, Plebani M, Aghi A, Gallieni M, Cozzolino M. Phosphate and bone fracture risk in chronic kidney disease patients. Nephrol Dial Transplant 2021; 36:405-412. [PMID: 31620773 DOI: 10.1093/ndt/gfz196] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 08/29/2019] [Indexed: 01/25/2023] Open
Abstract
In chronic kidney disease (CKD), phosphate homoeostasis plays a central role in the development of mineral and bone disorder (MBD) together with decreased serum calcium and elevated serum parathyroid hormone, fibroblast growth factor 23 and sclerostin levels. Today there are only a few data exploring the direct role of abnormal phosphate homoeostasis and hyperphosphataemia in the development of CKD-MBD. On the other hand, several studies have looked at the link between hyperphosphataemia and cardiovascular morbidity and mortality in CKD, but there is a lack of evidence to indicate that lowering phosphate levels improves cardiovascular outcomes in this population. Furthermore, the impact of liberalizing phosphate targets on CKD-MBD progression and bone fracture is currently not known. In this review we discuss the central role of phosphate in the pathogenesis of CKD-MBD and how it may be associated with fracture risk, both in hyper- and hypophosphataemia.
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Affiliation(s)
- Maria Fusaro
- National Research Council, Institute of Clinical Physiology, Pisa, Italy.,Department of Medicine, University of Padova, Padova, Italy
| | - Rachel Holden
- Department of Medicine, Division of Nephrology, Queen's University, Kingston, Ontario, Canada
| | - Charmaine Lok
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Giorgio Iervasi
- National Research Council, Institute of Clinical Physiology, Pisa, Italy
| | - Mario Plebani
- Department of Medicine, Laboratory Medicine Unit, University of Padova, Padova, Italy
| | - Andrea Aghi
- Department of Medicine, Clinica Medica 1, University of Padova, Padova, Italy
| | - Maurizio Gallieni
- Department of Biomedical and Clinical Sciences 'L. Sacco', Nephrology and Dialysis Unit, ASST Fatebenefratelli-Sacco, Università di Milano, Milan, Italy
| | - Mario Cozzolino
- Department of Health Sciences, ASST Santi Paolo and Carlo, University of Milan and Renal Division, Milan, Italy
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14
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Hiramatsu R, Ubara Y, Sawa N, Sakai A. Hypocalcemia and bone mineral changes in hemodialysis patients with low bone mass treated with denosumab: a 2-year observational study. Nephrol Dial Transplant 2021; 36:1900-1907. [PMID: 33544866 DOI: 10.1093/ndt/gfaa359] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Increases in bone mineral density (BMD) following a single dose of denosumab and increased incidence of denosumab-associated acute hypocalcemia (DAAH) have been reported in chronic kidney disease (CKD) patients. Little is known about clinical risk factors related to DAAH and the long-term effect of denosumab on BMD in hemodialysis patients. METHODS An observational non-controlled study involving 47 hemodialysis patients was conducted to determine the independent risk factors related to percent changes in serum Ca levels associated with denosumab using multivariate regression analysis. Optimal predictive markers for DAAH were explored by receiver operating characteristic (ROC) analysis. Percent changes of BMD at the lumbar spine (LS) and femoral neck (FN) over 24 months were investigated. RESULTS The incidence of DAAH (serum corrected Ca (cCa) ≤ 8 mg/dL) following denosumab was 25.5%. Multivariate regression analysis showed baseline bone alkaline phosphatase (BAP) was independently related to percent changes in cCa levels (β = -0.407, P = 0.008). Tartrate-resistant acid phosphatase (TRACP-5b) was found to be the most accurate marker to predict DAAH with AUC of 0.750 (95% CI; 0.546-0.954, P = 0.02) and the optimal cut-off level was 670 mU/mL with sensitivity; 0.727 and specificity; 0.733. BMD significantly increased by 5.9 ± 1.7% (P = 0.01) at LS and 4.2 ± 1.5% (P = 0.04) at FN at 24 months. CONCLUSION In hemodialysis patients, high bone turnover was an independent risk factor for the Ca declines induced by denosumab. Denosumab significantly increased BMD at LS and FN over 24 months.
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Affiliation(s)
- Rikako Hiramatsu
- Nephrology Centre, Toranomon Hospital, Tokyo, Japan.,Department of Orthopedic Surgery, University of Occupational and Environmental Health, Japan
| | | | - Naoki Sawa
- Nephrology Centre, Toranomon Hospital, Tokyo, Japan
| | - Akinori Sakai
- Department of Orthopedic Surgery, University of Occupational and Environmental Health, Japan
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15
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Harrak H, René E, Alsalemi N, Elftouh N, Lafrance JP. Osteoporotic fracture rates in chronic hemodialysis and effect of heparin exposure: a retrospective cohort study. BMC Nephrol 2020; 21:261. [PMID: 32646504 PMCID: PMC7350680 DOI: 10.1186/s12882-020-01916-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 06/28/2020] [Indexed: 11/12/2022] Open
Abstract
Background Patients receiving chronic hemodialysis treatments are at a higher risk of fracture compared to the general population. While the use of heparin during dialysis is crucial to avoid thrombosis of the extracorporeal circuit, the association of unfractionated heparin (UFH) and the risk of osteoporotic fracture has been shown for many years. However, this association was not as clear for low-molecular-weight heparin (LMWH) and the few collected data originated from studies among pregnant women. Our aim was to measure osteoporotic fracture rate among hemodialysis patients and to evaluate the association of LMWH compared to UFH in hemodialysis. Methods A retrospective cohort study was conducted on data extracted from the RAMQ and Med-Echo databases from January 2007 to March 2013 with patients chronically hemodialyzed in 21 participating centers. Incidence rates for each fracture sites were measured per 1000 patient-year (p-y) and their 95% confidence intervals (CI). Osteoporotic fracture risk for a first event with LMWH compared to UFH was estimated using a cox proportional hazard model using demographics, comorbidities and drug use as covariates. Results 4796 patients undergoing chronic hemodialysis were identified. The incidence rate for all fracture sites was 22.7 /1000 p-y (95% CI: 19.6–26.1) and 12.8 /1000 p-y (95% CI: 10.5–15.4) for hip and femur fractures. We found a similar risk of osteoporotic fracture for LMWH compared to UFH (adjusted HR = 1.01; 95%CI: 0.72–1.42). Age and malignancy increased the risk of fracture while cerebrovascular disease decreased the risk of fracture. Conclusions Compared to UFH, LMWH did not change the risk of osteoporotic fracture when used for the extracorporeal circuit anticoagulation in chronic hemodialysis.
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16
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Fuller DS, Dluzniewski PJ, Cooper K, Bradbury BD, Robinson BM, Tentori F. Combinations of mineral and bone disorder markers and risk of death and hospitalizations in the international Dialysis Outcomes and Practice Patterns Study. Clin Kidney J 2020; 13:1056-1062. [PMID: 33391749 PMCID: PMC7769536 DOI: 10.1093/ckj/sfz112] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/30/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Prior studies have developed a chronic kidney disease-mineral and bone disorder (CKD-MBD) composite score based on combinations of calcium (Ca), phosphorus (P) and parathyroid hormone (PTH) that have been shown to be associated with an increased risk of clinical outcomes in the USA. We examined this association in a contemporary, international cohort of hemodialysis patients. METHODS We studied 19 313 patients surviving ≥12 months in the Dialysis Outcomes and Practice Patterns Study Phases 3-5 (2005-15) from Europe, Canada and the USA. The CKD-MBD composite score was defined as the number of markers above target levels (P, 3.5-5.5 mg/dL; Ca, 8.4-10.2 mg/dL; PTH, 150-600 pg/mL). Using Cox models, we estimated hazard ratios (HRs) for death and a composite event (death or hospitalization), contrasting MBD 2/3 (2-3 parameters above target) with MBD 0 (all in target), adjusted for a disease risk score (DRS). RESULTS MBD 2/3 above target was observed in 10-14% of patients across regions and was associated with greater DRS-adjusted mortality {HR 1.41 [95% confidence interval (CI) 1.10-1.82]} and composite events [HR 1.23 (95% CI 1.10-1.38)] in the USA compared with MBD 0; the mortality association was stronger for patients ≥ 65 years of age [HR 1.82 (95% CI 1.28-2.58)] compared with patients <65 years of age [HR 1.11 (95% CI 0.80-1.55)]. HRs observed in Canada and Europe were generally consistent but weaker. Estimates for MBD 2/3 outside target (above or below) were slightly lower in all regions. CONCLUSIONS Simultaneous consideration of Ca, P and PTH may help in identifying patients on dialysis with a higher risk of major clinical outcomes related to CKD-MBD.
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Affiliation(s)
| | | | - Kerry Cooper
- Center for Observational Research, Amgen, Thousand Oaks, CA, USA
| | - Brian D Bradbury
- Center for Observational Research, Amgen, Thousand Oaks, CA, USA
| | - Bruce M Robinson
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Francesca Tentori
- DaVita Clinical Research, Minneapolis, MN, USA
- Vanderbilt University Medical Center, Nashville, TN, USA
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17
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Zhu Y, Hu J, Han W, Lu J, Zeng Y. Simultaneous bilateral femoral neck fractures in a dialysis-dependent patient: case report and literature review. BMC Musculoskelet Disord 2020; 21:242. [PMID: 32293406 PMCID: PMC7158116 DOI: 10.1186/s12891-020-03281-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 04/13/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Simultaneous bilateral femoral neck fractures are extremely rare without obvious injury. Herein, we report the case of a patient on dialysis presenting with bilateral femoral neck fractures, which is a condition with high complication and mortality rates according to a review of the pertinent literature. CASE PRESENTATION We report the case a 47-year-old female with a history of 8 years of haemodialysis due to polycystic kidney disease who presented with bilateral hip pain during walking. The clinical history and results of physical and radiographic examinations of this patient are shown. Single-stage bilateral hemiarthroplasty was performed after a multidisciplinary team consultation. Three days after the operation, she could ambulate with a walker. The woman gradually regained her previous ability to walk over 6 months after surgery. CONCLUSIONS A multidisciplinary team consultation for perioperative management is necessary and effective in patients on dialysis. Early diagnosis with prompt surgical treatment could lead to favourable recovery.
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Affiliation(s)
- Yunyun Zhu
- Department of Nephrology, Tongde Hospital of Zhejiang Province, HangZhou, Zhejiang Province, China
| | - Jingtao Hu
- Zhejiang Chinese Medical University, HangZhou, Zhejiang Province, China
| | - Wenlun Han
- Department of Nephrology, Tongde Hospital of Zhejiang Province, HangZhou, Zhejiang Province, China
| | - Jianwei Lu
- Department of Orthopaedics, Tongde Hospital of Zhejiang Province, 234 GuCui Road, HangZhou, 310012, Zhejiang Province, China
| | - Yuqing Zeng
- Department of Orthopaedics, Tongde Hospital of Zhejiang Province, 234 GuCui Road, HangZhou, 310012, Zhejiang Province, China.
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18
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Iseri K, Carrero JJ, Evans M, Felländer-Tsai L, Berg H, Runesson B, Stenvinkel P, Lindholm B, Qureshi AR. Major fractures after initiation of dialysis: Incidence, predictors and association with mortality. Bone 2020; 133:115242. [PMID: 31958531 DOI: 10.1016/j.bone.2020.115242] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 01/14/2020] [Accepted: 01/15/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Major fractures (MF) are common in dialysis patients. We investigated incidence, predictors and clinical outcomes associated with first MF occurring after initiation of dialysis (MFfirst). METHODS In Swedish Renal Registry of 9714 incident (2005-2016) dialysis patients (age 68 years, 67% men), we identified all MFfirst in hip, spine, humerus and forearm. Using flexible parametric hazard models and Fine-Gray analysis, we estimated incidence, mortality rates and predictors of MFfirst, and, in time-dependent analysis, risk of all-cause and cardiovascular disease (CVD) mortality following MFfirst. RESULTS During median follow-up of 2.2 years, the crude incidence rate of MFfirst (n = 835) was 23.7/1000 patient-years and that of hip fractures (n = 470) 13.3/1000 patient-years. The multivariate-adjusted fracture incidence rates increased gradually after dialysis initiation and were 47% higher among women. Female sex, higher age, comorbidity, and previous history of MF (MFprevious) were associated with increased risk for MFfirst, whereas peritoneal dialysis as compared to hemodialysis was associated with decreased risk. The adjusted fracture incidence rate of MFfirst during the first 90 days following dialysis initiation was higher in patients with MFprevious than in those without MFprevious. MFfirst independently predicted increased all-cause (sub-distribution hazard ratio, SHR, 1.67(95%CI 1.47-1.91)) and CVD (SHR 1.49 (95%CI 1.22-1.84)) mortality. Adjusted mortality rate following hip fractures was higher than for other types of MF. Spline curves showed that mortality following MFfirst was highest during the first 6 months of follow-up. CONCLUSIONS MF are common and associated with increased mortality in incident dialysis patients.
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Affiliation(s)
- Ken Iseri
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan.
| | - Juan Jesús Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Marie Evans
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Li Felländer-Tsai
- Division of Orthopaedics and Biotechnology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Hans Berg
- Division of Orthopaedics and Biotechnology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Björn Runesson
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Peter Stenvinkel
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Bengt Lindholm
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Abdul Rashid Qureshi
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
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19
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Przedlacki J, Buczyńska-Chyl J, Koźmiński P, Niemczyk E, Wojtaszek E, Gieglis E, Żebrowski P, Podgórzak A, Wściślak J, Wieliczko M, Grochowski J, Kędzierska M, Kaczanowska B, Wyszyńska A, Sitkowska-Kurzec Z, Klatko W, Gellert R, Daniewska D, Osuch D, Stryjewski D, Świtalski M, Piotrowski A, Stopiński M, Kędzierski P, Rydzewski A, Fiderkiewicz B, Wypych-Birecka M, Śliwicka D, Durlik M, Grzeszczyk M, Sokalski A, Papliński M, Hartman J, Imiela J, Małecki R, Bolesta A, Niemczyk S, Klimm W, Wierzbicki P, Gorczyńska J, Piórecki M, Gołębiewski S, Horbacz R, Małyszko J, Matuszkiewicz-Rowińska J. FRAX prognostic and intervention thresholds in the management of major bone fractures in hemodialysis patients: A two-year prospective multicenter cohort study. Bone 2020; 133:115188. [PMID: 31843681 DOI: 10.1016/j.bone.2019.115188] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 12/01/2019] [Accepted: 12/10/2019] [Indexed: 12/16/2022]
Abstract
PURPOSE The usefulness of FRAX in predicting major bone fractures in patients with end-stage kidney disease on maintenance hemodialysis treatment has been confirmed in previous studies. For meaningful clinical use, the prognostic and intervention FRAX thresholds need to be established. METHODS The primary aim of our study was to calculate the optimal cut-off point of FRAX for the best prediction of an increased bone fracture risk in dialysis patients and additionally, to propose its intervention threshold, indicating the need for antifracture pharmacological treatment. The study included 718 hemodialysis patients, who were followed up for two years. Thirty low-energy major bone fractures were diagnosed during the study period. We used the Polish version of FRAX (without the DXA examination) and some particular variables of the FRAX calculator. The optimal cut-off point for prediction of an increased major bone fracture risk was based on the analysis of the sensitivity and specificity curves of FRAX. RESULTS The analysis revealed FRAX >5% (sensitivity of 70.0%, specificity of 69.8%) as the prognostic threshold for major bone fractures. Its sensitivity for bone fracture prediction was significantly higher, but specificity lower than those of FRAX ≥10%, used in general Polish population. The reason for this can be an underestimation of bone fracture risk with FRAX in dialysis patients. CONCLUSIONS We conclude that the FRAX prognostic threshold for identification of an increased risk of major bone fractures in hemodialysis patients is >5%. We propose to use this specific value of FRAX as an intervention threshold for pharmacological antifracture treatment in hemodialysis patients.
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Affiliation(s)
- Jerzy Przedlacki
- Department of Nephrology, Dialysis and Internal Medicine, Medical University of Warsaw, Warsaw, Poland.
| | | | | | - Ewa Niemczyk
- Department of Internal Medicine, Independent Public Specialist Western Hospital John Paul II, Grodzisk Mazowiecki, Poland; Fresenius Dialysis Center, Płońsk, Poland
| | - Ewa Wojtaszek
- Department of Nephrology, Dialysis and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | | | - Paweł Żebrowski
- Department of Nephrology, Dialysis and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Andrzej Podgórzak
- Department of Nephrology, Mazovia Regional Hospital, Siedlce, Poland
| | - Jolanta Wściślak
- Department of Nephrology, Mazovia Regional Hospital, Siedlce, Poland
| | - Monika Wieliczko
- Department of Nephrology, Dialysis and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | | | | | | | | | - Zofia Sitkowska-Kurzec
- Fresenius Dialysis Center, Wołomin, Poland; Fresenius Dialysis Center, Ostrołęka, Poland
| | | | - Ryszard Gellert
- Department of Nephrology and Internal Medicine, Medical Center for Postgraduate Education, Warsaw, Poland
| | - Dorota Daniewska
- Dialysis and Diagnostic Center, Bielański Hospital, Warsaw, Poland
| | - Dariusz Osuch
- Department of Nephrology and Internal Medicine, Medical Center for Postgraduate Education, Warsaw, Poland
| | - Dariusz Stryjewski
- Fresenius Dialysis Center, Płońsk, Poland; Dialysis Unit, Szpital Praski, Warsaw, Poland
| | - Marek Świtalski
- Nephrology Unit, Wojewódzki Szpital Zespolony, Płock, Poland
| | | | - Marek Stopiński
- Department of Internal Medicine, Independent Public Specialist Western Hospital John Paul II, Grodzisk Mazowiecki, Poland
| | - Piotr Kędzierski
- Dialysis Unit, B. Brown Avitum Poland, Sp. z o.o., Garwolin, Poland
| | - Andrzej Rydzewski
- Department of Internal Medicine, Nephrology and Transplantation, Central Clinical Hospital of the Ministry of Interior, Warsaw, Poland; Department of Internal Medicine, Nephrology and Transplantation, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Bartosz Fiderkiewicz
- Department of Internal Medicine, Nephrology and Transplantation, Central Clinical Hospital of the Ministry of Interior, Warsaw, Poland
| | | | | | - Magdalena Durlik
- Department of Transplantation, Nephrology and Internal Medicine, Medical University of Warsaw, Poland
| | - Mirosław Grzeszczyk
- Department of Transplantation, Nephrology and Internal Medicine, Medical University of Warsaw, Poland
| | | | - Marek Papliński
- Nephrology and Dialysis Unit, Szpital Powiatowy Sp. z o.o., Sokołów Podlaski, Poland
| | - Jakub Hartman
- Fresenius Dialysis Center, Ostrów Mazowiecka, Poland
| | - Jacek Imiela
- Department of Internal Medicine, Międzyleski Szpital Specjalistyczny, Warsaw, Poland
| | - Robert Małecki
- Department of Internal Medicine, Międzyleski Szpital Specjalistyczny, Warsaw, Poland
| | - Agnieszka Bolesta
- Department of Internal Medicine, Międzyleski Szpital Specjalistyczny, Warsaw, Poland
| | - Stanisław Niemczyk
- Department of Internal Medicine, Nephrology and Dialysis, Military Medical Institute, Warsaw, Poland
| | - Wojciech Klimm
- Department of Internal Medicine, Nephrology and Dialysis, Military Medical Institute, Warsaw, Poland
| | - Przemysław Wierzbicki
- Internal Medicine and Nephrology Unit with Dialysis Unit, Szpital Powiatowy, Wołomin, Poland
| | - Joanna Gorczyńska
- Internal Medicine and Nephrology Unit with Dialysis Unit, Szpital Powiatowy, Wołomin, Poland
| | | | - Sewer Gołębiewski
- Dialysis Unit, Wojewódzki Szpital Chirurgii Urazowej św. Anny, Warsaw, Poland
| | | | - Jolanta Małyszko
- Department of Nephrology, Dialysis and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
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20
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Nickolas TL, Chen N, McMahon DJ, Dempster D, Zhou H, Dominguez J, Aponte MA, Sung J, Evenepoel P, D'Haese PC, Mac-Way F, Moyses R, Moe S. A microRNA Approach to Discriminate Cortical Low Bone Turnover in Renal Osteodystrophy. JBMR Plus 2020; 4:e10353. [PMID: 32490328 PMCID: PMC7254487 DOI: 10.1002/jbm4.10353] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 01/31/2020] [Accepted: 02/18/2020] [Indexed: 01/03/2023] Open
Abstract
A main obstacle to diagnose and manage renal osteodystrophy (ROD) is the identification of intracortical bone turnover type (low, normal, high). The gold standard, tetracycline‐labeled transiliac crest bone biopsy, is impractical to obtain in most patients. The Kidney Disease Improving Global Outcomes Guidelines recommend PTH and bone‐specific alkaline phosphatase (BSAP) for the diagnosis of turnover type. However, PTH and BSAP have insufficient diagnostic accuracy to differentiate low from non‐low turnover and were validated for trabecular turnover. We hypothesized that four circulating microRNAs (miRNAs) that regulate osteoblast (miRNA‐30b, 30c, 125b) and osteoclast development (miRNA‐155) would provide superior discrimination of low from non‐low turnover than biomarkers in clinical use. In 23 patients with CKD 3‐5D, we obtained tetracycline‐labeled transiliac crest bone biopsy and measured circulating levels of intact PTH, BSAP, and miRNA‐30b, 30c, 125b, and 155. Spearman correlations assessed relationships between miRNAs and histomorphometry and PTH and BSAP. Diagnostic test characteristics for discriminating low from non‐low intracortical turnover were determined by receiver operator curve analysis; areas under the curve (AUC) were compared by χ2 test. In CKD rat models of low and high turnover ROD, we performed histomorphometry and determined the expression of bone tissue miRNAs. Circulating miRNAs moderately correlated with bone formation rate and adjusted apposition rate at the endo‐ and intracortical envelopes (ρ = 0.43 to 0.51; p < 0.05). Discrimination of low versus non‐low turnover was 0.866, 0.813, 0.813, and 0.723 for miRNA‐30b, 30c, 125b, and 155, respectively, and 0.509 and 0.589 for PTH and BSAP, respectively. For all four miRNAs combined, the AUC was 0.929, which was superior to that of PTH and BSAP alone and together (p < 0.05). In CKD rats, bone tissue levels of the four miRNAs reflected the findings in human serum. These data suggest that a panel of circulating miRNAs provide accurate noninvasive identification of bone turnover in ROD. © 2020 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Thomas L Nickolas
- Department of Medicine Columbia University Medical Center New York NY USA
| | - Neal Chen
- Division of Nephrology Indiana University School of Medicine Indianapolis IN USA
| | - Donald J McMahon
- Department of Medicine Columbia University Medical Center New York NY USA
| | - David Dempster
- Department of Pathology and Cell Biology Columbia University New York NY USA.,Regional Bone Center Helen Hayes Hospital New York NY USA
| | - Hua Zhou
- Regional Bone Center Helen Hayes Hospital New York NY USA
| | - James Dominguez
- Division of Nephrology Indiana University School of Medicine Indianapolis IN USA
| | - Maria A Aponte
- Department of Medicine Columbia University Medical Center New York NY USA
| | - Joshua Sung
- Department of Medicine Columbia University Medical Center New York NY USA
| | - Pieter Evenepoel
- Department of Microbiology and Immunology, Laboratory of Nephrology Katholieke Universiteit Leuven, University of Leuven Leuven Belgium
| | - Patrick C D'Haese
- Department of Biomedical Sciences, Laboratory of Pathophysiology Antwerp University Wilrijk Belgium
| | - 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 Quebec City Canada
| | - Rosa Moyses
- Laboratório de Investigação Médica 16 Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo Sao Paulo Brazil
| | - Sharon Moe
- Division of Nephrology Indiana University School of Medicine Indianapolis IN USA.,Department of Medicine Roudebush Veterans Administration Medical Center Indianapolis IN USA
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21
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Abstract
PURPOSE OF REVIEW Chronic kidney disease (CKD) is associated with the development of mineral and bone disorders (MBD), including renal osteodystrophy (ROD). ROD is a global disorder of bone strength that is associated with an increased fracture risk. The use of bisphosphonates for fracture risk reduction in CKD remains controversial. This review provides a synopsis of the state-of-the literature regarding the safety and potential antifracture benefits of bisphosphonates in CKD patients. RECENT FINDINGS In preclinical studies of animals with CKD 3-4 and evidence of CKD-MBD, bisphosphonates resulted in changes in bone quality that improve bone strength. Bone turnover was generally reduced to a similar extent in animals with and without CKD. Post hoc analyses of randomized trials in patients with CKD 3-4 reported increases in bone mineral density (BMD) and fracture reduction that were similar in patients with and without CKD. There are no primary clinical trial data in patients with CKD-MBD. SUMMARY In patients with CKD without evidence of CKD-MBD, the use of bisphosphonates should follow general population guidelines. The lack of data for patients with CKD 4-5D and evidence of CKD-MBD makes treatment decisions challenging. Clinical studies are urgently needed to provide data on the safety and antifracture benefits of bisphosphonates in these cohorts.
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22
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Lin R, Toussaint ND, Gallagher M, Cass A, Kotwal S. Hospitalized fracture rates amongst patients with chronic kidney disease in Australia using data linkage. Nephrology (Carlton) 2019; 25:475-482. [PMID: 31743530 DOI: 10.1111/nep.13681] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 10/27/2019] [Accepted: 11/11/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Renal osteodystrophy leading to fractures in chronic kidney disease (CKD) is associated with significant hospitalization, morbidity, mortality and health care costs. There is a paucity of data on fractures in the CKD population in Australia. AIM To describe the trends and impact of hospitalized fractures in an Australian population of non-dialysis CKD patients. METHODS Retrospective observational data derived using data linkage. Fracture rates, trends in hospital admissions, comorbidity burden and mortality were analysed in a non-dialysis CKD population between 2000 and 2010 in the Australian state of New South Wales. Hospitalized patients with CKD and fractures were compared with CKD patients without fracture. RESULTS A total of 149 839 hospitalized patients with CKD were included, of whom 9898 (6.6%) experienced one or more fractures. Patients with fracture were older, more likely to be female with a higher comorbidity burden than those without. Hospital admissions involving fracture were longer than non-fracture admissions (14.3 vs 5.9 days, P < .0001) and patients were less likely to be discharged home (28.3% vs 80.9%, P < .0001). The 12-month mortality rate was high at 41%. CONCLUSION Australian non-dialysis CKD patients with hospitalized fractures were older, had a greater burden of disease, and have similar rates of fracture and associated mortality compared to international CKD cohorts. Implications of fracture requiring hospitalization are considerable, with longer admissions, greater healthcare costs, lower likelihood of discharge home and significant mortality. As fracture prevention in the CKD population evolves, treatment algorithms should account for those at greatest risk.
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Affiliation(s)
- Raymond Lin
- Renal and Metabolic Divisions, The George Institute for Global Health, Newtown, New South Wales, Australia
| | - Nigel D Toussaint
- Department of Nephrology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medicine (RMH), University of Melbourne, Melbourne, Victoria, Australia
| | - Martin Gallagher
- Renal and Metabolic Divisions, The George Institute for Global Health, Newtown, New South Wales, Australia.,Concord Clinical School, Faculty of Medicine & Health, University of Sydney, Sydney, New South Wales, Australia
| | - Alan Cass
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Sradha Kotwal
- Renal and Metabolic Divisions, The George Institute for Global Health, Newtown, New South Wales, Australia.,Department of Nephrology, Prince of Wales Hospital, Sydney, New South Wales, Australia
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23
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Management of Secondary Hyperparathyroidism in Chronic Kidney Disease: A Focus on the Elderly. Drugs Aging 2019; 36:885-895. [DOI: 10.1007/s40266-019-00696-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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24
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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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25
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Li C, Chen XM, Li Y, Zhou YL, Yan JN, Du XG. Factors and Outcome of Renal Osteodystrophy-Associated Initial Fragility Fracture in End-Stage Renal Disease Patients. KIDNEY DISEASES (BASEL, SWITZERLAND) 2019; 5:118-125. [PMID: 31019925 DOI: 10.1159/000494924] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 10/29/2018] [Indexed: 01/09/2023]
Abstract
Background Renal osteodystrophy has caused increased risk of fragility fracture in end-stage renal disease (ESRD) patients. However, risk factors and outcome of ESRD patients with fragility fracture remain uncharacterized. We aimed to assess these parameters in ESRD patients. Summary This retrospective case-control study analyzed 354 ESRD patients (initial fragility fracture [FF] group, n = 59; control group, n = 295). Pre-dialysis blood hemoglobin, serum albumin, lipid, calcium, phosphorus, alkaline phosphatase (ALP), and intact parathyroid hormone (iPTH) were collected. All procedures performed involving human participants were in accordance with the ethical standards of the institutional committee of The First Affiliated Hospital of Chongqing Medical University (IRB approval number 216-82), and informed consent was obtained from all participants. There were higher prevalence rates of primary hypertension and diabetes, higher serum ALP, corrected calcium, and lower serum total cholesterol, low-density lipoprotein, lipoprotein-α, and iPTH in the FF group. Fractures were more likely to occur in the higher level of corrected calcium as well as in the lower iPTH group. High corrected calcium (p = 0.010, OR = 11.308, 95% CI: 1.770-72.242) and serum ALP (p = 0.000, OR = 1.007, 95% CI: 1.004-1.011) were independent risk factors of fragility fracture. The incidence of all-cause mortality and cardiovascular (CV) events in ESRD patients with fragility fracture was higher than in those without fracture. Key Messages Patients with hypertension, diabetes, excessive suppression of PTH, and poor nutritional status are more prone to fractures. Serum corrected calcium and ALP were independent risk factors of fragility fracture. Patients with initial fragility fracture had more CV events and higher mortality.
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Affiliation(s)
- Cai Li
- Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xue-Mei Chen
- Emergency Department, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yin Li
- Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.,Department of Nephrology and Endocrinology, The People's Hospital of Tongliang District, Chongqing, China
| | - Yan-Lin Zhou
- Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jia-Ni Yan
- Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiao-Gang Du
- Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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26
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Sidibé A, Auguste D, Desbiens L, Fortier C, Wang YP, Jean S, Moore L, Mac‐Way F. Fracture Risk in Dialysis and Kidney Transplanted Patients: A Systematic Review. JBMR Plus 2019; 3:45-55. [PMID: 30680363 PMCID: PMC6339558 DOI: 10.1002/jbm4.10067] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 06/07/2018] [Accepted: 06/14/2018] [Indexed: 12/14/2022] Open
Abstract
Chronic kidney disease is associated with an increased risk of fracture and cardiovascular mortality. The risk of fracture in hemodialysis (HD), peritoneal dialysis (PD) and kidney transplant (KT) patients is higher when compared with the general population. However, there exists a knowledge gap concerning which group has the highest risk of fracture. We aimed to compare the risk of fracture in HD, PD, and KT populations. We conducted a systematic review of observational studies evaluating the risk of fracture in HD, PD, or KT patients. Eligible studies were searched using MEDLINE, Embase, Web of Science, and Cochrane Library from their inception to January 2016, and in grey literature. Incidences (cumulative and rate) of fracture were described together using the median, according to fracture sites, the data source (administrative database or cohort and clinical registry), and fracture diagnosis method. Prevalence estimates were described separately. We included 47 studies evaluating the risk of fracture in HD, PD, and KT populations. In administrative database studies, incidence of hip fracture in HD (median 11.45 per 1000 person-years [p-y]), range: 9.3 to 13.6 was higher than in KT (median 2.6 per 1000 p-y; range 1.5 to 3.8) or in PD (median 5.2 per 1000 p-y; range 4.1 to 6.3). In dialysis (HD+PD), three studies reported a higher incidence of hip fracture than in KT. Prevalent vertebral fracture (assessed by X-rays or questionnaire) reported in HD was in a similar range as that reported in KT. Incidence of overall fracture was similar in HD and KT, from administrative databases studies, but lower in HD compared with KT, from cohorts or clinical registry studies. This systematic review suggests an important difference in fracture risk between HD, PD, and KT population, which vary according to the diagnosis method for fracture identification. © 2018 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Aboubacar Sidibé
- Centre de Recherche du CHU de QuébecHôpital Hôtel‐Dieu de QuébecDivision of Nephrology, Endocrinology, and Nephrology AxisFaculty of MedicineDepartment of Social and Preventive MedicineLaval UniversityQuebecCanada
| | - David Auguste
- Centre de Recherche du CHU de QuébecHôpital Saint‐SacrementFaculty of MedicineDepartment of Social and Preventive MedicineLaval UniversityQuebecCanada
| | - Louis‐Charles Desbiens
- Centre de Recherche du CHU de QuébecHôpital Hôtel‐Dieu de QuébecDivision of Nephrology, Endocrinology, and Nephrology AxisFaculty and Department of MedicineLaval UniversityQuebecCanada
| | - Catherine Fortier
- Centre de Recherche du CHU de QuébecHôpital Hôtel‐Dieu de QuébecDivision of Nephrology, Endocrinology, and Nephrology AxisFaculty and Department of MedicineLaval UniversityQuebecCanada
| | - Yue Pei Wang
- Centre de Recherche du CHU de QuébecHôpital Hôtel‐Dieu de QuébecDivision of Nephrology, Endocrinology, and Nephrology AxisFaculty and Department of MedicineLaval UniversityQuebecCanada
| | - Sonia Jean
- Institut National de Santé Publique du QuébecMedicine FacultyDepartment of Social and Preventive MedicineLaval UniversityQuebecCanada
| | - Lynne Moore
- Centre de Recherche du CHU de QuébecHôpital de l'Enfant‐JésusTraumatology AxisMedicine FacultyDepartment of Social and Preventive MedicineLaval UniversityQuebecCanada
| | - Fabrice Mac‐Way
- Centre de Recherche du CHU de QuébecHôpital Hôtel‐Dieu de QuébecDivision of Nephrology, Endocrinology, and Nephrology AxisFaculty and Department of MedicineLaval UniversityQuebecCanada
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27
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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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28
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Time to rethink the use of bone biopsy to prevent fractures in patients with chronic kidney disease. Curr Opin Nephrol Hypertens 2018; 27:243-250. [DOI: 10.1097/mnh.0000000000000418] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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29
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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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30
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Przedlacki J, Buczyńska-Chyl J, Koźmiński P, Niemczyk E, Wojtaszek E, Gieglis E, Żebrowski P, Podgórzak A, Wściślak J, Wieliczko M, Matuszkiewicz-Rowińska J. The utility of FRAX® in predicting bone fractures in patients with chronic kidney disease on hemodialysis: a two-year prospective multicenter cohort study. Osteoporos Int 2018; 29:1105-1115. [PMID: 29411069 DOI: 10.1007/s00198-018-4406-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 01/23/2018] [Indexed: 01/05/2023]
Abstract
UNLABELLED We assessed the FRAX® method in 718 hemodialyzed patients in estimating increased risk of bone major and hip fractures. Over two prospective years, statistical analysis showed that FRAX® enables a better assessment of bone major fracture risk in these patients than any of its components and other risk factors considered in the analysis. INTRODUCTION Despite the generally increased risk of bone fractures among patients with end-stage renal disease, no prediction models for identifying individuals at particular risk have been developed to date. The goal of this prospective, multicenter observational study was to assess the usefulness of the FRAX® method in comparison to all its elements considered separately, selected factors associated with renal disease and the history of falls, in estimating increased risk of low-energy major bone and hip fractures in patients undergoing chronic hemodialysis. METHODS The study included a total of 1068 hemodialysis patients, who were followed for 2 years, and finally, 718 of them were analyzed. The risk analysis included the Polish version of the FRAX® calculator (without bone mineral density), dialysis vintage, mineral metabolism disorders (serum calcium, phosphate, and parathyroid hormone), and the number of falls during the last year before the study. RESULTS Over 2 years, low-energy 30 major bone fractures were diagnosed and 13 of hip fractures among them. Area under the curve for FRAX® was 0.76 (95% CI 0.69-0.84) for major fractures and 0.70 (95% CI 0.563-0.832) for hip fractures. The AUC for major bone fractures was significantly higher than for all elements of the FRAX® calculator. In logistic regression analysis FRAX® was the strongest independent risk factor of assessment of the major bone fracture risk. CONCLUSIONS FRAX® enables a better assessment of major bone fracture risk in ESRD patients undergoing hemodialysis than any of its components and other risk factors considered in the analysis.
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Affiliation(s)
- J Przedlacki
- Department of Nephrology, Dialysis and Internal Diseases, Medical University of Warsaw, Warsaw, Poland.
| | | | | | - E Niemczyk
- Department of Internal Diseases, John Paul II Western Hospital, Grodzisk Mazowiecki, Poland
- Fresenius Dialysis Center, Płońsk, Poland
| | - E Wojtaszek
- Department of Nephrology, Dialysis and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - E Gieglis
- Fresenius Dialysis Center, Otwock, Poland
| | - P Żebrowski
- Department of Nephrology, Dialysis and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - A Podgórzak
- Department of Nephrology, Mazovia Regional Hospital, Siedlce, Poland
| | - J Wściślak
- Department of Nephrology, Mazovia Regional Hospital, Siedlce, Poland
| | - M Wieliczko
- Department of Nephrology, Dialysis and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - J Matuszkiewicz-Rowińska
- Department of Nephrology, Dialysis and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
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31
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Kim SM, Liu S, Long J, Montez-Rath ME, Leonard MB, Chertow GM. Declining Rates of Hip Fracture in End-Stage Renal Disease: Analysis From the 2003-2011 Nationwide Inpatient Sample. J Bone Miner Res 2017; 32. [PMID: 28639740 PMCID: PMC5685922 DOI: 10.1002/jbmr.3201] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The incidence of hip fracture in patients with end-stage renal disease (ESRD) is considerably higher than that in the general age- and sex-matched population. Although medical therapy for chronic kidney disease mineral bone disorder (CKD-MBD) has changed considerably over the last decade, rates of hip fracture in the entire ESRD population have not been well-characterized. Herein, we evaluated temporal trends in rates of hip fracture, in-hospital mortality, and costs of associated hospital stay in ESRD. We identified hospitalizations for hip fracture from 2003 to 2011 using the Nationwide Inpatient Sample, a representative national database inclusive of all ages and payers. We incorporated data from the United States Renal Data System and the US Census to calculate population-specific rates. Between 2003 and 2011, we identified 47,510 hip fractures in the ESRD population. The overall rate of hip fracture was 10.04/1000 person-years. The rate was 3.73/1000 person-years in patients aged less than 65 years, and 20.97/1000 person-years in patients aged 65 or older. Age- and sex-standardized rates decreased by 12.6% from 2003 (10.23/1000 person-years; 95% confidence interval [CI], 7.99/1000 to 12.47/1000) to 2011 (8.94/1000 person-years; 95% CI, 7.12/1000 to 10.75/1000). Hip fracture rates over time were virtually identical in patients aged less than 65 years; however, rates decreased by 15.3% among patients aged 65 years or older; rates declined more rapidly in older women compared with older men (p for interaction = 0.047). In-hospital mortality rate after hip fracture operation declined by 26.7% from 2003 (8.6%; 95% CI, 6.8 to 10.4) to 2011 (6.3%; 95% CI, 4.9 to 7.7). In ESRD, age- and sex-standardized hip fracture rates and associated in-hospital mortality have declined substantially over the last decade. © 2017 American Society for Bone and Mineral Research.
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Affiliation(s)
- Sun Moon Kim
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Sai Liu
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Jin Long
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Maria E Montez-Rath
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Mary B Leonard
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Glenn M Chertow
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
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32
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Abstract
PURPOSE OF REVIEW In this paper, we review the epidemiology, diagnosis, and pathogenesis of fractures and renal osteodystrophy. RECENT FINDINGS The role of bone quality in the pathogenesis of fracture susceptibility in chronic kidney disease (CKD) is beginning to be elucidated. Bone quality refers to bone material properties, such as cortical and trabecular microarchitecture, mineralization, turnover, microdamage, and collagen content and structure. Recent data has added to our understanding of the effects of CKD on alterations to bone quality, emerging data on the role of abnormal collagen structure on bone strength, the potential of non-invasive methods to inform our knowledge of bone quality, and how we can use these methods to inform strategies that protect against bone loss and fractures. However, more prospective data is required. CKD is associated with abnormal bone quality and strength which results in high fracture incidence.
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Affiliation(s)
- Erin M B McNerny
- Indiana University School of Medicine, Indianapolis, IN, USA
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, 622 West 168th Street, PH4-124, New York, NY, 10032, USA
| | - Thomas L Nickolas
- Indiana University School of Medicine, Indianapolis, IN, USA.
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, 622 West 168th Street, PH4-124, New York, NY, 10032, USA.
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33
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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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Atteritano M, Di Mauro E, Canale V, Bruzzese AM, Ricciardi CA, Cernaro V, Lacquaniti A, Buemi M, Santoro D. Higher serum sclerostin levels and insufficiency of vitamin D are strongly associated with vertebral fractures in hemodialysis patients: a case control study. Osteoporos Int 2017; 28:577-584. [PMID: 27682249 DOI: 10.1007/s00198-016-3770-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 09/08/2016] [Indexed: 10/20/2022]
Abstract
UNLABELLED In hemodialysis patients, vertebral fractures were associated with elevated sclerostin levels, suggesting that sclerostin could reflect bone fragility in these patients. INTRODUCTION Fragility fractures are common in hemodialysis patients. The aims of our study were to determine the prevalence of vertebral fracture and analyze associations between sclerostin serum levels and vertebral fractures in hemodialysis patients. METHODS Ninety-two hemodialysis patients and 100 controls matched for age and sex were studied. Bone mineral density was measured by ultrasonography at non-dominant heel. The markers of bone turnover included serum osteocalcin, C-terminal telopeptide, and sclerostin. All participants underwent radiography of the thoracic and lumbar spine to ascertain the presence of vertebral fractures. RESULTS Bone ultrasound parameters at calcaneus were significantly lower in hemodialysis patients compared with controls; bone turnover markers and parathyroid hormone level were significantly higher, while serum of 25-OH-D3 was significantly lower in hemodialysis group. One or more moderate or severe vertebral fractures were found in 38 hemodialysis patients, whereas in control group, 10 patients had a vertebral fracture. In hemodialysis group, the comparison between patients with and without vertebral fractures showed that the patients with vertebral fractures had the serum sclerostin levels statistically higher than patients without vertebral, while serum levels of 25-OH-D3 was significantly lower in patients with vertebral fractures compared to the patients without vertebral fractures. Multivariate analysis disclosed that sclerostin levels were associated with an increased risk of vertebral fractures in hemodialysis patients after adjusting for multiple variables. CONCLUSIONS Our data shows high prevalence of vertebral fractures in hemodialysis patients and that it is associated with elevated sclerostin levels, reflecting bone fragility in these patients.
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Affiliation(s)
- M Atteritano
- Department of Clinical and Experimental Medicine, University of Messina, Pad. B, 2nd floor, A.O.U. Policlinico "G. Martino" Via C. Valeria, 98125, Messina, Italy.
| | - E Di Mauro
- Department of Clinical and Experimental Medicine, University of Messina, Pad. B, 2nd floor, A.O.U. Policlinico "G. Martino" Via C. Valeria, 98125, Messina, Italy
| | - V Canale
- Department of Clinical and Experimental Medicine, University of Messina, Pad. B, 2nd floor, A.O.U. Policlinico "G. Martino" Via C. Valeria, 98125, Messina, Italy
| | - A M Bruzzese
- Department of Clinical and Experimental Medicine, University of Messina, Pad. B, 2nd floor, A.O.U. Policlinico "G. Martino" Via C. Valeria, 98125, Messina, Italy
| | - C A Ricciardi
- Department of Clinical and Experimental Medicine, University of Messina, Pad. B, 2nd floor, A.O.U. Policlinico "G. Martino" Via C. Valeria, 98125, Messina, Italy
| | - V Cernaro
- Department of Clinical and Experimental Medicine, University of Messina, Pad. B, 2nd floor, A.O.U. Policlinico "G. Martino" Via C. Valeria, 98125, Messina, Italy
| | - A Lacquaniti
- Department of Clinical and Experimental Medicine, University of Messina, Pad. B, 2nd floor, A.O.U. Policlinico "G. Martino" Via C. Valeria, 98125, Messina, Italy
| | - M Buemi
- Department of Clinical and Experimental Medicine, University of Messina, Pad. B, 2nd floor, A.O.U. Policlinico "G. Martino" Via C. Valeria, 98125, Messina, Italy
| | - D Santoro
- Department of Clinical and Experimental Medicine, University of Messina, Pad. B, 2nd floor, A.O.U. Policlinico "G. Martino" Via C. Valeria, 98125, Messina, Italy
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Drüeke TB, Massy ZA. Changing bone patterns with progression of chronic kidney disease. Kidney Int 2017; 89:289-302. [PMID: 26806832 DOI: 10.1016/j.kint.2015.12.004] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 09/04/2015] [Accepted: 09/16/2015] [Indexed: 01/01/2023]
Abstract
It is commonly held that osteitis fibrosa and mixed uremic osteodystrophy are the predominant forms of renal osteodystrophy in patients with chronic kidney disease. Osteitis fibrosa is a high-turnover bone disease resulting mainly from secondary hyperparathyroidism, and mixed uremic osteodystrophy is in addition characterized by a mineralization defect most often attributed to vitamin D deficiency. However, there is ancient and more recent evidence that in early chronic kidney disease stages adynamic bone disease characterized by low bone turnover occurs first, at least in a significant proportion of patients. This could be due to the initial predominance of bone turnover-inhibitory conditions such as resistance to the action of parathyroid hormone (PTH), reduced calcitriol levels, sex hormone deficiency, diabetes, and, last but not least, uremic toxins leading to repression of osteocyte Wnt/β-catenin signaling and increased expression of Wnt antagonists such as sclerostin, Dickkopf-1, and sFRP4. The development of high-turnover bone disease would occur only later on, when serum PTH levels are able to overcome peripheral PTH resistance and the other inhibitory factors of bone formation. Whether FGF23 and Klotho play a direct role in the transition from low- to high-turnover bone disease or participate only indirectly via regulating PTH secretion remains to be seen.
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Affiliation(s)
- Tilman B Drüeke
- Institut National de la Santé et de la Recherche Médicale (Inserm) Unité 1018, Centre de recherche en épidémiologie et santé des populations, Equipe 5, Villejuif; Paris-Sud University and University of Paris-Ouest, Versailles-Saint-Quentin-en-Yvelines; Paris, France.
| | - Ziad A Massy
- Institut National de la Santé et de la Recherche Médicale (Inserm) Unité 1018, Centre de recherche en épidémiologie et santé des populations, Equipe 5, Villejuif; Paris-Sud University and University of Paris-Ouest, Versailles-Saint-Quentin-en-Yvelines; Paris, France; Division of Nephrology, Ambroise Paré Hospital, Assistance Publique Hôpitaux de Paris, Boulogne-Billancourt/Paris; University of Paris-Ouest, Versailles-Saint-Quentin-en-Yvelines; Paris, France
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Affiliation(s)
- Sharon M. Moe
- Department of Medicine, Division of Nephrology, Indiana University School of Medicine, Indianapolis, Indiana
- Roudebush Veterans Administration Medical Center, Indianapolis, Indiana; and
| | - Thomas L. Nickolas
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York
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Wetmore JB, Liu J, Wirtz HS, Gilbertson DT, Cooper K, Nieman KM, Collins AJ, Bradbury BD. Geovariation in Fracture Risk among Patients Receiving Hemodialysis. Clin J Am Soc Nephrol 2016; 11:1413-1421. [PMID: 27269611 PMCID: PMC4974888 DOI: 10.2215/cjn.11651115] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 04/04/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Fractures are a major source of morbidity and mortality in patients receiving dialysis. We sought to determine whether rates of fractures and tendon ruptures vary geographically. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Data from the US Renal Data System were used to create four yearly cohorts, 2007-2010, including all eligible prevalent patients on hemodialysis in the United States on January 1 of each year. A secondary analysis comprising patients in a large dialysis organization conducted over the same period permitted inclusion of patient-level markers of mineral metabolism. Patients were grouped into 10 regions designated by the Centers for Medicare and Medicaid Services and divided by latitude into one of three bands: south, <35°; middle, 35° to <40°; and north, ≥40°. Poisson regression was used to calculate unadjusted and adjusted region-level rate ratios for events. RESULTS Overall, 327,615 patients on hemodialysis were included. Mean (SD) age was 61.8 (15.0) years old, 52.7% were white, and 55.0% were men. During 716,962 person-years of follow-up, 44,014 fractures and tendon ruptures occurred, the latter being only 0.3% of overall events. Event rates ranged from 5.36 to 7.83 per 100 person-years, a 1.5-fold rate difference across regions. Unadjusted region-level rate ratios varied from 0.83 (95% confidence interval, 0.81 to 0.85) to 1.20 (95% confidence interval, 1.18 to 1.23), a 1.45-fold rate difference. After adjustment for a wide range of case mix variables, a 1.33-fold variation in rates remained. Rates were higher in north and middle bands than the south (north rate ratio, 1.18; 95% confidence interval, 1.13 to 1.23; middle rate ratio, 1.13; 95% confidence interval, 1.10 to 1.17). Latitude explained 11% of variation, independent of region. A complementary analysis of 87,013 patients from a large dialysis organization further adjusted for circulating mineral metabolic parameters and protein energy wasting yielded similar results. CONCLUSIONS Rates of fractures vary geographically in the United States dialysis population, even after adjustment for known patient characteristics. Latitude seems to contribute to this phenomenon, but additional analyses exploring whether other factors might influence variation are warranted.
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Affiliation(s)
- James B. Wetmore
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Jiannong Liu
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | | | - David T. Gilbertson
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Kerry Cooper
- Global Medical Organization, Amgen, Inc., Thousand Oaks, California; and
| | - Kimberly M. Nieman
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Allan J. Collins
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
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Fishbane S, Hazzan AD, Jhaveri KD, Ma L, Lacson E. Bone Parameters and Risk of Hip and Femur Fractures in Patients on Hemodialysis. Clin J Am Soc Nephrol 2016; 11:1063-1072. [PMID: 27026521 PMCID: PMC4891749 DOI: 10.2215/cjn.09280915] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 02/23/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Patients on hemodialysis have a high rate of hip fractures. In this study, we performed a contemporary analysis of mineral and bone parameters and their relationship to hip and femur fracture risk. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Patients on hemodialysis treated between 2000 and 2013 in Fresenius Medical Care North America facilities were included. Predictors were on the basis of data as of December 31 of each baseline year and time-averaged values of selected laboratory parameters and medication doses throughout the year. Four period cohorts were constructed from baseline years: 2000, 2003, 2006, and 2009. Follow-up for each cohort was ≤3 years. RESULTS The incidence of hip and femur fractures remained generally unchanged (P=0.40), except among patients who were white and >65 years of age, in whom the rate decreased significantly over the 14-year period (P<0.01). Results from combined multivariable models indicated that the lowest quartiles of time-averaged intact parathyroid hormone were independently associated with higher hip fracture risk (intact parathyroid hormone =181-272 pg/ml: hazard ratio, 1.20; 95% confidence interval [95% CI], 1.03 to 1.41 and intact parathyroid hormone <181 pg/ml: hazard ratio, 1.20; 95% CI, 1.01 to 1.44; referent third quartile, 273 to <433 pg/ml). The lowest quartile of time-averaged serum calcium was also associated with higher risk (calcium <8.7 mg/dl; hazard ratio, 1.17; 95% CI, 1.00 to 1.37) compared with the referent third quartile of 9.1 to <9.5 mg/dl. CONCLUSIONS We found an association between lower levels of intact parathyroid hormone and serum calcium and greater risk for hip and femur fractures among patients on hemodialysis. These findings support additional research toward elucidating long-term safety of treatment approaches for hyperparathyroidism in patients with ESRD.
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Affiliation(s)
- Steven Fishbane
- Department of Medicine, Division of Nephrology, Hofstra North Shore–Long Island Jewish School of Medicine, Great Neck, New York
| | - Azzour D. Hazzan
- Department of Medicine, Division of Nephrology, Hofstra North Shore–Long Island Jewish School of Medicine, Great Neck, New York
| | - Kenar D. Jhaveri
- Department of Medicine, Division of Nephrology, Hofstra North Shore–Long Island Jewish School of Medicine, Great Neck, New York
| | - Lin Ma
- Fresenius Medical Care North America, Waltham, Massachusetts; and
| | - Eduardo Lacson
- Division of Nephrology, Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts
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Sharma AK, Masterson R, Holt SG, Toussaint ND. Emerging role of high-resolution imaging in the detection of renal osteodystrophy. Nephrology (Carlton) 2016; 21:801-11. [PMID: 27042945 DOI: 10.1111/nep.12790] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 03/14/2016] [Accepted: 03/25/2016] [Indexed: 12/17/2022]
Abstract
The term renal osteodystrophy refers to changes in bone morphology induced by chronic kidney disease (CKD) and represents the skeletal component of the entity 'chronic kidney disease - mineral and bone disorder'. Changes in turnover, mineralization, mass and microarchitecture impair bone quality, compromising strength and increasing susceptibility to fractures. Fractures are more common in CKD compared with the general population and result in increased morbidity and mortality. Screening for fracture risk and management of renal osteodystrophy are hindered by the complex, and still only partially understood, pathophysiology and the inadequacy of currently available diagnostic methods. Bone densitometry and bone turnover markers, although potentially helpful, have significant limitations in patients with CKD, and the 'gold standard' test of bone biopsy is infrequently performed in routine clinical practice. However, recent advances in high-resolution bone microarchitecture imaging may offer greater potential for quantification and assessment of bone structure and strength and, when used in conjunction with serum biomarkers, may allow non-invasive testing for a diagnostic virtual bone biopsy.
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Affiliation(s)
- Ashish K Sharma
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Victoria, Australia
| | - Rosemary Masterson
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Victoria, Australia
| | - Stephen G Holt
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Victoria, Australia
| | - Nigel D Toussaint
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Victoria, Australia. .,Department of Medicine (RMH), The University of Melbourne, Melbourne, Victoria, Australia.
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Fractures in chronic kidney disease: pursuing the best screening and management. Curr Opin Nephrol Hypertens 2016; 24:317-23. [PMID: 26050117 DOI: 10.1097/mnh.0000000000000131] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Osteoporotic fractures are common and cause increased sickness and death. Men and women with chronic kidney disease (CKD) are at particularly high risk of osteoporotic fractures. Currently, however, there are no guidelines concerning noninvasive methods to assess fracture risk in CKD. Further, approved treatments to prevent fractures in otherwise healthy men and women are only recommended for use with caution in those with CKD. This review focuses on the recent data that support the use of noninvasive methods to assess fracture risk in CKD and highlights new therapies that could be used in fracture prevention in CKD. RECENT FINDINGS Data from prospective studies demonstrate that low bone mineral density predicts fracture in CKD patients. Post-hoc analyses demonstrate that agents approved for the treatment of postmenopausal osteoporosis (bisphosphonates, denosumab and teriparatide) when given to those with CKD are well tolerated and potentially efficacious with respect to fracture risk reduction. SUMMARY To date, patients, and nephrologists taking care of them, have largely ignored fracture risk assessment and treatment in CKD. This should change given recent data. Further studies are needed, specifically bone histomorphometric studies, which will increase our understanding of CKD-mineral bone disease (MBD) pathophysiology, and randomized clinical trials of therapy in patients with CKD.
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Babayev R, Nickolas TL. Bone Disorders in Chronic Kidney Disease: An Update in Diagnosis and Management. Semin Dial 2015; 28:645-53. [DOI: 10.1111/sdi.12423] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Revekka Babayev
- Department of Medicine; Division of Nephrology; Columbia University Medical Center; New York City New York
| | - Thomas L. Nickolas
- Department of Medicine; Division of Nephrology; Columbia University Medical Center; New York City New York
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Nüsken E, Imschinetzki D, Nüsken KD, Körber F, Mentzel HJ, Peitz J, Bald M, Büscher R, John U, Klaus G, Konrad M, Pape L, Tönshoff B, Martin D, Weber L, Dötsch J. Automated Greulich-Pyle bone age determination in children with chronic kidney disease. Pediatr Nephrol 2015; 30:1173-9. [PMID: 25787071 DOI: 10.1007/s00467-015-3042-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Revised: 12/11/2014] [Accepted: 01/05/2015] [Indexed: 01/23/2023]
Abstract
BACKGROUND Growth restriction and retarded bone age are common findings in children with chronic kidney disease (CKD). We compared the automated BoneXpert™ method with the manual assessment of an X-ray of the non-dominant hand. METHODS In this retrospective multicenter study, 359 patients with CKD stages 2-5, aged 2-14.5 (girls) or 2.5-17 years (boys) were included. Bone age was determined manually by three experts (according to Greulich and Pyle). Automated determination of bone age was performed using the image analysis software BoneXpert™. RESULTS There was a strong correlation between the automatic and the manual method (r = 0.983, p < 0.001). The automatic method tended to generate higher bone age values (0.64 ± 0.73 years) in the younger patients (4-5 years) and to underestimate retardation or acceleration of bone age. The so-called "bone health index" (BHI) was reduced in comparison to the reference population. Bone health index standard deviation score (BHI-SDS) was not related to the stage of CKD, but weakly negatively correlated with plasma PTH concentrations (r = 0.12, p = 0.019). CONCLUSIONS BoneXpert™ allows an objective, time-saving, and in general valid bone age assessment in children with CKD. Possible underestimation of retarded or accelerated bone age should be taken into account. Validation of the BHI needs further study.
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Affiliation(s)
- Eva Nüsken
- Department of Pediatrics and Adolescent Medicine, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
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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: 23] [Impact Index Per Article: 2.6] [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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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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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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Abstract
End-stage renal disease is a prevalent condition that substantially impacts a patient's quality of life. As medical advancements improve function and rates of survival, the number of persons with end-stage renal disease will grow, with orthopaedic surgeons increasingly encountering patients with the disease in their practice. End-stage renal disease is a complex medical condition that is often associated with multiple medical comorbidities. Orthopaedic surgery in patients with this disease is associated with at least a twofold risk of complications and mortality compared with a population without end-stage renal disease. Patients are at an increased risk for cardiovascular, metabolic, hematologic, and infectious complications. Orthopaedic surgeons should be familiar with pertinent issues in the preoperative evaluation and the postoperative management of these patients and should understand the risks of surgery to better inform patients and family. Careful coordination with consulting specialists is necessary to minimize morbidity and improve outcome.
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Mathew AT, Hazzan A, Jhaveri KD, Block GA, Chidella S, Rosen L, Wagner J, Fishbane S. Increasing hip fractures in patients receiving hemodialysis and peritoneal dialysis. Am J Nephrol 2014; 40:451-7. [PMID: 25427771 DOI: 10.1159/000369039] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 10/08/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND/AIMS Dialysis patients are at increased risk for hip fractures. Because changes in treatment of metabolic bone disease in this population may have impacted bone fragility, this study aims to analyze the longitudinal risk for fractures in hemodialysis (HD) and peritoneal dialysis (PD) patients. METHODS Using the United States Renal Data System database from 1992 to 2009, the temporal trend in hip fractures requiring hospitalization was analyzed using an overdispersed Poisson regression model. Generalized Estimating Equations were used to assess the adjusted effect of dialysis modality on hip fractures. RESULTS 842,028 HD and 87,086 PD patients were included. There was a significant temporal increase in hip fractures in both HD and PD with stabilization of rates after 2005. With stratification, the increase in fractures occurred in patients who were white and over 65 years of age. In adjusted analyses, HD patients had 1.6 times greater odds of hip fracture than PD patients (OR 1.60 95% CI 1.52, 1.68, p < 0.001). CONCLUSIONS In contrast to the declining hip fracture rates in the general population, we identified a temporal rise in incidence of hip fractures in HD and PD patients. HD patients were at a higher risk for hip fractures than PD patients after adjustment for recognized bone fragility risk factors. The increase in fracture rate over time was limited to older white patients in both HD and PD, the demographics being consistent with osteoporosis risk. Further research is indicated to better understand the longitudinal trend in hip fractures and the discordance between HD and PD.
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Affiliation(s)
- Anna T Mathew
- Hofstra NSLIJ School of Medicine, North Shore University Hospital and Long Island Jewish Medical Center, Great Neck, N.Y., USA
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El Husseini N, Kaskar O, Goldstein LB. Chronic kidney disease and stroke. Adv Chronic Kidney Dis 2014; 21:500-8. [PMID: 25443575 DOI: 10.1053/j.ackd.2014.09.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 09/05/2014] [Accepted: 09/05/2014] [Indexed: 12/19/2022]
Abstract
Chronic kidney disease (CKD) is associated with an increased risk of both ischemic and hemorrhagic stroke. In addition to shared risk factors, this higher cerebrovascular risk is mediated by several CKD-associated mechanisms including platelet dysfunction, coagulation disorders, endothelial dysfunction, inflammation, and increased risk of atrial fibrillation. CKD can also modify the effect of treatments used in acute stroke and in secondary stroke prevention. We review the epidemiology and pathophysiology that link CKD and stroke and the impact of CKD on stroke outcomes. Interdisciplinary collaboration between nephrologists, pharmacists, hematologists, nutrition therapists, primary care physicians, and neurologists in providing care to these subjects may potentially improve outcomes.
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Sherman RA. Briefly Noted. Semin Dial 2014. [DOI: 10.1111/sdi.12296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Sherman RA. Briefly Noted. Semin Dial 2014. [DOI: 10.1111/sdi.12250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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