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Kuang C, Shang J, Ma M, Huang S, Yan B, Zhong Y, Guan B, Gong J, Liu F, Chen L. Risk factors and clinical prediction models for osteoporosis in pre-dialysis chronic kidney disease patients. Ren Fail 2024; 46:2361802. [PMID: 38874080 PMCID: PMC11182074 DOI: 10.1080/0886022x.2024.2361802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 05/24/2024] [Indexed: 06/15/2024] Open
Abstract
BACKGROUND Osteoporosis in pre-dialysis chronic kidney disease (CKD) patients has been overlooked, and the risk factors of osteoporosis in these patients have not been adequately studied. OBJECTIVE To identify risk factors for osteoporosis in pre-dialysis CKD patients and develop predictive models to estimate the likelihood of osteoporosis. METHODS Dual-energy X-ray absorptiometry was used to measure bone mineral density, and clinical examination results were collected from 326 pre-dialysis CKD patients. Binary logistic regression was employed to explore the risk factors associated with osteoporosis and develop predictive models. RESULTS In this cohort, 53.4% (n = 174) were male, 46.6% (n = 152) were female, and 21.8% (n = 71) were diagnosed with osteoporosis. Among those diagnosed with osteoporosis, 67.6% (n = 48) were female and 32.4% (n = 23) were male. Older age and low 25-(OH)-Vitamin D levels were identified as risk factors for osteoporosis in males. For females, older age, being underweight, higher bone alkaline phosphatase (NBAP), and advanced CKD (G5) were significant risk factors, while higher iPTH was protective. Older age, being underweight, and higher NBAP were risk factors for osteoporosis in the G1-4 subgroup. In the G5 subgroup, older age and higher NBAP increased the risk, while high 25-(OH)-Vitamin D or iPTH had protective effects. Nomogram models were developed to assess osteoporosis risk in pre-dialysis patients based on gender and renal function stage. CONCLUSION Risk factors for osteoporosis vary by gender and renal function stages. The nomogram clinical prediction models we constructed may aid in the rapid screening of patients at high risk of osteoporosis.
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Affiliation(s)
- Chaoying Kuang
- Nephrology Department, The First Affiliated Hospital of Jinan University, Jinan University, Guangzhou, Guangdong, China
| | - Jingjie Shang
- Nuclear Medicine, The First Affiliated Hospital of Jinan University, Jinan University, Guangzhou, Guangdong, China
| | - Mingming Ma
- Nephrology Department, The First Affiliated Hospital of Jinan University, Jinan University, Guangzhou, Guangdong, China
| | - Shengling Huang
- Nephrology Department, The First Affiliated Hospital of Jinan University, Jinan University, Guangzhou, Guangdong, China
| | - Bing Yan
- Nephrology Department, The First Affiliated Hospital of Jinan University, Jinan University, Guangzhou, Guangdong, China
| | - Yuzhen Zhong
- Nephrology Department, The First Affiliated Hospital of Jinan University, Jinan University, Guangzhou, Guangdong, China
| | - Baozhang Guan
- Nephrology Department, The First Affiliated Hospital of Jinan University, Jinan University, Guangzhou, Guangdong, China
| | - Jian Gong
- Nuclear Medicine, The First Affiliated Hospital of Jinan University, Jinan University, Guangzhou, Guangdong, China
| | - Fanna Liu
- Nephrology Department, The First Affiliated Hospital of Jinan University, Jinan University, Guangzhou, Guangdong, China
| | - Liangmei Chen
- Nephrology Department, The First Affiliated Hospital of Jinan University, Jinan University, Guangzhou, Guangdong, China
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Chesnaye NC, Ortiz A, Zoccali C, Stel VS, Jager KJ. The impact of population ageing on the burden of chronic kidney disease. Nat Rev Nephrol 2024; 20:569-585. [PMID: 39025992 DOI: 10.1038/s41581-024-00863-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2024] [Indexed: 07/20/2024]
Abstract
The burden of chronic kidney disease (CKD) and its risk factors are projected to rise in parallel with the rapidly ageing global population. By 2050, the prevalence of CKD category G3-G5 may exceed 10% in some regions, resulting in substantial health and economic burdens that will disproportionately affect lower-income countries. The extent to which the CKD epidemic can be mitigated depends largely on the uptake of prevention efforts to address modifiable risk factors, the implementation of cost-effective screening programmes for early detection of CKD in high-risk individuals and widespread access and affordability of new-generation kidney-protective drugs to prevent the development and delay the progression of CKD. Older patients require a multidisciplinary integrated approach to manage their multimorbidity, polypharmacy, high rates of adverse outcomes, mental health, fatigue and other age-related symptoms. In those who progress to kidney failure, comprehensive conservative management should be offered as a viable option during the shared decision-making process to collaboratively determine a treatment approach that respects the values and wishes of the patient. Interventions that maintain or improve quality of life, including pain management and palliative care services when appropriate, should also be made available.
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Affiliation(s)
- Nicholas C Chesnaye
- ERA Registry, Amsterdam UMC location University of Amsterdam, Medical Informatics, Amsterdam, Netherlands
- Amsterdam Public Health Research Institute, Quality of Care, Amsterdam, the Netherlands
| | - Alberto Ortiz
- Department of Nephrology and Hypertension, IIS-Fundacion Jimenez Diaz UAM, Madrid, Spain
- RICORS2040, Madrid, Spain
| | - Carmine Zoccali
- Associazione Ipertensione Nefrologia Trapianto Renale (IPNET), c/o Nefrologia, Grande Ospedale Metropolitano, Reggio Calabria, Italy
- Institute of Molecular Biology and Genetics (Biogem), Ariano Irpino, Italy
- Renal Research Institute, New York, NY, USA
| | - Vianda S Stel
- ERA Registry, Amsterdam UMC location University of Amsterdam, Medical Informatics, Amsterdam, Netherlands
- Amsterdam Public Health Research Institute, Quality of Care, Amsterdam, the Netherlands
| | - Kitty J Jager
- ERA Registry, Amsterdam UMC location University of Amsterdam, Medical Informatics, Amsterdam, Netherlands.
- Amsterdam Public Health Research Institute, Quality of Care, Amsterdam, the Netherlands.
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3
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Gifre L, Massó E, Fusaro M, Haarhaus M, Ureña P, Cozzolino M, Mazzaferro S, Calabia J, Peris P, Bover J. Vertebral fractures in patients with CKD and the general population: a call for diagnosis and action. Clin Kidney J 2024; 17:sfae191. [PMID: 39099567 PMCID: PMC11294886 DOI: 10.1093/ckj/sfae191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Indexed: 08/06/2024] Open
Abstract
Vertebral fractures (VFs) are the most common osteoporotic fractures in the general population, and they have been associated with high mortality, decreased quality of life, and high risk of subsequent fractures, especially when recent, multiple, or severe. Currently, VF diagnosis and classification determine fracture risk and the most appropriate anti-osteoporotic treatment. However, VFs are clearly underdiagnosed, especially in patients with chronic kidney disease (CKD), and CKD-associated osteoporosis has been disregarded until recently. VFs are associated with higher morbidity and mortality, and their prevalence and incidence differ depending on the grade of renal dysfunction (CKD G1-G5) and/or the type of renal replacement therapy (dialysis or transplantation). In addition to classical risk factors [such as higher age, female sex, reduced bone mineral density, diabetes and steroid use], various other factors have been associated with an increased risk of VFs in CKD, including CKD grade, haemodialysis vintage, time since renal transplantation, low or high intact parathyroid hormone and phosphate levels, and/or vitamin D and K1 deficiencies. Importantly, several clinical societies have recently modified their algorithms according to the fracture risk classification (including the presence of VFs) and determined the most appropriate anti-osteoporotic treatment for the general population. However, there are no specific guidelines addressing this topic in patients with CKD despite an important paradigm shift regarding the prognostic value of bone mineral density in 2017 after the publication of the CKD-Mineral and Bone Disorder Kidney Disease: Improving Global Outcomes guidelines. A proactive attitude towards diagnosis, treatment, and research is proposed to avoid therapeutic nihilism.
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Affiliation(s)
- Laia Gifre
- Rheumatology Department, Hospital Germans Trias i Pujol, Research Institute Germans Trias i Pujol (IGTP), Universitat Autònoma de Barcelona, Badalona (Barcelona), Catalonia, Spain
| | - Elisabet Massó
- Nephrology Department, University Hospital Germans Trias i Pujol, REMAR-IGTP Group, Research Institute Germans Trias i Pujol (IGTP), Universitat Autònoma de Barcelona, Badalona (Barcelona), Catalonia, Spain
| | - Maria Fusaro
- National Research Council (CNR), Institute of Clinical Physiology, Pisa (Italy). Department of Medicine, University of Padua, Padua, Italy
| | - Mathias Haarhaus
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm, Sweden
- Diaverum AB, Hyllie Boulevard 53, Malmö, Sweden
| | - Pablo Ureña
- Department of Nephrology and Dialysis, AURA Nord Saint-Ouen, Saint-Ouen, Paris, France
- Department of Renal Physiology, Necker Hospital, University of Paris Descartes, Paris, France
| | - Mario Cozzolino
- Renal Division, Department of Health Sciences, University of Milan, Milan, Italy
| | - Sandro Mazzaferro
- Department of Translation and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Jordi Calabia
- Nephrology Department, University Hospital Josep Trueta. IdIBGi Research Institute. Universitat de Girona, Catalonia, Spain
| | - Pilar Peris
- Rheumatology Department, Hospital Clinic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Catalonia, Spain
| | - Jordi Bover
- Nephrology Department, University Hospital Germans Trias i Pujol, REMAR-IGTP Group, Research Institute Germans Trias i Pujol (IGTP), Universitat Autònoma de Barcelona, Badalona (Barcelona), Catalonia, Spain
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4
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Jørgensen HS, Lloret MJ, Lalayiannis AD, Shroff R, Evenepoel P. Ten tips on how to assess bone health in patients with chronic kidney disease. Clin Kidney J 2024; 17:sfae093. [PMID: 38817914 PMCID: PMC11137676 DOI: 10.1093/ckj/sfae093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Indexed: 06/01/2024] Open
Abstract
Patients with chronic kidney disease (CKD) experience a several-fold increased risk of fracture. Despite the high incidence and the associated excess morbidity and premature mortality, bone fragility in CKD, or CKD-associated osteoporosis, remains a blind spot in nephrology with an immense treatment gap. Defining the bone phenotype is a prerequisite for the appropriate therapy of CKD-associated osteoporosis at the patient level. In the present review, we suggest 10 practical 'tips and tricks' for the assessment of bone health in patients with CKD. We describe the clinical, biochemical, and radiological evaluation of bone health, alongside the benefits and limitations of the available diagnostics. A bone biopsy, the gold standard for diagnosing renal bone disease, is invasive and not widely available; although useful in complex cases, we do not consider it an essential component of bone assessment in patients with CKD-associated osteoporosis. Furthermore, we advocate for the deployment of multidisciplinary expert teams at local, national, and potentially international level. Finally, we address the knowledge gaps in the diagnosis, particularly early detection, appropriate "real-time" monitoring of bone health in this highly vulnerable population, and emerging diagnostic tools, currently primarily used in research, that may be on the horizon of clinical practice.
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Affiliation(s)
- Hanne Skou Jørgensen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Nephrology, Aalborg University Hospital, Aalborg, Denmark
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Maria Jesús Lloret
- Department of Nephrology, Hospital Fundació Puigvert, Barcelona, Spain
- Institut de Recerca Sant-Pau (IR-Sant Pau), Barcelona, Spain
| | - Alexander D Lalayiannis
- Department of Pediatric Nephrology, Birmingham Women's and Children's Hospitals, Birmingham, UK
| | - Rukshana Shroff
- Renal Unit, UCL Great Ormond Street Hospital and Institute of Child Health, London, UK
| | - Pieter Evenepoel
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, Katholieke Universiteit Leuven, Leuven, Belgium
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
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5
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Pollock C, Moon JY, Ngoc Ha LP, Gojaseni P, Ching CH, Gomez L, Chan TM, Wu MJ, Yeo SC, Nugroho P, Bhalla AK. Framework of Guidelines for Management of CKD in Asia. Kidney Int Rep 2024; 9:752-790. [PMID: 38765566 PMCID: PMC11101746 DOI: 10.1016/j.ekir.2023.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 11/29/2023] [Accepted: 12/11/2023] [Indexed: 05/22/2024] Open
Affiliation(s)
- Carol Pollock
- Kolling Institute of Medical Research, University of Sydney, St Leonards, New South Wales, Australia
| | - Ju-young Moon
- Kyung Hee University School of Medicine, Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea
| | - Le Pham Ngoc Ha
- University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
| | | | | | - Lynn Gomez
- Asian Hospital and Medical Center, Muntinlupa City, Metro Manila, Philippines
| | - Tak Mao Chan
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Ming-Ju Wu
- Taichung Veterans General Hospital, Taichung City, Taiwan
| | | | | | - Anil Kumar Bhalla
- Department of Nephrology-Sir Ganga Ram Hospital Marg, New Delhi, Delhi, India
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6
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Bover J, Gómez-Alonso C, Casado E, Rodríguez-García M, Lloret MJ, Castro-Alonso C, Gifre L, Henríquez-Palop F, Prior-Español Á, López de la Manzanara V, Láiz AM, Martínez-Ferrer À, Torregrosa JV, Cigarrán S, Górriz JL, Montomoli M, Panizo N, Costa E, Martínez-Laguna D, Rodríguez M, Navarro-González JF. Osteoporosis management in patients with chronic kidney disease (ERCOS Study): A challenge in nephrological care. Nefrologia 2024; 44:241-250. [PMID: 38531765 DOI: 10.1016/j.nefroe.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 05/07/2023] [Indexed: 03/28/2024] Open
Abstract
Fracture risk assessment in patients with chronic kidney disease (CKD) has been included in the CKD-MBD ("Chronic Kidney Disease-Mineral and Bone Disorders") complex in international and national nephrology guidelines, suggesting for the first time the assessment of bone mineral density (BMD) if the results can influence therapeutic decision-making. However, there is very little information on actual clinical practice in this population. The main objective of the ERCOS (ERC-Osteoporosis) study is to describe the profile of patients with CKD G3-5D with osteoporosis (OP) and/or fragility fractures treated in specialized nephrology, rheumatology and internal medicine clinics in Spain. Fifteen centers participated and 162 patients (mostly women [71.2%] postmenopausal [98.3%]) with a median age of 77 years were included. Mean estimated glomerular filtration rate (eGFR) was 36 mL/min/1.73 m2 and 38% of the included patients were on dialysis. We highlight the high frequency of prevalent fragility fractures [37.7%), mainly vertebral (52.5%) and hip (24.6%)], the disproportionate history of patients with glomerular disease compared to purely nephrological series (corticosteroids) and undertreatment for fracture prevention, especially in nephrology consultations. This study is an immediate call to action with the dissemination of the new, more proactive, clinical guidelines, and underlines the need to standardize a coordinated and multidisciplinary care/therapeutic approach to these patients in an efficient way to avoid current discrepancies and therapeutic nihilism.
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Affiliation(s)
- Jordi Bover
- Servicio de Nefrología, Hospital Universitari Germans Trias i Pujol, REMAR-IGTP Group, Can Ruti Campus, Badalona, Barcelona, Spain.
| | - Carlos Gómez-Alonso
- Unidad de Gestión Clínica de Metabolismo Óseo y Mineral, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Enrique Casado
- Servicio de Reumatología, Hospital Universitari Parc Taulí, Sabadell, Barcelona, Spain
| | - Minerva Rodríguez-García
- Unidad de Gestión Clínica de Nefrología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - María Jesús Lloret
- Servicio de Nefrología, Fundació Puigvert, Institut d'Investigació Biomèdica Sant Pau (IIB-SANT PAU), Barcelona, Spain
| | - Cristina Castro-Alonso
- Servicio de Nefrología, Hospital Universitario Doctor Peset, Fundació per al Foment de la Investigació Sanitària i Biomèdica de la Comunitat Valenciana (FISABIO), Valencia, Spain
| | - Laia Gifre
- Servicio de Reumatología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | | | - Águeda Prior-Español
- Servicio de Reumatología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | | | - Ana María Láiz
- Servicio de Reumatología, Hospital Universitari de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | | | | | - José Luis Górriz
- Servicio de Nefrología, Hospital Clínico Universitario de Valencia, Universidad de Valencia, Valencia, Spain
| | - Marco Montomoli
- Servicio de Nefrología, Hospital Clínico Universitario de Valencia, Universidad de Valencia, Valencia, Spain
| | - Nayara Panizo
- Servicio de Nefrología, Hospital Clínico Universitario de Valencia, Universidad de Valencia, Valencia, Spain
| | - Ester Costa
- Servicio de Reumatología, Hospital Universitari Parc Taulí, Sabadell, Barcelona, Spain
| | | | - Mariano Rodríguez
- Servicio de Nefrología, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Juan F Navarro-González
- Unidad de Investigación y Servicio de Nefrología, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Islas Canarias, Spain
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7
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Teh JW, Mac Gearailt C, Lappin DWP. Post-Transplant Bone Disease in Kidney Transplant Recipients: Diagnosis and Management. Int J Mol Sci 2024; 25:1859. [PMID: 38339137 PMCID: PMC10856017 DOI: 10.3390/ijms25031859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 01/24/2024] [Accepted: 02/01/2024] [Indexed: 02/12/2024] Open
Abstract
Kidney transplantation is the preferred gold standard modality of treatment for kidney failure. Bone disease after kidney transplantation is highly prevalent in patients living with a kidney transplant and is associated with high rates of hip fractures. Fractures are associated with increased healthcare costs, morbidity and mortality. Post-transplant bone disease (PTBD) includes renal osteodystrophy, osteoporosis, osteonecrosis and bone fractures. PTBD is complex as it encompasses pre-existing chronic kidney disease-mineral bone disease and compounding factors after transplantation, including the use of immunosuppression and the development of de novo bone disease. After transplantation, the persistence of secondary and tertiary hyperparathyroidism, renal osteodystrophy, relative vitamin D deficiency and high levels of fibroblast growth factor-23 contribute to post-transplant bone disease. Risk assessment includes identifying both general risk factors and kidney-specific risk factors. Diagnosis is complex as the gold standard bone biopsy with double-tetracycline labelling to diagnose the PTBD subtype is not always readily available. Therefore, alternative diagnostic tools may be used to aid its diagnosis. Both non-pharmacological and pharmacological therapy can be employed to treat PTBD. In this review, we will discuss pathophysiology, risk assessment, diagnosis and management strategies to manage PTBD after kidney transplantation.
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Affiliation(s)
- Jia Wei Teh
- Department of Nephrology, Galway University Hospital, H91 YR71 Galway, Ireland
| | - Conall Mac Gearailt
- Department of Rheumatology, Galway University Hospital, H91 YR71 Galway, Ireland
| | - David W. P. Lappin
- Department of Nephrology, Galway University Hospital, H91 YR71 Galway, Ireland
- School of Medicine, University of Galway, H91 TK33 Galway, Ireland
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8
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Masrouri S, Esmaeili F, Tohidi M, Azizi F, Hadaegh F. Rapid decline of kidney function increases fracture risk in the general population: Insights from TLGS. Bone 2024; 179:116974. [PMID: 37981179 DOI: 10.1016/j.bone.2023.116974] [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: 09/05/2023] [Revised: 11/06/2023] [Accepted: 11/16/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Although the association between Chronic Kidney Disease (CKD) and all-cause fractures was addressed in previous studies, the association between estimated glomerular filtration rate (eGFR) decline and fractures was poorly addressed. For the first time we examined the association between rapid kidney function decline (RKFD) and fracture incidence among Iranian general population. METHODS In a Tehranian community-based cohort, RKFD was defined as a 30 % decline in eGFR over 2-3 years. Cox proportional hazards models, adjusted for age, sex, current eGFR, diabetes mellitus, hypertension, dyslipidemia, current smoking, obesity status, waist circumference, prevalent cardiovascular diseases, aspirin, steroid use, education level, and marital status, were used to examine the association of RKFD with different fracture outcomes. RESULTS Among 5305 (3031 women) individuals aged ≥30 years, during the median follow-up of 9.62 years, 226 fracture events were observed. The multivariable hazard ratio of RKFD for any-fracture events, lower-extremity, and major osteoporotic fractures were 2.18 (95 % CI, 1.24-3.85), 2.32 (1.15-4.71), and 2.91 (1.29-6.58), respectively. These associations remained significant after accounting for the competing risk of death. The impact of RKFD on the development of incident all-cause fractures was not modified by gender [men: 2.64 (1.11-6.25) vs. women: 2.11 (1.00-4.47)] and according to current CKD status [without CKD: 2.34 (1.00-5.52) vs. with CKD: 2.59 (1.04-6.44)] (all P for interaction >0.5). CONCLUSIONS RKFD can increase the incidence of fractures among general population, the issue that was equally important among non-CKD individuals, emphasizing the need for early identification and management in those with rapidly declining eGFR.
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Affiliation(s)
- Soroush Masrouri
- Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farzad Esmaeili
- Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maryam Tohidi
- Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Fereidoun Azizi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farzad Hadaegh
- Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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9
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Kanagalingam T, Khan T, Sultan N, Cowan A, Thain J, Hoy C, Ledger S, Clemens KK. Reducing the risk of denosumab-induced hypocalcemia in patients with advanced chronic kidney disease: a quality improvement initiative. Arch Osteoporos 2023; 18:138. [PMID: 37985504 DOI: 10.1007/s11657-023-01341-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 10/23/2023] [Indexed: 11/22/2023]
Abstract
Denosumab can improve bone health in advanced kidney disease (CKD) but is associated with hypocalcemia. We created a clinical care pathway focused on the safe provision of denosumab in advanced CKD that reduced the risk of hypocalcemia by 37% at our hospital. Similar pathways could be adopted and tested in other centers. PURPOSE There is an increased risk of hypocalcemia with denosumab in advanced chronic kidney disease (CKD). We aimed to reduce the proportion of patients with advanced CKD who experienced denosumab-induced hypocalcemia at our center. METHODS We conducted a quality improvement (QI) project of patients with CKD stage 3b or less (i.e., estimated glomerular filtration rate <45 mL/min/1.73m2 including dialysis) who were part of the Osteoporosis and Bone Disease Program at St. Joseph's Health Care London (Canada) between December 2020 and January 2023. Our intervention was a clinical care pathway which optimized CKD mineral and bone disorder (CKD-MBD) and 25-hydroxyvitamin levels; provided calcium and vitamin D prophylaxis; promoted multidisciplinary communication between bone and kidney specialists; and carefully monitored calcium post-denosumab injection. Our primary outcome measure was the proportion of patients with hypocalcemia (defined by albumin-corrected serum calcium <1.9mmol/L) at 60 days. Process measures included the appropriate provision of calcium and vitamin D prophylaxis. Balance measures included the development of hypercalcemia and hyperphosphatemia following prophylaxis. We used plan-do-see-act cycles to study four tests of change and presented results using descriptive statistics and run charts. RESULTS There were 6 patients with advanced CKD treated with denosumab prior to the implementation of our care pathway (March 2015-October 2020; 83% receiving dialysis). At the time of their denosumab injection, 83% were using 500-1000 mg of calcium, and 83% used 1000-2000 IU of vitamin D3. Fifty percent developed denosumab-induced hypocalcemia. Following the implementation of our care pathway, 15 patients (40% receiving dialysis) were treated with denosumab. Ninety-three percent received calcium at a daily dose of 350 to 2250 mg and 87% received 1000-2000 IU of vitamin D3. Thirteen percent developed denosumab-induced hypocalcemia. There was no hypercalcemia or hyperphosphatemia. CONCLUSIONS A clinical care pathway focused on the safe provision of denosumab in advanced CKD reduced the risk of hypocalcemia in patients treated in our hospital. Similar pathways could be adopted and tested in other centers.
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Affiliation(s)
- Tharsan Kanagalingam
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Tayyab Khan
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Division of Endocrinology and Metabolism, Western University, London, ON, Canada
- St Joseph's Health Care London, London, ON, Canada
- Centre for Diabetes, Endocrinology, and Metabolism, St. Joseph's Hospital, PO BOX 5777, STN B, London, Ontario, N6A 4V2, Canada
| | - Nabil Sultan
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- London Health Sciences Centre, London, ON, Canada
- Division of Nephrology, Western University, London, ON, Canada
| | - Andrea Cowan
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- London Health Sciences Centre, London, ON, Canada
- Division of Nephrology, Western University, London, ON, Canada
| | - Jenny Thain
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- St Joseph's Health Care London, London, ON, Canada
- Division of Geriatrics, Western University, London, ON, Canada
| | - Cindy Hoy
- St Joseph's Health Care London, London, ON, Canada
| | | | - Kristin K Clemens
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.
- Division of Endocrinology and Metabolism, Western University, London, ON, Canada.
- St Joseph's Health Care London, London, ON, Canada.
- Centre for Diabetes, Endocrinology, and Metabolism, St. Joseph's Hospital, PO BOX 5777, STN B, London, Ontario, N6A 4V2, Canada.
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada.
- Lawson Health Research Institute, London, ON, Canada.
- ICES, London, ON, Canada.
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Shukuri T, Nakai K, Tanaka S, Yamada S, Tokumoto M, Tsuruya K, Nakano T, Kitazono T. Angiotensin II receptor blockers and bone fracture in chronic kidney disease patients: the Fukuoka kidney disease Registry Study. Clin Exp Nephrol 2023; 27:919-927. [PMID: 37498346 DOI: 10.1007/s10157-023-02385-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 07/14/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND Angiotensin II receptor blockers (ARBs) reportedly reduce the risk of developing bone fractures; however, this association remains unclear among patients with chronic kidney disease (CKD). METHODS This was a cross-sectional study of 3380 CKD patients enrolled in the Fukuoka Kidney disease Registry Study, a multicenter prospective observational cohort study of non-dialysis-dependent CKD patients. The patients were divided into two groups, those taking ARBs and those who were not. Logistic regression models were used to examine the association between ARBs and bone fracture. RESULTS Approximately 67.0% of the participants were on ARBs, and 6.3% had a history of bone fracture. The history of bone fracture was significantly lower in patients with prescribed ARB and remained significant even after multivariable adjustment (odds ratio, 0.68; 95% confidence interval, 0.51-0.93). Other antihypertensive drugs, such as thiazide diuretics, which were reportedly helpful in preventing fractures, did not alter the bone fracture history and did not change among ARB users and non-users. CONCLUSIONS The present study showed that administering ARB was significantly associated with a lower frequency of bone fracture history.
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Affiliation(s)
- Tomoya Shukuri
- Departure of Nephrology, Japanese Red Cross Fukuoka Hospital, Fukuoka, Japan
| | - Kentaro Nakai
- Departure of Nephrology, Japanese Red Cross Fukuoka Hospital, Fukuoka, Japan
| | - Shigeru Tanaka
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higasi-Ku, Fukuoka, Japan
| | - Shunsuke Yamada
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higasi-Ku, Fukuoka, Japan
| | - Masanori Tokumoto
- Departure of Nephrology, Japanese Red Cross Fukuoka Hospital, Fukuoka, Japan
| | - Kazuhiko Tsuruya
- Department of Nephrology, Nara Medical University, Kashihara, Japan
| | - Toshiaki Nakano
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higasi-Ku, Fukuoka, Japan.
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higasi-Ku, Fukuoka, Japan
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11
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Cejka D, Wakolbinger-Habel R, Zitt E, Fahrleitner-Pammer A, Amrein K, Dimai HP, Muschitz C. [Diagnosis and treatment of osteoporosis in patients with chronic kidney disease : Joint guidelines of the Austrian Society for Bone and Mineral Research (ÖGKM), the Austrian Society of Physical and Rehabilitation Medicine (ÖGPMR) and the Austrian Society of Nephrology (ÖGN)]. Wien Med Wochenschr 2023; 173:299-318. [PMID: 36542221 PMCID: PMC10516794 DOI: 10.1007/s10354-022-00989-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 11/09/2022] [Indexed: 12/24/2022]
Abstract
DEFINITION AND EPIDEMIOLOGY Chronic kidney disease (CKD): abnormalities of kidney structure or function, present for over 3 months. Staging of CKD is based on GFR and albuminuria (not graded). Osteoporosis: compromised bone strength (low bone mass, disturbance of microarchitecture) predisposing to fracture. By definition, osteoporosis is diagnosed if the bone mineral density T‑score is ≤ -2.5. Furthermore, osteoporosis is diagnosed if a low-trauma (inadequate trauma) fracture occurs, irrespective of the measured T‑score (not graded). The prevalence of osteoporosis, osteoporotic fractures and CKD is increasing worldwide (not graded). PATHOPHYSIOLOGY, DIAGNOSIS AND TREATMENT OF CHRONIC KIDNEY DISEASE-MINERAL AND BONE DISORDER (CKD-MBD): Definition of CKD-MBD: a systemic disorder of mineral and bone metabolism due to CKD manifested by either one or a combination of the following: abnormalities of calcium, phosphorus, PTH, or vitamin D metabolism; renal osteodystrophy; vascular calcification (not graded). Increased, normal or decreased bone turnover can be found in renal osteodystrophy (not graded). Depending on CKD stage, routine monitoring of calcium, phosphorus, alkaline phosphatase, PTH and 25-OH-vitamin D is recommended (2C). Recommendations for treatment of CKD-MBD: Avoid hypercalcemia (1C). In cases of hyperphosphatemia, lower phosphorus towards normal range (2C). Keep PTH within or slightly above normal range (2D). Vitamin D deficiency should be avoided and treated when diagnosed (1C). DIAGNOSIS AND RISK STRATIFICATION OF OSTEOPOROSIS IN CKD Densitometry (using dual X‑ray absorptiometry, DXA): low T‑score correlates with increased fracture risk across all stages of CKD (not graded). A decrease of the T‑score by 1 unit approximately doubles the risk for osteoporotic fracture (not graded). A T-score ≥ -2.5 does not exclude osteoporosis (not graded). Bone mineral density of the lumbar spine measured by DXA can be increased and therefore should not be used for the diagnosis or monitoring of osteoporosis in the presence of aortic calcification, osteophytes or vertebral fracture (not graded). FRAX can be used to aid fracture risk estimation in all stages of CKD (1C). Bone turnover markers can be measured in individual cases to monitor treatment (2D). Bone biopsy may be considered in individual cases, especially in patients with CKD G5 (eGFR < 15 ml/min/1.73 m2) or CKD 5D (dialysis). SPECIFIC TREATMENT OF OSTEOPOROSIS IN PATIENTS WITH CKD Hypocalcemia should be treated and serum calcium normalized before initiating osteoporosis therapy (1C). CKD G1-G2 (eGFR ≥ 60 ml/min/1.73 m2): treat osteoporosis as recommended for the general population (1A). CKD G3-G5D (eGFR < 60 ml/min/1.73 m2 to dialysis): treat CKD-MBD first before initiating osteoporosis treatment (2C). CKD G3 (eGFR 30-59 ml/min/1.73 m2) with PTH within normal limits and osteoporotic fracture and/or high fracture risk according to FRAX: treat osteoporosis as recommended for the general population (2B). CKD G4-5 (eGFR < 30 ml/min/1.73 m2) with osteoporotic fracture (secondary prevention): Individualized treatment of osteoporosis is recommended (2C). CKD G4-5 (eGFR < 30 ml/min/1.73 m2) and high fracture risk (e.g. FRAX score > 20% for a major osteoporotic fracture or > 5% for hip fracture) but without prevalent osteoporotic fracture (primary prevention): treatment of osteoporosis may be considered and initiated individually (2D). CKD G4-5D (eGFR < 30 ml/min/1.73 m2 to dialysis): Calcium should be measured 1-2 weeks after initiation of antiresorptive therapy (1C). PHYSICAL MEDICINE AND REHABILITATION Resistance training prioritizing major muscle groups thrice weekly (1B). Aerobic exercise training for 40 min four times per week (1B). Coordination and balance exercises thrice weekly (1B). Flexibility exercise 3-7 times per week (1B).
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Affiliation(s)
- Daniel Cejka
- Abteilung für Innere Medizin III, Nieren- und Hochdruckerkrankungen, Transplantationsmedizin, Rheumatologie, Akutgeriatrie, Ordensklinikum Linz – Krankenhaus der Elisabethinen, Fadingerstr. 1, 4020 Linz, Österreich
| | - Robert Wakolbinger-Habel
- Department of Physical and Rehabilitation Medicine (PRM), Vienna Healthcare Group – Clinic Donaustadt, Langobardenstr. 122, 1220 Wien, Österreich
| | - Emanuel Zitt
- Department of Internal Medicine 3 (Nephrology and Dialysis), Feldkirch Academic Teaching Hospital, Feldkirch, Österreich
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Feldkirch, Österreich
- Agency for Preventive and Social Medicine (aks), Bregenz, Österreich
| | - Astrid Fahrleitner-Pammer
- Division of Endocrinology and Diabetology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Österreich
| | - Karin Amrein
- Division of Endocrinology and Diabetology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Österreich
| | - Hans Peter Dimai
- Division of Endocrinology and Diabetology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Österreich
| | - Christian Muschitz
- Medical Department II – VINFORCE, St. Vincent Hospital Vienna (Barmherzige Schwestern Krankenhaus Wien), Stumpergasse 13, 1060 Wien, Österreich
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12
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Jiajue R, Liang H, Jiang Y, Cui L, Pang Q, Chi Y, Liu W, Wang Q, Wang W, Pei Y, Wang X, Huang W, Zheng X, Ning Z, Wang O, Li M, Xing X, Yu W, Xu L, Xia W. Incident vertebral fracture and longitudinal BMD change in Chinese postmenopausal women with early CKD: Peking Vertebral Fracture Study. Arch Osteoporos 2023; 18:116. [PMID: 37697181 DOI: 10.1007/s11657-023-01324-9] [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: 11/28/2022] [Accepted: 08/25/2023] [Indexed: 09/13/2023]
Abstract
Early chronic kidney disease (CKD) and non-CKD individuals had similar morphometric vertebral fracture (mVF) incidence and longitudinal bone mineral density (BMD) change. CKD did not modify the association between BMD and incident mVF status. Patients with a higher baseline BMD had a higher longitudinal BMD loss in early CKD. PURPOSE The aim of this 5-year longitudinal cohort study was to compare the risk of incident morphometric vertebral fracture (mVF) and longitudinal bone mineral density (BMD) change between individuals with early chronic kidney disease (CKD) and those without CKD. METHODS A total of 869 Chinese postmenopausal women were enrolled in the study. Serum creatinine levels were assessed using standard methods, and estimated glomerular filtration rate (eGFR) was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation. Incident mVF was confirmed through lateral radiographs of the thoracolumbar spine. BMDs at the lumbar spine (LS) and femoral neck (FN) were measured using dual-energy X-ray absorptiometry. CKD was defined based on eGFR values: 60-89 mL/min/1.73m2 for stage 2 (n = 511) and 30-59 mL/min/1.73m2 for stage 3 (n = 92). The non-CKD group included individuals with an eGFR greater than or equal to 90 mL/min/1.73m2. RESULTS The incidence of mVF was not statistically different between individuals with early CKD and those without CKD (4.1% in non-CKD, 6.3% in CKD stage 2, and 7.6% in CKD stage 3; p = 0.348). Neither eGFR nor CKD status was significantly associated with incident mVF in the multivariate logistic regression analysis. Baseline BMD T-scores were negatively associated with incident mVF (LS T-score, OR = 0.603, 95% CI = 0.468-0.777; FN T-score, OR = 0.511, 95% CI = 0.350-0.746). No evidence of interaction between BMD T-scores and CKD status were identified (p = 0.284-0.785) . The differences in longitudinal BMD changes between non-CKD and CKD groups were comparable (FN BMD: -6.31 ± 7.20% in non-CKD, -5.07 ± 8.20% in CKD stage 2, and -4.49 ± 8.40% in CKD stage 3, p = 0.556; LS BMD: -1.38 ± 8.18% in non-CKD, -0.32 ± 7.14% in CKD stage 2, and 1.5 ± 6.97% in CKD stage 3, p = 0.406). Individuals with a higher baseline FN BMD showed a greater longitudinal FN BMD loss (r = -0.185, p < 0.001) . CONCLUSIONS Our study revealed that early CKD was not associated with an increased risk of incident mVF or greater longitudinal BMD loss. Moreover, CKD did not modify the association between BMD and the risk of incident mVF, suggesting that the management and prevention of fractures in early CKD should be approached similarly to those without CKD. Measurement of BMD appears to be crucial for predicting incident mVF risk and longitudinal bone loss in early CKD.
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Affiliation(s)
- Ruizhi Jiajue
- Department of Endocrinology, Key Laboratory of Endocrinology, National Commission of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, No. 1 Shuaifuyuan, Wangfujing Street, Dongcheng District, Beijing, 100730, China
| | - Hanting Liang
- Department of Endocrinology, Key Laboratory of Endocrinology, National Commission of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, No. 1 Shuaifuyuan, Wangfujing Street, Dongcheng District, Beijing, 100730, China
| | - Yan Jiang
- Department of Endocrinology, Key Laboratory of Endocrinology, National Commission of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, No. 1 Shuaifuyuan, Wangfujing Street, Dongcheng District, Beijing, 100730, China
| | - Lijia Cui
- Department of Endocrinology, Key Laboratory of Endocrinology, National Commission of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, No. 1 Shuaifuyuan, Wangfujing Street, Dongcheng District, Beijing, 100730, China
| | - Qianqian Pang
- Department of Endocrinology, Key Laboratory of Endocrinology, National Commission of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, No. 1 Shuaifuyuan, Wangfujing Street, Dongcheng District, Beijing, 100730, China
| | - Yue Chi
- Department of Endocrinology, Key Laboratory of Endocrinology, National Commission of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, No. 1 Shuaifuyuan, Wangfujing Street, Dongcheng District, Beijing, 100730, China
| | - Wei Liu
- Department of Endocrinology, Key Laboratory of Endocrinology, National Commission of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, No. 1 Shuaifuyuan, Wangfujing Street, Dongcheng District, Beijing, 100730, China
| | - Qiuping Wang
- Department of Endocrinology, Beijing Liangxiang Hospital, Beijing, 102401, China
| | - Wenbo Wang
- Department Endocrinology, Peking University Shougang Hospital, Beijing, 100144, China
| | - Yu Pei
- Department of Geriatric Endocrinology, Chinese PLA General Hospital, Beijing, 100853, China
| | - Xiran Wang
- Department of Cadre Unit, General Hospital of the Second Artillery Force, Beijing, 100088, China
| | - Wei Huang
- Department of Endocrinology Beijing Haidian Hospital, Beijing, 100080, China
| | - Xin Zheng
- Department of Endocrinology, China Rehabilitation Research Center, Beijing, 100068, China
| | - Zhiwei Ning
- Department of Endocrinology, Beijing Chaoyang Hospital, Beijing, 100020, China
| | - Ou Wang
- Department of Endocrinology, Key Laboratory of Endocrinology, National Commission of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, No. 1 Shuaifuyuan, Wangfujing Street, Dongcheng District, Beijing, 100730, China
| | - Mei Li
- Department of Endocrinology, Key Laboratory of Endocrinology, National Commission of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, No. 1 Shuaifuyuan, Wangfujing Street, Dongcheng District, Beijing, 100730, China
| | - Xiaoping Xing
- Department of Endocrinology, Key Laboratory of Endocrinology, National Commission of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, No. 1 Shuaifuyuan, Wangfujing Street, Dongcheng District, Beijing, 100730, China
| | - Wei Yu
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan No. 1, Wangfujing, Dongcheng District, Beijing, 100730, China
| | - Ling Xu
- Department of Gynaecology and Obstetrics, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, 100730, China
| | - Weibo Xia
- Department of Endocrinology, Key Laboratory of Endocrinology, National Commission of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, No. 1 Shuaifuyuan, Wangfujing Street, Dongcheng District, Beijing, 100730, China.
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13
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Lafage-Proust MH. Bone and Chronic Kidney Disease. Semin Musculoskelet Radiol 2023; 27:463-470. [PMID: 37748470 DOI: 10.1055/s-0043-1770353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
Chronic kidney disease (CKD) induces mineral and bone disorders (CKD-MBD) that affect calcium and phosphate metabolism. This review links pathophysiology, histologic aspects, and radiologic signs. CKD leads to bone lesions, namely renal osteodystrophy, which may combine low or high bone remodeling, impaired mineralization, and bone loss. CKD-MBD also comprises vascular calcifications, which, together with bone disease, lead to a high risk of cardiovascular events and osteoporotic fractures that increase both morbidity and mortality. Osteoporosis assessment is based on screening for classic risk factors and CKD-related factors (disease duration/severity, transplantation history, dialysis vintage). Treatment of mineral disorders may combine serum phosphate lowering drugs, natural vitamin D or its 1-α derivatives, or calcium-sensing receptor agonists. Treatment of osteoporosis is conventional in mild to moderate stages but more complex in severe CKD because evidence about the efficacy and safety of anti-osteoporosis drugs is scant.
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Affiliation(s)
- Marie-Hélène Lafage-Proust
- INSERM U1059 SAINBIOSE Université Jean Monnet, Saint-Etienne, France
- Service de Rhumatologie, CHU Saint-Etienne, Saint-Etienne, France
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14
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Aguilar A, Gifre L, Ureña-Torres P, Carrillo-López N, Rodriguez-García M, Massó E, da Silva I, López-Báez V, Sánchez-Bayá M, Prior-Español Á, Urrutia M, Paul J, Bustos MC, Vila A, Garnica-León I, Navarro-González JF, Mateo L, Bover J. Pathophysiology of bone disease in chronic kidney disease: from basics to renal osteodystrophy and osteoporosis. Front Physiol 2023; 14:1177829. [PMID: 37342799 PMCID: PMC10277623 DOI: 10.3389/fphys.2023.1177829] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 05/23/2023] [Indexed: 06/23/2023] Open
Abstract
Chronic kidney disease (CKD) is a highly prevalent disease that has become a public health problem. Progression of CKD is associated with serious complications, including the systemic CKD-mineral and bone disorder (CKD-MBD). Laboratory, bone and vascular abnormalities define this condition, and all have been independently related to cardiovascular disease and high mortality rates. The "old" cross-talk between kidney and bone (classically known as "renal osteodystrophies") has been recently expanded to the cardiovascular system, emphasizing the importance of the bone component of CKD-MBD. Moreover, a recently recognized higher susceptibility of patients with CKD to falls and bone fractures led to important paradigm changes in the new CKD-MBD guidelines. Evaluation of bone mineral density and the diagnosis of "osteoporosis" emerges in nephrology as a new possibility "if results will impact clinical decisions". Obviously, it is still reasonable to perform a bone biopsy if knowledge of the type of renal osteodystrophy will be clinically useful (low versus high turnover-bone disease). However, it is now considered that the inability to perform a bone biopsy may not justify withholding antiresorptive therapies to patients with high risk of fracture. This view adds to the effects of parathyroid hormone in CKD patients and the classical treatment of secondary hyperparathyroidism. The availability of new antiosteoporotic treatments bring the opportunity to come back to the basics, and the knowledge of new pathophysiological pathways [OPG/RANKL (LGR4); Wnt-ß-catenin pathway], also affected in CKD, offers great opportunities to further unravel the complex physiopathology of CKD-MBD and to improve outcomes.
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Affiliation(s)
- Armando Aguilar
- Autonomous University of Chiapas, Tuxtla Gutiérrez, Mexico
- Department of Nephrology, Mexican Social Security, IMSS General Hospital of Zone No 2, Tuxtla Gutiérrez, Mexico
| | - Laia Gifre
- Department of Rheumatology, Hospital Germans Trias i Pujol, Badalona (Barcelona), Catalonia, Spain
| | - Pablo Ureña-Torres
- AURA Saint Ouen, Department of Nephrology and Dialysis and Department of Renal Physiology, Necker Hospital, University of Paris Descartes, Paris, France
| | - Natalia Carrillo-López
- Bone and Mineral Research Unit, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Asturias, Spain
| | - Minerva Rodriguez-García
- Nephrology Clinical Management Unit, Central University Hospital of Asturias (HUCA), Oviedo, Asturias, Spain
| | - Elisabeth Massó
- Department of Nephrology, University Hospital Germans Trias i Pujol (HGiTP), Badalona (Barcelona), Catalonia, Spain
- REMAR-IGTP Group, Research Institute Germans Trias i Pujol, Can Ruti Campus, Badalona (Barcelona), Catalonia, Spain
| | - Iara da Silva
- Department of Nephrology, University Hospital Germans Trias i Pujol (HGiTP), Badalona (Barcelona), Catalonia, Spain
- REMAR-IGTP Group, Research Institute Germans Trias i Pujol, Can Ruti Campus, Badalona (Barcelona), Catalonia, Spain
| | - Víctor López-Báez
- Department of Nephrology, University Hospital Germans Trias i Pujol (HGiTP), Badalona (Barcelona), Catalonia, Spain
- REMAR-IGTP Group, Research Institute Germans Trias i Pujol, Can Ruti Campus, Badalona (Barcelona), Catalonia, Spain
| | - Maya Sánchez-Bayá
- Department of Nephrology, University Hospital Germans Trias i Pujol (HGiTP), Badalona (Barcelona), Catalonia, Spain
- REMAR-IGTP Group, Research Institute Germans Trias i Pujol, Can Ruti Campus, Badalona (Barcelona), Catalonia, Spain
| | - Águeda Prior-Español
- Department of Rheumatology, Hospital Germans Trias i Pujol, Badalona (Barcelona), Catalonia, Spain
| | - Marina Urrutia
- Department of Nephrology, University Hospital Germans Trias i Pujol (HGiTP), Badalona (Barcelona), Catalonia, Spain
- REMAR-IGTP Group, Research Institute Germans Trias i Pujol, Can Ruti Campus, Badalona (Barcelona), Catalonia, Spain
| | - Javier Paul
- Department of Nephrology, University Hospital Germans Trias i Pujol (HGiTP), Badalona (Barcelona), Catalonia, Spain
- REMAR-IGTP Group, Research Institute Germans Trias i Pujol, Can Ruti Campus, Badalona (Barcelona), Catalonia, Spain
| | - Misael C. Bustos
- Department of Nephrology, Pontificia Catholic University of Chile, Santiago, Chile
| | - Anna Vila
- Department of Nephrology, University Hospital Germans Trias i Pujol (HGiTP), Badalona (Barcelona), Catalonia, Spain
- REMAR-IGTP Group, Research Institute Germans Trias i Pujol, Can Ruti Campus, Badalona (Barcelona), Catalonia, Spain
| | - Isa Garnica-León
- Department of Nephrology, Mexican Social Security, IMSS General Hospital of Zone No 2, Tuxtla Gutiérrez, Mexico
| | - Juan F. Navarro-González
- Research Unit and Nephrology Service, University Hospital of Nuestra Señora de la Candelaria, Santa Cruz de Tenerife, Islas Canarias, Spain
- Instituto de Tecnologías Biomédicas, Universidad de la Laguna, Islas Canarias, Spain
| | - Lourdes Mateo
- Department of Rheumatology, Hospital Germans Trias i Pujol, Badalona (Barcelona), Catalonia, Spain
| | - Jordi Bover
- Department of Nephrology, University Hospital Germans Trias i Pujol (HGiTP), Badalona (Barcelona), Catalonia, Spain
- REMAR-IGTP Group, Research Institute Germans Trias i Pujol, Can Ruti Campus, Badalona (Barcelona), Catalonia, Spain
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15
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Torregrosa JV, Bover J, Rodríguez Portillo M, González Parra E, Dolores Arenas M, Caravaca F, González Casaus ML, Martín-Malo A, Navarro-González JF, Lorenzo V, Molina P, Rodríguez M, Cannata Andia J. Recommendations of the Spanish Society of Nephrology for the management of mineral and bone metabolism disorders in patients with chronic kidney disease: 2021 (SEN-MM). Nefrologia 2023; 43 Suppl 1:1-36. [PMID: 37202281 DOI: 10.1016/j.nefroe.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 03/26/2022] [Indexed: 05/20/2023] Open
Abstract
As in 2011, when the Spanish Society of Nephrology (SEN) published the Spanish adaptation to the Kidney Disease: Improving Global Outcomes (KDIGO) universal Guideline on Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD), this document contains an update and an adaptation of the 2017 KDIGO guidelines to our setting. In this field, as in many other areas of nephrology, it has been impossible to irrefutably answer many questions, which remain pending. However, there is no doubt that the close relationship between the CKD-MBD/cardiovascular disease/morbidity and mortality complex and new randomised clinical trials in some areas and the development of new drugs have yielded significant advances in this field and created the need for this update. We would therefore highlight the slight divergences that we propose in the ideal objectives for biochemical abnormalities in the CKD-MBD complex compared to the KDIGO suggestions (for example, in relation to parathyroid hormone or phosphate), the role of native vitamin D and analogues in the control of secondary hyperparathyroidism and the contribution of new phosphate binders and calcimimetics. Attention should also be drawn to the adoption of important new developments in the diagnosis of bone abnormalities in patients with kidney disease and to the need to be more proactive in treating them. In any event, the current speed at which innovations are taking place, while perhaps slower than we might like, globally drives the need for more frequent updates (for example, through Nefrología al día).
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Affiliation(s)
| | - Jordi Bover
- Hospital Germans Trias i Pujol, Badalona, Spain
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16
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Kim H, Kim AJ, Ro H, Chang JH, Lee HH, Chung W, Jung JY. Serum calcification propensity and its association with biochemical parameters and bone mineral density in hemodialysis patients. Kidney Res Clin Pract 2023; 42:262-271. [PMID: 36328988 PMCID: PMC10085723 DOI: 10.23876/j.krcp.22.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/20/2022] [Accepted: 06/03/2022] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND T50 is a novel serum-based marker that assesses the propensity for calcification in serum. A shorter T50 indicates a greater propensity to calcify and has been associated with cardiovascular disease and mortality among patients with chronic kidney disease. The factors associated with T50 and the correlation between T50 and bone mineral density (BMD) are unknown in hemodialysis (HD) patients. METHODS This cross-sectional study included 184 patients undergoing HD. Individuals were grouped into tertiles of T50 to compare the demographic and disease indicators of the tertiles. Linear regression was used to evaluate the association between T50 and hip and spinal BMD in a multivariate model. RESULTS Mineral and inflammatory parameters, including serum phosphate (r = -0.156, p = 0.04), albumin (r = 0.289, p < 0.001), and high-sensitivity C-reactive protein (r = -0.224, p = 0.003) levels, were associated with T50. We found a weak association between T50 and BMD in the total hip area in the unadjusted model (β = 0.030, p = 0.04) but did not find a statistically significant association with the total hip (β = 0.017, p = 0.12), femoral neck (β = -0.001, p = 0.96), or spinal BMD (β = 0.019, p = 0.33) in multivariable-adjusted models. CONCLUSION T50 was moderately associated with mineral and inflammatory parameters but did not conclusively establish an association with BMD in HD patients. Broad-scale future studies should determine whether T50 can provide insights into BMD beyond traditional risk factors in this population.
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Affiliation(s)
- Hyunsook Kim
- Department of Health Sciences and Technology, Gachon University, Incheon, Republic of Korea
| | - Ae Jin Kim
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Han Ro
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Jae Hyun Chang
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Hyun Hee Lee
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Wookyung Chung
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Ji Yong Jung
- Department of Health Sciences and Technology, Gachon University, Incheon, Republic of Korea
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
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17
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Duarte MP, Ribeiro HS, Neri SGR, Almeida LS, Oliveira JS, Viana JL, Lima RM. Prevalence of low bone mineral density (T-score ≤ - 2.5) in the whole spectrum of chronic kidney disease: a systematic review and meta-analysis. Osteoporos Int 2023; 34:467-477. [PMID: 36370217 DOI: 10.1007/s00198-022-06598-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 11/03/2022] [Indexed: 11/13/2022]
Abstract
The prevalence of low bone mineral density (LBMD) in people with chronic kidney disease (CKD) remains unknown. We identified a high prevalence of LBMD in CKD population. Thus, public health strategies should include efforts to prevent, early detect, and manage LBMD in CKD patients, especially in patients undergoing kidney replacement therapy. Mineral and bone disorders are common among patients with CKD, which affects bone mineral density. We conducted a systematic review and meta-analysis to estimate the prevalence of low bone mineral density (LBMD) in adults with CKD. We searched MEDLINE, EMBASE, Web of Science, CINAHL, and LILACS databases from inception to February 2021. Observational studies that reported the prevalence of LBMD in adults with CKD stages 3a-5D were included. The LBMD was defined according to the World Health Organization criterion (T-score ≤ - 2.5). Random-effect model meta-analyses were used to estimate the pooled prevalence of LBMD. Meta-regressions and subgroup analyses were conducted for stages of CKD, dialysis modality, gender, bone sites and morphology, and geographical region. This study was registered in PROSPERO, number CRD42020211077. One-hundred and fifty-three studies with 78,092 patients were included. The pooled global prevalence of LBMD in CKD was 24.5% (95% CI, 21.3 - 27.8%). Subgroup analyses indicated a higher prevalence of LBMD in dialysis patients (30%, 95% CI 25 - 35%) compared with non-dialysis CKD patients (12%, 95% CI 8 - 16%), cortical bone sites (28%, 95% CI 23 - 35%) relative to trabecular sites (19%, 95% CI 14 - 24%), while similar estimates in the European and the Asiatic continents (26%, 95% CI 21 - 30% vs 25%, 95% CI 21 - 29). The prevalence of LBMD in CKD patients is high, particularly in those undergoing dialysis and in cortical bone sites. Therefore, efforts to early diagnosis and management strategies should be implemented in clinical routine for an epidemiological control of LBMD in CKD patients.
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Affiliation(s)
- Marvery P Duarte
- Faculty of Physical Education, University of Brasilia, Brasília, Brazil.
| | - Heitor S Ribeiro
- Faculty of Physical Education, University of Brasilia, Brasília, Brazil
- Research Center in Sports Sciences and Human Development, CIDESD, University of Maia, Maia, Portugal
| | - Silvia G R Neri
- Faculty of Physical Education, University of Brasilia, Brasília, Brazil
| | - Lucas S Almeida
- Faculty of Physical Education, University of Brasilia, Brasília, Brazil
| | - Juliana S Oliveira
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - João L Viana
- Research Center in Sports Sciences and Human Development, CIDESD, University of Maia, Maia, Portugal
| | - Ricardo M Lima
- Faculty of Physical Education, University of Brasilia, Brasília, Brazil
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18
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Lee WT, Fang YW, Chen M, Liou HH, Lee CJ, Tsai MH. Serum Intact Fibroblast Growth Factor 23 Levels Are Negatively Associated with Bone Mineral Density in Chronic Hemodialysis Patients. J Clin Med 2023; 12:jcm12041550. [PMID: 36836085 PMCID: PMC9964480 DOI: 10.3390/jcm12041550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 02/09/2023] [Accepted: 02/14/2023] [Indexed: 02/18/2023] Open
Abstract
(1) Background: Fibroblast growth factor 23 (FGF23) is predominantly secreted from bone and plays an important role in mineral balance in chronic kidney disease. However, the relationship between FGF23 and bone mineral density (BMD) in chronic hemodialysis (CHD) patients remains unclear. (2) Methods: This was a cross-sectional observational study that involved 43 stable outpatients on CHD. A linear regression model was used to determine risk factors for BMD. Measurements included serum hemoglobin, intact FGF23 (iFGF23), C-terminal FGF23 (cFGF23), sclerostin, Dickkopf-1, α-klotho, 1,25-hydroxyvitamin D, intact parathyroid hormone levels and dialysis profiles. (3) Results: Study participants had a mean age of 59.4 ± 12.3 years, and 65% were male. In the multivariable analysis, cFGF23 levels showed no significant associations with the BMD of the lumbar spine (p = 0.387) nor that of the femoral head (p = 0.430). However, iFGF23 levels showed a significant negative association with the BMD of the lumbar spine (p = 0.015) and that of the femoral neck (p = 0.037). (4) Conclusions: Among patients on CHD, higher serum iFGF23 levels, but not serum cFGF23 levels, were associated with lower BMD values of the lumbar spine and femoral neck. However, further research is required to validate our findings.
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Affiliation(s)
- Wen-Teng Lee
- Division of Nephrology, Department of Internal Medicine, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei 111045, Taiwan
| | - Yu-Wei Fang
- Division of Nephrology, Department of Internal Medicine, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei 111045, Taiwan
- Department of Medicine, Fu-Jen Catholic University School of Medicine, Taipei 242062, Taiwan
| | - Mingchih Chen
- Graduate Institute of Business Administration, College of Management, Fu Jen Catholic University, New Taipei City 242062, Taiwan
- AI Development Center, Fu Jen Catholic University, New Taipei City 242062, Taiwan
| | - Hung-Hsiang Liou
- Division of Nephrology, Department of Internal Medicine, Hsin-Jen Hospital, New Taipei City 242009, Taiwan
| | - Chung-Jen Lee
- Department of Nursing, Tzu Chi University of Science and Technology, Section 2, Chien-Kuo Rd., Hualien City 970046, Taiwan
| | - Ming-Hsien Tsai
- Division of Nephrology, Department of Internal Medicine, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei 111045, Taiwan
- Department of Medicine, Fu-Jen Catholic University School of Medicine, Taipei 242062, Taiwan
- Correspondence:
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19
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Bone Disease in Chronic Kidney Disease and Kidney Transplant. Nutrients 2022; 15:nu15010167. [PMID: 36615824 PMCID: PMC9824497 DOI: 10.3390/nu15010167] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/19/2022] [Accepted: 12/19/2022] [Indexed: 12/31/2022] Open
Abstract
Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD) comprises alterations in calcium, phosphorus, parathyroid hormone (PTH), Vitamin D, and fibroblast growth factor-23 (FGF-23) metabolism, abnormalities in bone turnover, mineralization, volume, linear growth or strength, and vascular calcification leading to an increase in bone fractures and vascular disease, which ultimately result in high morbidity and mortality. The bone component of CKD-MBD, referred to as renal osteodystrophy, starts early during the course of CKD as a result of the effects of progressive reduction in kidney function which modify the tight interaction between mineral, hormonal, and other biochemical mediators of cell function that ultimately lead to bone disease. In addition, other factors, such as osteoporosis not apparently dependent on the typical pathophysiologic abnormalities resulting from altered kidney function, may accompany the different varieties of renal osteodystrophy leading to an increment in the risk of bone fracture. After kidney transplantation, these bone alterations and others directly associated or not with changes in kidney function may persist, progress or transform into a different entity due to new pathogenetic mechanisms. With time, these alterations may improve or worsen depending to a large extent on the restoration of kidney function and correction of the metabolic abnormalities developed during the course of CKD. In this paper, we review the bone lesions that occur during both CKD progression and after kidney transplant and analyze the factors involved in their pathogenesis as a means to raise awareness of their complexity and interrelationship.
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20
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Aleksova J, Ebeling PR, Milat F, Elder GJ. DXA-derived advanced hip analysis and the trabecular bone score in end-stage kidney disease secondary to type 1 diabetes. Eur J Endocrinol 2022; 187:883-892. [PMID: 36315195 DOI: 10.1530/eje-22-0687] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 10/31/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Patients with end-stage kidney disease (ESKD) caused by type 1 diabetes mellitus (T1DM) have a heightened fracture risk. Bone mineral density (BMD) may predict fracture less accurately in ESKD than in patients with chronic kidney disease (CKD) stages 1-3b or the general population. Alternate, readily available imaging modalities are needed to improve ESKD fracture risk assessment. This study aimed to assess dual-energy X-ray absorptiometry (DXA)-derived BMD, the trabecular bone score (TBS) and advanced hip analysis parameters in patients with ESKD due to T1DM and to compare their results with those of patients with ESKD from other causes. METHODS We compared the DXA-derived TBS, hip cortical thickness (CT) and femoral neck (FN) buckling ratio (BR), an index of FN stability, of patients with T1DM and ESKD undergoing simultaneous pancreas kidney transplantation, patients with ESKD from other causes receiving kidney transplants and population reference ranges. RESULTS Of 227 patients with ESKD, 28% had T1DM and 65% were male. Compared with other ESKD patients, patients with T1DM were younger (42 ± 7.7 vs 51 ± 13.8 years), had shorter dialysis duration (24.4 ± 21 vs 42.6 ± 40 months), had higher HbA1c (7.9 ± 1.57% vs 5.4 ± 0.95%) and had lower BMI (25 ± 6 vs 27 ± 5 kg/m2). They had lower spine, hip and UD radius BMD Z-scores (all P ≤ 0.001), TBS (1.33 ± 0.12 vs 1.36 ± 0.12; P = 0.05), CT at the FN (P = 0.03), calcar (P = 0.006) and shaft (P < 0.001) and higher BR (10.1±7.1 vs 7.7±4; P = 0.006). All ESKD parameters were lower than population-based reference ranges (P < 0.001). Adjusting for age, sex, dialysis vintage and weight, prevalent vertebral fractures in patients with T1DM and ESKD were associated with higher BR (odds ratio (OR): 3.27 (95% CI: 1.19-8.92), P = 0.002) and lower FN CT (OR: 3.70 (95% CI: 1.13-12.50)). CONCLUSION Patients with ESKD and T1DM have reduced TBS, reduced CT and increased BR compared with other ESKD patients. Prospective study of these parameters is warranted to determine their utility in fracture risk prediction and management. SIGNIFICANCE STATEMENT Patients with ESKD and T1DM have an elevated fracture risk due to decreased bone strength. As an adjunct to BMD, evaluating dual-energy X-ray absorptiometry parameters that incorporate structural change may have greater value in patients with ESKD and T1DM than in the general population. In this study, patients with ESKD due to T1DM had lower BMD, lower trabecular bone scores, more severe loss of CT and higher BR than other patients with ESKD and people from the general population. Both lower CT and higher BR were associated with prevalent vertebral fractures in patients with T1DM and ESKD. Changes to these parameters should be evaluated for incident fracture prediction.
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Affiliation(s)
- Jasna Aleksova
- Hudson Institute for Medical Research
- Department of Medicine, Monash University
- Department of Endocrinology, Monash Health
| | - Peter R Ebeling
- Department of Medicine, Monash University
- Department of Endocrinology, Monash Health
| | - Frances Milat
- Hudson Institute for Medical Research
- Department of Medicine, Monash University
- Department of Endocrinology, Monash Health
| | - Grahame J Elder
- Department of Renal Medicine, Westmead Hospital
- Skeletal Biology Program, Garvan Institute of Medical Research
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21
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Pediatric CKD-MBD: existing and emerging treatment approaches. Pediatr Nephrol 2022; 37:2599-2614. [PMID: 35038008 DOI: 10.1007/s00467-021-05265-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 07/08/2021] [Accepted: 07/08/2021] [Indexed: 12/13/2022]
Abstract
The effects of bone and mineral metabolism on skeletal formation, as well as vascular and soft tissue calcifications, define chronic kidney disease-metabolic bone disease (CKD-MBD). Treatment recommendations center on establishing adequate vitamin D status, phosphate control through diet restriction and phosphate binders, and the use of vitamin D analogs for specific indications. Several emerging bone-promoting therapies have now been studied in adults with CKD, including bisphosphonates and denosumab. These approaches are associated with improved bone mass and, in some cases, decreased fracture rates in adults with CKD-MBD and are of potential interest for some children with CKD-MBD. In children with CKD and immobilization and/or muscle weakness, bisphosphonates appear to be an effective treatment to increase bone mass; baseline assessment and careful monitoring of bone density and/or bone biopsy findings are important in consideration of any new bone therapies for children with CKD-MBD.
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22
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Abdalbary M, Sobh M, Elnagar S, Elhadedy MA, Elshabrawy N, Abdelsalam M, Asadipooya K, Sabry A, Halawa A, El-Husseini A. Management of osteoporosis in patients with chronic kidney disease. Osteoporos Int 2022; 33:2259-2274. [PMID: 35748896 DOI: 10.1007/s00198-022-06462-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 05/31/2022] [Indexed: 12/19/2022]
Abstract
Patients with CKD have a 4-fivefold higher rate of fractures. The incidence of fractures increases with deterioration of kidney function. The process of skeletal changes in CKD patients is characterized by compromised bone strength because of deterioration of bone quantity and/or quality. The fractures lead to a deleterious effect on the quality of life and higher mortality in patients with CKD. The pathogenesis of bone loss and fracture is complex and multi-factorial. Renal osteodystrophy, uremic milieu, drugs, and systemic diseases that lead to renal failure all contribute to bone damage in CKD patients. There is no consensus on the optimal diagnostic method of compromised bone assessment in patients with CKD. Bone quantity and mass can be assessed by dual-energy x-ray absorptiometry (DXA) or quantitative computed tomography (QCT). Bone quality on the other side can be assessed by non-invasive methods such as trabecular bone score (TBS), high-resolution bone imaging methods, and invasive bone biopsy. Bone turnover markers can reflect bone remodeling, but some of them are retained by kidneys. Understanding the mechanism of bone loss is pivotal in preventing fracture in patients with CKD. Several non-pharmacological and therapeutic interventions have been reported to improve bone health. Controlling laboratory abnormalities of CKD-MBD is crucial. Anti-resorptive therapies are effective in improving BMD and reducing fracture risk, but there are uncertainties about safety and efficacy especially in advanced CKD patients. Accepting the prevalent of low bone turnover in patients with advanced CKD, the osteo-anabolics are possibly promising. Parathyroidectomy should be considered a last resort for intractable cases of renal hyperparathyroidism. There is a wide unacceptable gap in osteoporosis management in patients with CKD. This article is focusing on the updated management of CKD-MBD and osteoporosis in CKD patients. Chronic kidney disease deteriorates bone quality and quantity. The mechanism of bone loss mainly determines pharmacological treatment. DXA and QCT provide information about bone quantity, but assessing bone quality, by TBS, high-resolution bone imaging, invasive bone biopsy, and bone turnover markers, can guide us about the mechanism of bone loss.
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Affiliation(s)
- M Abdalbary
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, 800 Rose Street, Room MN-560, Lexington, KY, 40536-0298, USA
| | - M Sobh
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - S Elnagar
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - M A Elhadedy
- Nephrology and Transplantation Unit, Mansoura Urology and Nephrology Center, Mansoura, Egypt
| | - N Elshabrawy
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - M Abdelsalam
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - K Asadipooya
- Division of Endocrinology, University of Kentucky, Lexington, USA
| | - A Sabry
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - A Halawa
- Sheffield Teaching Hospital, University of Liverpool, Liverpool, UK
| | - A El-Husseini
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, 800 Rose Street, Room MN-560, Lexington, KY, 40536-0298, USA.
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23
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Haarhaus M, Aaltonen L, Cejka D, Cozzolino M, de Jong RT, D'Haese P, Evenepoel P, Lafage-Proust MH, Mazzaferro S, McCloskey E, Salam S, Skou Jørgensen H, Vervloet M. Management of fracture risk in CKD-traditional and novel approaches. Clin Kidney J 2022; 16:456-472. [PMID: 36865010 PMCID: PMC9972845 DOI: 10.1093/ckj/sfac230] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Indexed: 11/13/2022] Open
Abstract
The coexistence of osteoporosis and chronic kidney disease (CKD) is an evolving healthcare challenge in the face of increasingly aging populations. Globally, accelerating fracture incidence causes disability, impaired quality of life and increased mortality. Consequently, several novel diagnostic and therapeutic tools have been introduced for treatment and prevention of fragility fractures. Despite an especially high fracture risk in CKD, these patients are commonly excluded from interventional trials and clinical guidelines. While management of fracture risk in CKD has been discussed in recent opinion-based reviews and consensus papers in the nephrology literature, many patients with CKD stages 3-5D and osteoporosis are still underdiagnosed and untreated. The current review addresses this potential treatment nihilism by discussing established and novel approaches to diagnosis and prevention of fracture risk in patients with CKD stages 3-5D. Skeletal disorders are common in CKD. A wide variety of underlying pathophysiological processes have been identified, including premature aging, chronic wasting, and disturbances in vitamin D and mineral metabolism, which may impact bone fragility beyond established osteoporosis. We discuss current and emerging concepts of CKD-mineral and bone disorders (CKD-MBD) and integrate management of osteoporosis in CKD with current recommendations for management of CKD-MBD. While many diagnostic and therapeutic approaches to osteoporosis can be applied to patients with CKD, some limitations and caveats need to be considered. Consequently, clinical trials are needed that specifically study fracture prevention strategies in patients with CKD stages 3-5D.
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Affiliation(s)
| | - Louise Aaltonen
- Turku University Hospital, Kidney Center, Department of Medicine, Turku, Finland
| | - Daniel Cejka
- Department of Medicine III – Nephrology, Hypertension, Transplantation, Rheumatology, Geriatrics, Ordensklinikum Linz - Elisabethinen Hospital, Linz, Austria
| | - Mario Cozzolino
- Department of Health Sciences, Renal Division, University of Milan, ASST Santi Paolo e Carlo, Milan, Italy
| | - Renate T de Jong
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Internal Medicine and Endocrinology, Amsterdam, The Netherlands,Amsterdam Gastroenterology Endocrinology Metabolism Institute, Amsterdam, The Netherlands
| | - Patrick D'Haese
- Laboratory of Pathophysiology, Department of Biomedical Sciences, University of Antwerp, Antwerp, Belgium
| | - Pieter Evenepoel
- Department of Nephrology, University Hospitals Leuven, Leuven, Belgium,Department of Microbiology Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven-University of Leuven, Leuven, Belgium
| | | | - Sandro Mazzaferro
- Nephrology Unit at Policlinico Umberto I Hospital and Department of Translation and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Eugene McCloskey
- Academic Unit of Bone Metabolism, Centre for Integrated research in Musculoskeletal Ageing, Mellanby Centre for Musculoskeletal Research, Department of Oncology & Metabolism, University of Sheffield, Sheffield, UK
| | - Syazrah Salam
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK and Sheffield Kidney Institute, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Hanne Skou Jørgensen
- Department of Microbiology Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven-University of Leuven, Leuven, Belgium,Aarhus University Hospital, Department of Kidney Diseases, Aarhus,Denmark,Aarhus University, Department of Clinical Medicine, Aarhus,Denmark
| | - Marc Vervloet
- Department of Nephrology, Amsterdam University Medical Center, VU University Amsterdam, Amsterdam, The Netherlands,Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, Amsterdam, The Netherlands
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24
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Campagnaro LS, Carvalho AB, Pina PM, Watanabe R, Canziani MEF. Bone mass measurement by DXA should be interpreted with caution in the CKD population with vascular calcification. Bone Rep 2022; 16:101169. [PMID: 35146076 PMCID: PMC8819399 DOI: 10.1016/j.bonr.2022.101169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 01/23/2022] [Accepted: 01/24/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND KDIGO guidelines suggest the use of dual-energy X-ray absorptiometry (DXA) to assess bone mineral density (BMD) in patients with CKD 3a-5D. Previous studies have demonstrated an association between trabecular bone mass loss and coronary artery calcification (CAC) progression. This study aimed to prospectively investigate the relationship between BMD changes, quantified by DXA, and CAC progression in the non-dialyzed CKD population. METHODS In this post hoc study, BMD by DXA was measured at the lumbar spine and total hip at baseline and 12-months. Patients were categorized according to BMD changes into 3 different groups: LOSS, UNCHANGED and GAIN. CAC quantification was obtained by multislice computed tomography at baseline and 12-months. RESULTS 87 patients (55.6 ± 10.7 years, 62% males, 30% diabetic, eGFR = 39.2 ± 18.1 mL/min/1.73m2) were enrolled. CAC was found in 41 (47%) of the patients at baseline and CAC progression in 25 (64%) of them. Considering the lumbar spine and total hip BMD changes together, 24%, 48%, and 25% of the patients were in the LOSS, UNCHANGED and GAIN groups, respectively. Compared to the UNCHANGED or LOSS groups, the GAIN group had an increase in calcium score (p = 0.04) and a higher proportion of patients with CAC progression (p = 0.01). In the logistic regression analysis, CAC progression was 4.5 times more likely to be in the GAIN group. CONCLUSIONS The association between the increase in BMD values and the progression of vascular calcification was the result of two concomitant processes overlapping, leading to a misinterpretation of DXA results. Thus, the use of DXA for the evaluation of bone mass, especially at the lumbar spine, must be applied with restraint and its results very carefully interpreted in CKD patients.
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Affiliation(s)
- Layon S. Campagnaro
- Nephrology Division of Federal University of São Paulo, Rua Pedro de Toledo, 299 - Vila Clementino, São Paulo, SP 04039-000, Brazil
| | - Aluizio B. Carvalho
- Nephrology Division of Federal University of São Paulo, Rua Pedro de Toledo, 299 - Vila Clementino, São Paulo, SP 04039-000, Brazil
| | - Paula M. Pina
- Nephrology Division of Federal University of São Paulo, Rua Pedro de Toledo, 299 - Vila Clementino, São Paulo, SP 04039-000, Brazil
| | - Renato Watanabe
- Nephrology Division of Federal University of São Paulo, Rua Pedro de Toledo, 299 - Vila Clementino, São Paulo, SP 04039-000, Brazil
| | - Maria Eugênia F. Canziani
- Nephrology Division of Federal University of São Paulo, Rua Pedro de Toledo, 299 - Vila Clementino, São Paulo, SP 04039-000, Brazil
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25
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Cailleaux PE, Cohen-Solal M. Managing Musculoskeletal and Kidney Aging: A Call for Holistic Insights. Clin Interv Aging 2022; 17:717-732. [PMID: 35548383 PMCID: PMC9081621 DOI: 10.2147/cia.s357501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/20/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
| | - Martine Cohen-Solal
- Inserm UMR-S 1132 Bioscar, Université Paris Cité - Hôpital Lariboisiere, Paris, F-75010, France
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26
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Keronen S, Martola L, Finne P, Burton IS, Tong XF, Kröger H, Honkanen E. Bone volume, mineral density, and fracture risk after kidney transplantation. PLoS One 2022; 17:e0261686. [PMID: 35349587 PMCID: PMC8963906 DOI: 10.1371/journal.pone.0261686] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 12/07/2021] [Indexed: 11/18/2022] Open
Abstract
Background
Disordered mineral metabolism reverses incompletely after kidney transplantation in numerous patients. Post-transplantation bone disease is a combination of pre-existing chronic kidney disease and mineral disorder and often evolving osteoporosis. These two frequently overlapping conditions increase the risk of post-transplantation fractures.
Material and methods
We studied the prevalence of low bone volume in bone biopsies obtained from kidney transplant recipients who were biopsied primarily due to the clinical suspicion of persistent hyperparathyroidism between 2000 and 2015 at the Hospital District of Helsinki and Uusimaa. Parameters of mineral metabolism, results of dual-energy x-ray absorptiometry scans, and the history of fractures were obtained concurrently.
One hundred nine bone biopsies taken at a median of 31 (interquartile range, IQR, 18–70) months after transplantation were included in statistical analysis. Bone turnover was classified as high in 78 (72%) and normal/low in 31 (28%) patients. The prevalence of low bone volume (n = 47, 43%) was higher among patients with low/normal turnover compared to patients with high turnover [18 (58%) vs. 29 (37%), P = 0.05]. Thirty-seven fragility fractures in 23 (21%) transplant recipients corresponding to fracture incidence 15 per 1000 person-years occurred during a median follow-up 9.1 (IQR, 6.3–12.1) years. Trabecular bone volume did not correlate with incident fractures. Accordingly, low bone mineral density at the lumbar spine correlated with low trabecular bone volume, but not with incident fractures. The cumulative corticosteroid dose was an important determinant of low bone volume, but not of incident fractures.
Conclusions
Despite the high prevalence of trabecular bone loss among kidney transplant recipients, the number of fractures was limited. The lack of association between trabecular bone volume and fractures suggests that the bone cortical compartment and quality are important determinants of bone strength and post-transplantation fracture.
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Affiliation(s)
- Satu Keronen
- Department of Nephrology, Abdominal Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- * E-mail:
| | - Leena Martola
- Department of Nephrology, Abdominal Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Patrik Finne
- Department of Nephrology, Abdominal Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Inari S. Burton
- Kuopio Musculoskeletal Research Unit (KMRU), University of Eastern Finland, Kuopio, Finland
| | - Xiaoyu F. Tong
- Kuopio Musculoskeletal Research Unit (KMRU), University of Eastern Finland, Kuopio, Finland
| | - Heikki Kröger
- Kuopio Musculoskeletal Research Unit (KMRU), University of Eastern Finland, Kuopio, Finland
- Department of Orthopedics, Traumatology and Hand Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Eero Honkanen
- Department of Nephrology, Abdominal Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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27
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Ureña Torres PA, Souberbielle JC, Solal MC. Bone Fragility in Chronic Kidney Disease Stage 3 to 5: The Use of Vitamin D Supplementation. Metabolites 2022; 12:metabo12030266. [PMID: 35323709 PMCID: PMC8953916 DOI: 10.3390/metabo12030266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 03/10/2022] [Accepted: 03/17/2022] [Indexed: 12/02/2022] Open
Abstract
Frequently silent until advanced stages, bone fragility associated with chronic kidney disease-mineral and bone disease (CKD-MBD) is one of the most devastating complications of CKD. Its pathophysiology includes the reduction of active vitamin D metabolites, phosphate accumulation, decreased intestinal calcium absorption, renal alpha klotho production, and elevated fibroblast growth factor 23 (FGF23) levels. Altogether, these factors contribute firstly to secondary hyperparathyroidism, and ultimately, to micro- and macrostructural bone changes, which lead to low bone mineral density and an increased risk of fracture. A vitamin D deficiency is common in CKD patients, and low circulating 25(OH)D levels are invariably associated with high serum parathyroid hormone (PTH) levels as well as with bone mineralization defects, such as osteomalacia in case of severe forms. It is also associated with a variety of non-skeletal diseases, including cardiovascular disease, diabetes mellitus, multiple sclerosis, cancer, and reduced immunological response. Current international guidelines recommend supplementing CKD patients with nutritional vitamin D as in the general population; however, there is no randomized clinical trial (RCT) evaluating the effect of vitamin D (or vitamin D+calcium) supplementation on the risk of fracture in the setting of CKD. It is also unknown what level of circulating 25(OH)D would be sufficient to prevent bone abnormalities and fractures in these patients. The impact of vitamin D supplementation on other surrogate endpoints, including bone mineral density and bone-related circulating biomarkers (PTH, FGF23, bone-specific alkaline phosphatase, sclerostin) has been evaluated in several RTCs; however, the results were not always translated into an improvement in long-term outcomes, such as reduced fracture risk. This review provides a brief and comprehensive update on CKD-related bone fragility and the use of natural vitamin D supplementation in these patients.
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Affiliation(s)
- Pablo Antonio Ureña Torres
- Department of Dialysis AURA Nord Saint Ouen, 12, Rue Anselme, 93400 Saint Ouen, France
- Department of Renal Physiology, Necker Hospital, University of Paris Descartes, 75015 Paris, France;
- Correspondence: (P.A.U.T.); (M.C.S.)
| | - Jean Claude Souberbielle
- Department of Renal Physiology, Necker Hospital, University of Paris Descartes, 75015 Paris, France;
| | - Martine Cohen Solal
- Bioscar INSERM U1132, Department of Rheumatology, Université de Paris, Hôpital Lariboisière, 75010 Paris, France
- Correspondence: (P.A.U.T.); (M.C.S.)
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Lateral spine dual-energy X-ray absorptiometry and the risk of fragility fractures in long-term kidney graft recipients. Clin Exp Nephrol 2022; 26:724-732. [PMID: 35304690 DOI: 10.1007/s10157-022-02210-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 03/06/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Although the prevalence of osteoporosis and fractures in the first 6-12 months post-renal transplantation is high, little is known about the utility of bone mineral density (BMD) to predict fractures in long-term kidney graft recipients. Lateral spine dual-energy X-ray absorptiometry (DXA) scanning is a reliable tool for measuring glucocorticoid-induced and age-related bone loss in the elderly population. However, little is known about the utility of lateral spine DXA for patients with chronic kidney diseases. This study aimed to analyze the utility of lateral spine BMD for fragility fractures in long-term kidney graft recipients. METHODS A total of 357 stable kidney transplant recipients for a minimum of 1 year after kidney transplantation underwent DXA measurements at several sites, including the lateral spine between January 2017 and December 2018. We collected data on new incident fractures from the patients' medical records. RESULTS The median post-transplantation time at baseline DXA measurement was 12.6 years. During the median follow-up period of 3.5 years, 41 (11.4%) fractures occurred. The lateral spine BMDs were independently associated with fractures (adjusted hazard ratio 0.076; 95% confidence interval 0.012-0.42, p = 0.003). The cumulative incidence rate of fractures was significantly higher in the lower lateral spine BMD group (< 0.471 g/cm2, optimal cut-off value by receiver operating characteristic curve) than in the higher lateral spine BMD group (23.4 vs. 7.4%, adjusted hazard ratio 4.92; 95% confidence interval 2.33-10.74, p < 0.001). CONCLUSION Lateral lumbar spine BMD can be used to predict the risk of fragility fractures in long-term kidney graft recipients.
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Ebeling PR, Nguyen HH, Aleksova J, Vincent AJ, Wong P, Milat F. Secondary Osteoporosis. Endocr Rev 2022; 43:240-313. [PMID: 34476488 DOI: 10.1210/endrev/bnab028] [Citation(s) in RCA: 100] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Indexed: 02/07/2023]
Abstract
Osteoporosis is a global public health problem, with fractures contributing to significant morbidity and mortality. Although postmenopausal osteoporosis is most common, up to 30% of postmenopausal women, > 50% of premenopausal women, and between 50% and 80% of men have secondary osteoporosis. Exclusion of secondary causes is important, as treatment of such patients often commences by treating the underlying condition. These are varied but often neglected, ranging from endocrine to chronic inflammatory and genetic conditions. General screening is recommended for all patients with osteoporosis, with advanced investigations reserved for premenopausal women and men aged < 50 years, for older patients in whom classical risk factors for osteoporosis are absent, and for all patients with the lowest bone mass (Z-score ≤ -2). The response of secondary osteoporosis to conventional anti-osteoporosis therapy may be inadequate if the underlying condition is unrecognized and untreated. Bone densitometry, using dual-energy x-ray absorptiometry, may underestimate fracture risk in some chronic diseases, including glucocorticoid-induced osteoporosis, type 2 diabetes, and obesity, and may overestimate fracture risk in others (eg, Turner syndrome). FRAX and trabecular bone score may provide additional information regarding fracture risk in secondary osteoporosis, but their use is limited to adults aged ≥ 40 years and ≥ 50 years, respectively. In addition, FRAX requires adjustment in some chronic conditions, such as glucocorticoid use, type 2 diabetes, and HIV. In most conditions, evidence for antiresorptive or anabolic therapy is limited to increases in bone mass. Current osteoporosis management guidelines also neglect secondary osteoporosis and these existing evidence gaps are discussed.
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Affiliation(s)
- Peter R Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia
| | - Hanh H Nguyen
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Department of Endocrinology and Diabetes, Western Health, Victoria 3011, Australia
| | - Jasna Aleksova
- Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
| | - Amanda J Vincent
- Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Monash Centre for Health Research and Implementation, School of Public Health and Preventative Medicine, Monash University, Clayton, Victoria 3168, Australia
| | - Phillip Wong
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
| | - Frances Milat
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
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Jirasirirak S, Disthabanchong S, Ongphiphadhanakul B, Arj-Ong Vallibhakara S, Nimitphong H. Prevalence and predictors of asymptomatic vertebral fracture in patients with end-stage renal disease. Heliyon 2022; 8:e09158. [PMID: 35368525 PMCID: PMC8965903 DOI: 10.1016/j.heliyon.2022.e09158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 12/23/2021] [Accepted: 03/18/2022] [Indexed: 12/03/2022] Open
Abstract
Objective This study aimed to investigate the prevalence and predictors of asymptomatic vertebral fracture in patients with end-stage renal disease undergoing hemodialysis. Methods This cross-sectional study included 80 patients with end-stage renal disease undergoing hemodialysis. Medical history, Fracture Risk Assessment Tool and anteroposterior and lateral radiographs of the thoracolumbar and lumbosacral spine were obtained. Vertebral fractures were identified using the Genant semiquantitative assessment. Results Radiography demonstrated asymptomatic vertebral fracture in 22 patients (27.5%). FRAX® results for major osteoporotic fracture (area under the curve, 0.64) and hip fracture (area under the curve, 0.62) were able to discriminate patients with prevalent asymptomatic vertebral fracture. A multivariate analysis demonstrated that a 1-year average corrected calcium (odds ratio, 0.38), steroid use (odds ratio, 8.99), and a serum albumin concentration <25 g/dL (odds ratio, 28.82) significantly predicted prevalent asymptomatic vertebral fracture (clinical model; area under the curve, 0.82). Combining the 1-year average corrected calcium and serum albumin concentration <25 g/dL with FRAX® results for major osteoporotic fracture (area under the curve, 0.78) and FRAX® results for hip (area under the curve, 0.75) produced a significantly greater area under the curve value to predict fracture when compared with FRAX® result for major osteoporotic fracture and FRAX® result for hip (P = 0.022). Conclusion Asymptomatic vertebral fracture is prevalent. FRAX® results for major osteoporotic fracture and hip provided lower ability in predicting asymptomatic vertebral facture when compared to the clinical model. Combining a 1-year average corrected calcium and serum albumin concentration <25 g/dL with FRAX® result for major osteoporotic fracture or hip improved the model's performance and provided comparable area under the curve to the clinical model.
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Affiliation(s)
- Sasipim Jirasirirak
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Sinee Disthabanchong
- Division of Nephrology, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Boonsong Ongphiphadhanakul
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Sakda Arj-Ong Vallibhakara
- Faculty of Medicine, Bangkokthonburi University, Bangkok 10170, Thailand.,Child Safety Promotion and Injury Prevention Research Center, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Hataikarn Nimitphong
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
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Karatas A, Erdem E, Arıcı YK, Canakci E, Turkmen E, Turker NT. The frequency of osteoporosis in patients with predialysis chronic renal failure and the factors affecting the development of osteoporosis. Niger J Clin Pract 2022; 25:137-143. [PMID: 35170438 DOI: 10.4103/njcp.njcp_326_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Osteoporosis is a common public health problem in chronic kidney patients. The risk factors for osteoporosis in patients with nondialysis CKD have not been fully investigated. It is not known exactly whether the risk factors of osteoporosis in the general population are also valid for the nondialysis CKD patients. Aims: This study aims to determine the frequency of osteoporosis and the risk factors for osteoporosis in nondialysis CKD patients. Patients and Methods Our study was performed with 283 nondialysis stage 3-5 CKD patients. According to the BMD results, the patients were classified into groups as normal, osteopenia and osteoporosis according to World Health Organization criteria. Monocyte/high-density lipoprotein-cholesterol ratio (MHR), neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR) were calculated individually for all cases. Results According to our BMD results, 67 (24%) patients were found to have osteoporosis. In the osteoporosis patient group, compared to the normal BMD group, females were higher and the mean age was higher (P = 0.025, P = 0.028). Body mass index (BMI) and eGFR were lower in the osteoporosis group (P = 0.013). Parathyroid Hormone and Platelet-to-lymphocyte ratio in the patients in the osteoporosis group was higher than of those in the normal group (P = 0.026, P = 0.035). In the multivariate logistic regression analysis, advanced age, female gender, and low BMI were determined as independent risk factors for the development of osteoporosis in nondialysis CKD patients. Conclusion Advanced age, female gender and low BMI are the risk factors for osteoporosis in nondialysis CKD patients. It may be a rational approach to measure BMD for the diagnosis of osteoporosis in nondialysis CKD patients who are elderly, female and have low BMI.
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Affiliation(s)
- A Karatas
- Department of Internal Medicine, Division of Nephrology, Education and Research Hospital, Ordu University School of Medicine, Ordu, Turkey
| | - E Erdem
- Samsun Dialysis Clinic, Ondokuz Mayis University, School of Medicine, Samsun, Turkey
| | - Y K Arıcı
- Department of Biostatistics and Medical Informatics, Ordu University, School of Medicine, Ordu, Turkey
| | - E Canakci
- Department of Anesthesiology and Reanimation, Education and Research Hospital, Ordu University, School of Medicine, Ordu, Turkey
| | - E Turkmen
- Department of Internal Medicine, Division of Nephrology, Ondokuz Mayis University, School of Medicine, Samsun, Turkey
| | - N T Turker
- Department of Internal Medicine, Education and Research Hospital, Ordu University School of Medicine, Ordu, Turkey
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Bucharles SGE, Carmo LPDFD, Carvalho AB, Jorgetti V. Diagnosis of bone abnormalities in CKD-MBD (Imaging and bone biopsy). J Bras Nefrol 2021; 43:621-627. [PMID: 34910795 PMCID: PMC8823924 DOI: 10.1590/2175-8239-jbn-2021-s103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 06/11/2021] [Indexed: 12/03/2022] Open
Affiliation(s)
| | | | | | - Vanda Jorgetti
- Universidade de São Paulo, Pathophysiology Laboratory (LIM-16), Hospital das Clínicas da Faculdade de Medicina da USP, São Paulo, SP, Brazil
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Xiang T, Zhou L, Fu P, Yan XP, Zeng XQ. Value of quantitative ultrasound and bioelectrical impedance analysis in detecting low bone mineral density in hemodialysis. Ren Fail 2021; 43:1198-1204. [PMID: 34369272 PMCID: PMC8354166 DOI: 10.1080/0886022x.2021.1959347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 07/19/2021] [Accepted: 07/19/2021] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION Patients on maintenance hemodialysis (MHD) are highly predisposed to low bone mineral density (BMD). This study aims to assess the value of quantitative ultrasound (QUS), bioelectrical impedance analysis (BIA), and their combination in detecting high-risk patients for low BMD in MHD. METHODS Patients' BMD of the total hip, femoral neck, and lumbar spine were measured using dual-energy X-ray absorptiometry (DXA). Bone mineral content (BMC) was assessed using BIA. Calcaneal BMD was measured using QUS. Patients with a T-score of ≤-2.5 were recorded as 'low BMD.' RESULTS Overall, 93 subjects (62.37% female; mean age, 60.8 ± 16.2 years) were included in this cross-sectional study; approximately 36.56% met the 'low BMD' criteria. QUS-T score predicted low BMD with an area under the curve (AUC) value of 0.738, sensitivity of 70.59%, and specificity of 76.27%. The AUC for low BMD diagnosis using the BMC index (BMCI) measured through BIA was 0.679 (sensitivity, 91.18%; specificity, 38.98%). On the other hand, the combination of QUS-T score and BMCI yielded a higher AUC value of 0.762 with an improved specificity of 88.14%. Compared with the QUS and BIA alone, the net reclassification improvement (NRI) of the combination model increased by 47.16% (p = 0.022) and 78.36% (p < 0.0001), respectively. Integrated discrimination improvement (IDI) increased by 5.25% (p = 0.043) and 9.99% (p = 0.003), respectively. QUS-T score and BMCI were related to BMD independently assessed by DXA. CONCLUSION The combination of QUS and BIA is effective in screening for low BMD among MHD patients.
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Affiliation(s)
- Ting Xiang
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Li Zhou
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Ping Fu
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Xue-Ping Yan
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Xiao-Qing Zeng
- Nutrition Department, West China Hospital of Sichuan University, Chengdu, Sichuan, China
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34
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Guía de unidades de hemodiálisis 2020. Nefrologia 2021. [DOI: 10.1016/j.nefro.2021.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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35
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Evenepoel P, Cunningham J, Ferrari S, Haarhaus M, Javaid MK, Lafage-Proust MH, Prieto-Alhambra D, Torres PU, Cannata-Andia J. Diagnosis and management of osteoporosis in chronic kidney disease stages 4 to 5D: a call for a shift from nihilism to pragmatism. Osteoporos Int 2021; 32:2397-2405. [PMID: 34129059 DOI: 10.1007/s00198-021-05975-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/21/2021] [Indexed: 12/22/2022]
Abstract
The European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) CKD-MBD working group, in collaboration with the Committee of Scientific Advisors of the International Osteoporosis Foundation, published a position paper for the diagnosis and management of osteoporosis in patients with CKD stages 4-5D (eGFR < 30 ml/min 1.73 m2). The present article reports and summarizes the main recommendations included in this 2021 document. The following areas are reviewed: diagnosis of osteoporosis; risk factors for fragility fractures; fracture risk assessment; intervention thresholds for pharmacological intervention; general and pharmacological management of osteoporosis; monitoring of treatment, and systems of care, all in patients with CKD stages 4-5D. Guidance is provided for clinicians caring for CKD stages 4-5D patients with osteoporosis, allowing for a pragmatic individualized diagnostic and therapeutic approach as an alternative to current variations in care and treatment nihilism.
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Affiliation(s)
- P Evenepoel
- Division of Nephrology, University Hospitals Leuven, KU Leuven, Herestraat 49, B-3000, Leuven, Belgium.
| | - J Cunningham
- Centre for Nephrology, Royal Free Campus, UCL Medical School, Rowland Hill Street, London, NW3 2PF, UK
| | - S Ferrari
- Service of Bone diseases, Geneva university Hospital Switzerland, Rue Gabrielle-Perret-Gentil 4, 1205, Genève, Switzerland
| | - M Haarhaus
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet,, Karolinska University Hospital, Solna, Sweden
| | - M K Javaid
- NDORMS, University of Oxford, Windmill Road, Oxford, OX3 7HE, UK
| | | | - D Prieto-Alhambra
- CSM-NDORMS, University of Oxford, Windmill Road, Oxford, OX3 7LD, UK
| | - P U Torres
- AURA Nord Saint Ouen, 108 bis, avenue Gabriel Péri, 93400, Saint Ouen, France
- Department of Renal Physiology, Necker Hospital, University of Paris Descartes, Paris, France
| | - J Cannata-Andia
- Bone and Mineral Research Unit (ISPA) (REDinREN), Hospital Universitario Central Asturias, Oviedo University, Asturias, Spain
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Hampson G, Elder GJ, Cohen-Solal M, Abrahamsen B. A review and perspective on the assessment, management and prevention of fragility fractures in patients with osteoporosis and chronic kidney disease. Endocrine 2021; 73:509-529. [PMID: 33974225 PMCID: PMC8325650 DOI: 10.1007/s12020-021-02735-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 04/19/2021] [Indexed: 01/01/2023]
Abstract
This article aims to review the methods used for the assessment of fracture risk and the use of osteoporosis medications for fracture prevention in the population with CKD, and highlights the difficulties faced by clinicians in the management of these patients and the latest recommendations and guidelines. Chronic kidney disease (CKD) and osteoporosis often co-exist in older adults, and they present a major healthcare challenge. CKD mineral and bone disorder (CKD-MBD) occurs as renal function declines and this syndrome affects most patients in CKD stages 4 and 5. The biochemical abnormalities of CKD-MBD, renal bone disease and risk factors associated with age-related bone loss and osteoporosis lead to a cumulative effect on fracture risk and mortality. There is a need for routine evaluation of fracture risk and fracture prevention in this population. Measurement of bone mineral density (BMD) and the use of the FRAX tool have predictive value for incident fractures in the general population and in CKD. This enables physicians to identify CKD patients most at risk of sustaining a fragility fracture and allows a more targeted approach to fracture prevention. Data analysis from the pivotal trials of therapeutic agents used in osteoporosis show that these drugs can be considered in mild and moderate CKD (stages 1-3 CKD). Off-label drug use in patients with CKD-MBD and more severe renal impairment (CKD stages 4 and 5) could offer significant benefits to sub-groups of patients when carefully tailored to each individual's bone turnover and calcium and phosphate balance. However, this requires a selective approach and treatment decisions based on inference from pathophysiology while we await further trials. Guidelines advocate the correction and/or reduction of the biochemical abnormalities of CKD-MBD before initiation of treatment with osteoporosis drugs and close monitoring during treatment.
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Affiliation(s)
- Geeta Hampson
- Department of Chemical Pathology and Metabolic Medicine, St Thomas' Hospital, London, UK.
- Metabolic Bone Clinic, Department of Rheumatology, Guy's Hospital, London, UK.
| | - Grahame J Elder
- Department of Renal Medicine, Westmead Hospital, Sydney, New South Wales, Australia
- Osteoporosis and Bone Biology Program, Garvan Institute of Medical Research, Sydney, New South Wales, Australia
- Faculty of Medicine, University of Notre Dame Australia, Level 2, 88-90 Water Street, Auburn, New South Wales, 2144, Australia
| | - Martine Cohen-Solal
- Bioscar Inserm U1132 and Université de Paris, Hôpital Lariboisière, F-75010, Paris, France
| | - Bo Abrahamsen
- Department of Medicine, Holbæk Hospital, Holbæk, Denmark
- Department of Clinical Research, Open Data Explorative Network, University of Southern Denmark, Odense, Denmark
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Kim K, Song SH, Kim IJ, Jeon YK. Is dual-energy absorptiometry accurate in the assessment of bone status of patients with chronic kidney disease? Osteoporos Int 2021; 32:1859-1868. [PMID: 33598794 DOI: 10.1007/s00198-020-05670-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 10/05/2020] [Indexed: 02/06/2023]
Abstract
UNLABELLED Several patients with chronic kidney disease (CKD) have deteriorated bone status. Estimation of bone status using DXA has limitations especially in patients with CKD accompanying aortic calcifications. Quantitative CT and the trabecular bone score could be more accurate methods to estimate bone status for patients with CKD and vascular calcifications. INTRODUCTION It remains unclear whether dual-energy absorptiometry (DXA) is appropriate for the assessment of bone status in patients with chronic kidney disease (CKD), a disease that impacts bone health. The aims of this study were to compare DXA and central quantitative computed tomography (cQCT) and to evaluate bone status in patients with pre-dialysis CKD. METHODS This retrospective study included 363 healthy control subjects whose bone mineral density (BMD) was evaluated with DXA and 117 CKD patients whose BMD was evaluated using both cQCT and DXA. Diagnostic discordance was assessed between the lumbar spine (LS) and femur neck (FN) from DXA or between two modalities. The trabecular bone score (TBS) was extracted from DXA images. The volume of abdominal aortic calcification (AAC) was calculated using CT images from cQCT. RESULTS Using LS DXA T-score, osteoporosis was less common in the CKD group than in controls. Patients with normal LS BMD using DXA were reclassified into osteopenia or osteoporosis using cQCT in CKD patients. Among discordant subjects between FN and LS in DXA, a higher BMD of LS was more common in CKD patients than in controls. CKD patients had lower TBS than controls despite having the same diagnosis using DXA. AAC volume negatively correlated with BMD from cQCT and with TBS but not with BMD from DXA. CONCLUSIONS TBS and cQCT could accurately assess bone status in CKD patients since DXA may overestimate LS BMD, likely due to an increased AAC volume.
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Affiliation(s)
- K Kim
- Department of Nuclear Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - S H Song
- Division of Nephrology, Department of Internal Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - I-J Kim
- Department of Nuclear Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine and Biomedical Research Institute, Pusan National University School of Medicine, Pusan National University Hospital, Gudeok-ro 179, Seo-gu, Busan, 602-739, South Korea
| | - Y K Jeon
- Division of Endocrinology and Metabolism, Department of Internal Medicine and Biomedical Research Institute, Pusan National University School of Medicine, Pusan National University Hospital, Gudeok-ro 179, Seo-gu, Busan, 602-739, South Korea.
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Jafari M, Anwar S, Kour K, Sanjoy S, Goyal K, Prasad B. T Scores, FRAX, Frailty Phenotype, Falls, and Its Relationship to Fractures in Patients on Maintenance Hemodialysis. Can J Kidney Health Dis 2021; 8:20543581211041184. [PMID: 34457317 PMCID: PMC8392815 DOI: 10.1177/20543581211041184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 07/18/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Despite the magnitude of fracture and the consequences in patients receiving hemodialysis, optimal risk assessment tools in this population are not well explored. Frailty and falls-known risk factors for fracture in chronic kidney disease (CKD) and non-CKD populations-are common in patients receiving hemodialysis (HD) therapy. While the relationship between T scores in relation to fractures in patients receiving HD is recognized, there is a paucity of data to the additional contributions of fracture assessment tool (FRAX), frailty status, and falls in its relationship with fracture. OBJECTIVES To evaluate the clinical utility of adding FRAX, frailty status, and falls to T scores at the femoral neck to determine whether it enhances fracture discrimination in patients on maintenance HD. DESIGN A cross-sectional observational study. SETTING Two main dialysis units in Regina, Saskatchewan, Canada. PATIENTS A total of 109 patients on maintenance HD at two dialysis units from January 1, 2017, to December 31, 2018, were included in the study. MEASUREMENTS Fracture (the main outcome) was documented based on the review of medical charts, self-recall, and additionally vertebral fractures were identified by an x-ray. Areal bone mineral density (BMD) was measured by dual-energy x-ray absorptiometry (DXA). FRAX score was calculated using an online algorithm based on 11 clinical risk factors. We calculated the FRAX score for hip fracture and major osteoprotoic fracture with and without the inclusion of BMD. Frailty was assessed using the Fried criteria, which included assessments of unintentional weight loss, weakness (handgrip strength), slowness (walking speed), and questionnaires for physical activity and self-perceived exhaustion. Patients were enquired about the history and frequency of falls. METHODS A total of 131 patients underwent frailty assessments at the two dialysis units during the dialysis treatment. Following frailty assessments, they were referred for DXA scans and upon receipt of the results undertook FRAX questionnaires. They were additionally sent for lumbar x-rays and contacted for a history of falls. Association between the BMD-T score, FRAX, frailty status, falls, with fracture were examined with sequential multivariable logistic regression models. Differences were considered statistically significant at P values <.05. RESULTS A total of 109 patients were included in the data analysis. The composite of fracture occurred in 37.6% of patients. About 59.3% were identified as frail, and 29% of the participants had at least one fall in the last year. On multivariate regression analysis, each lower standard deviation (SD) in femoral neck T score was associated with 48% higher odds of fracture (odds ratio [OR] = 1.48; 95% confidence interval [CI] 1.20-1.68, P = .005). With the inclusion for FRAX scores (hip), the OR for fracture remained significant at 1.38 (OR = 1.38, 95% CI 1.04-1.63, P = .043). The addition of frailty status and history of falls did not further improve the model. Low T score and FRAX were both independent risk factors in patients on HD therapy. LIMITATIONS This is a single-center study with a small sample size which limits the generalizability of the findings. Due to the cross-sectional study, associations identified may be difficult to interpret. CONCLUSIONS Both BMD measurements by DXA and FRAX are useful tools to assess fracture in patients receiving HD. The addition of frailty status and history of falls is not associated with fractures in this population. Larger prospective studies are needed to determine whether the inclusion of frailty and falls to the conventional models will improve fracture assessment in the population receiving HD. TRIAL REGISTRATION The study was not registered on a publicly accessible registry as it did not involve health care intervention on human participants.
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Affiliation(s)
- Maryam Jafari
- Dr. T. Bhanu Prasad Medical Professional Corporation, Regina, SK, Canada
| | - Salman Anwar
- College of Medicine, University of Saskatchewan, Regina, Canada
| | - Kaval Kour
- Dr. T. Bhanu Prasad Medical Professional Corporation, Regina, SK, Canada
| | - Shubrandu Sanjoy
- Research Department, Saskatchewan Health Authority, Regina, Canada
| | - Kunal Goyal
- Department of Radiology, Regina General Hospital, Regina, SK, Canada
| | - Bhanu Prasad
- Section of Nephrology, Department of Medicine, Regina General Hospital, Regina, SK, Canada
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Chen PC, Chang SW, Hsieh CY, Liou JC, Chang JF, Wang TM. Fat-Bone Relationship in Chronic Kidney Disease-Mineral Bone Disorders: Adiponectin Is Associated with Skeletal Events among Hemodialysis Patients. Diagnostics (Basel) 2021; 11:diagnostics11071254. [PMID: 34359336 PMCID: PMC8303150 DOI: 10.3390/diagnostics11071254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/08/2021] [Accepted: 07/11/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The risk of skeletal events is rising in parallel with the burden of chronic kidney disease and mineral bone disorder (CKD-MBD), whilst the role of the fat-bone axis in CKD-MBD remains elusive. Adiponectin derived from adipocytes has emerged as a valid biomarker of low bone mineral density and increased marrow adiposity. We aimed to explore the association between adiponectin and bone fracture (BF) risks in patients with maintenance hemodialysis (MHD). METHODS Serum concentrations of adiponectin and bio-clinical data were determined at study entry. The Cox proportional hazard regression analyses were used to assess unadjusted and adjusted hazard ratios (aHRs) of adiponectin and various clinical predictors for BF risks. The predictive accuracy of adiponectin for BF events was evaluated by receiver operating characteristic (ROC) curve analysis. RESULTS Age and serum concentrations of adiponectin, phosphate, and intact parathyroid hormone were significantly associated with higher risks of BF. With respect to the risk of BF events, the cumulative event-free survival curves differed significantly between the high and low concentration groups of adiponectin (p = 0.02). In multivariable analysis, higher adiponectin levels were associated with an incremental risk of BF (adjusted hazard ratios (aHRs): 1.08 (95% confidence interval (CI): 1.01-1.15, p < 0.05). The ROC analysis of adiponectin cutoff point concentration (18.15 ug/mL) for prediction of BF showed 0.66 (95% CI = 0.49 to 0.84). CONCLUSION Adiponectin was associated with an incremental risk of BF that could serve as a potential predictor of BF in MHD patients. In the high-risk population with hyperphosphatemia, an elevated adiponectin level could alert clinicians to the urgent need to correct mineral dysregulation and undertake further bone survey.
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Affiliation(s)
- Po-Cheng Chen
- Department of Urology, En Chu Kong Hospital, New Taipei City 237, Taiwan;
| | - Shu-Wei Chang
- Department of Civil Engineering, National Taiwan University, Taipei 106, Taiwan;
| | - Chih-Yu Hsieh
- School of Biomedical Engineering, Taipei Medical University, Taipei 110, Taiwan; (C.-Y.H.); (J.-C.L.)
| | - Jian-Chiun Liou
- School of Biomedical Engineering, Taipei Medical University, Taipei 110, Taiwan; (C.-Y.H.); (J.-C.L.)
| | - Jia-Feng Chang
- Department of Internal Medicine, Division of Nephrology, Shuang Ho Hospital, Taipei Medical University, New Taipei City 235, Taiwan
- Department of Internal Medicine, Division of Nephrology, En Chu Kong Hospital, New Taipei City 237, Taiwan
- Renal Care Joint Foundation, New Taipei City 220, Taiwan
- Department of Nursing, Yuanpei University of Medical Technology, Hsinchu 300, Taiwan
- Correspondence:
| | - Ting-Ming Wang
- Department of Orthopaedic Surgery, School of Medicine, National Taiwan University, Taipei 106, Taiwan;
- Department of Orthopaedic Surgery, National Taiwan University Hospital, Taipei 106, Taiwan
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Chang JF, Hsieh CY, Liou JC, Lu KC, Zheng CM, Wu MS, Chang SW, Wang TM, Wu CC. Circulating p-Cresyl Sulfate, Non-Hepatic Alkaline Phosphatase and Risk of Bone Fracture Events in Chronic Kidney Disease-Mineral Bone Disease. Toxins (Basel) 2021; 13:toxins13070479. [PMID: 34357951 PMCID: PMC8310177 DOI: 10.3390/toxins13070479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 07/06/2021] [Accepted: 07/07/2021] [Indexed: 12/12/2022] Open
Abstract
Patients with chronic kidney disease (CKD), especially those undergoing hemodialysis, are at a considerably high risk of bone fracture events. Experimental data indicate that uremic toxins intricately involved in bone-related proteins exert multi-faced toxicity on bone cells and tissues, leading to chronic kidney disease–mineral and bone disorder (CKD-MBD). Nonetheless, information regarding the association between p-cresyl sulfate (PCS), non-hepatic alkaline phosphatase (NHALP) and skeletal events remains elusive. We aim to explore the association between PCS, NHALP and risk of bone fracture (BF) in patients with hemodialysis. Plasma concentrations of PCS and NHALP were ascertained at study entry. Cox proportional hazard regression analyses were used to determine unadjusted and adjusted hazard ratios (aHRs) of PCS for BF risk. In multivariable analysis, NHALP was associated with incremental risks of BFs [aHR: 1.06 (95% CI: 1.01–1.11)]. The association between the highest PCS tertile and BF risk remained robust [aHR: 2.87 (95% CI: 1.02–8.09)]. With respect to BF events, the interaction between NHALP and PCS was statistically significant (p value for the interaction term < 0.05). In addition to mineral dysregulation and hyperparathyroidism in hemodialysis patients, higher circulating levels of PCS and NHALP are intricately associated with incremental risk of BF events, indicating that a joint evaluation is more comprehensive than single marker. In light of the extremely high prevalence of CKD-MBD in the hemodialysis population, PCS may act as a pro-osteoporotic toxin and serve as a potential surrogate marker for skeletal events.
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Affiliation(s)
- Jia-Feng Chang
- Division of Nephrology, Department of Internal Medicine, En Chu Kong Hospital, New Taipei City 237, Taiwan;
- Department of Nursing, Yuanpei University of Medical Technology, Hsinchu 300, Taiwan
- Division of Nephrology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City 235, Taiwan; (C.-M.Z.); (M.-S.W.)
- Research Center of Urology and Kidney, Taipei Medical University, Taipei City 110, Taiwan
- Renal Care Joint Foundation, New Taipei City 220, Taiwan
| | - Chih-Yu Hsieh
- School of Biomedical Engineering, Taipei Medical University, Taipei 110, Taiwan; (C.-Y.H.); (J.-C.L.)
| | - Jian-Chiun Liou
- School of Biomedical Engineering, Taipei Medical University, Taipei 110, Taiwan; (C.-Y.H.); (J.-C.L.)
| | - Kuo-Cheng Lu
- Division of Nephrology, Department of Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City 231, Taiwan;
| | - Cai-Mei Zheng
- Division of Nephrology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City 235, Taiwan; (C.-M.Z.); (M.-S.W.)
- Research Center of Urology and Kidney, Taipei Medical University, Taipei City 110, Taiwan
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan
| | - Mai-Szu Wu
- Division of Nephrology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City 235, Taiwan; (C.-M.Z.); (M.-S.W.)
- Research Center of Urology and Kidney, Taipei Medical University, Taipei City 110, Taiwan
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan
| | - Shu-Wei Chang
- Department of Civil Engineering, National Taiwan University, Taipei 106, Taiwan;
| | - Ting-Ming Wang
- Department of Orthopaedic Surgery, School of Medicine, National Taiwan University, Taipei 100, Taiwan;
- Department of Orthopaedic Surgery, National Taiwan University Hospital, Taipei 100, Taiwan
| | - Chang-Chin Wu
- Department of Orthopaedic Surgery, National Taiwan University Hospital, Taipei 100, Taiwan
- Department of Biomedical Engineering, Yuanpei University of Medical Technology, Hsinchu 300, Taiwan
- Department of Orthopaedic Surgery, En-Chu-Kong Hospital, New Taipei City 237, Taiwan
- Correspondence:
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Habas E, Eledrisi M, Khan F, Elzouki ANY. Secondary Hyperparathyroidism in Chronic Kidney Disease: Pathophysiology and Management. Cureus 2021; 13:e16388. [PMID: 34408941 PMCID: PMC8362860 DOI: 10.7759/cureus.16388] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2021] [Indexed: 12/25/2022] Open
Abstract
Serum calcium concentration is the main determinant of parathyroid hormone (PTH) release. Defect in the activation of vitamin D in the kidneys due to chronic kidney disease (CKD) leads to hypocalcemia and hyperphosphatemia, resulting in a compensatory increase in parathyroid gland cellularity and parathyroid hormone production and causing secondary hyperparathyroidism (SHP). Correction and maintenance of normal serum calcium and phosphate are essential to preventing SHP, hungry bone disease, cardiovascular events, and anemia development. Understanding the pathophysiology of PTH and possible therapeutic agents can reduce the development and associated complications of SHP in patients with CKD. Medical interventions to control serum calcium, phosphate, and PTH such as vitamin D analogs, calcium receptor blockers, and parathyroidectomy are needed in some CKD patients. In this review, we discuss the pathophysiology, clinical presentation, and management of SHP in CKD patients.
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Affiliation(s)
| | | | - Fahmi Khan
- Internal Medicine, Hamad General Hospital, Doha, QAT
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Cerdas Pérez S, Herrera LE, González E. Clinical impact of misinterpretation of dual-energy X-ray absorptiometry during the evaluation of osteoporotic patients. Climacteric 2021; 24:577-586. [PMID: 34008476 DOI: 10.1080/13697137.2021.1918079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Osteoporosis is a highly prevalent systemic skeletal disorder leading to decreased bone strength and increased susceptibility to fragility fracture. The global burden of osteoporosis negatively impacts health systems around the world, and the estimation of millions of individuals at high risk for fracture in 2010 will double by the year 2040. There are many techniques to evaluate bone mineral density, but the preferred method in clinical practice is dual-energy X-ray absorptiometry (DXA). This method, despite offering multiple advantages, can lead us to a wrong diagnosis if we do not take into account certain clinical and technical considerations. The objective of this review is to analyze the different aspects that we must consider when, as clinicians, we have to evaluate a densitometric report. These aspects are presented as technical factors influencing DXA results and patients' conditions limiting DXA interpretation.
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Affiliation(s)
- S Cerdas Pérez
- Department of Endocrinology, Hospital Cima San José, Faculty of Medicine, University of Costa Rica, San José, Costa Rica
| | - L E Herrera
- Department of Endocrinology, Hospital La Católica, Faculty of Medicine, University of Costa Rica, San José, Costa Rica
| | - E González
- Centro Radiológico Santa María, Faculty of Medicine, University of Costa Rica, San José, Costa Rica
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Ferreira AC, Mendes M, Silva C, Cotovio P, Aires I, Navarro D, Caeiro F, Salvador R, Correia B, Cabral G, Nolasco F, Ferreira A. Bone densitometry versus bone histomorphometry in renal transplanted patients: a cross-sectional study. Transpl Int 2021; 34:1065-1073. [PMID: 33909300 DOI: 10.1111/tri.13888] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/23/2021] [Accepted: 04/14/2021] [Indexed: 11/28/2022]
Abstract
Bone loss leads to increase risk of fractures in renal transplantation. The aim of this study was to analyse the relationship between bone densitometry (DXA) findings, bone histomorphometry and bone-related molecules 1-year after renal transplantation. We performed a cross-sectional study of de novo renal transplanted patients that agreed to perform a bone biopsy and a DXA examination 1 year after transplantation. All patients underwent a laboratory evaluation, bone biopsy, DXA examination and cardiac CT 1 year after transplantation. 67 patients were included, 16 had a normal examination, and 18 patients were classified as having osteoporosis by DXA. Correlations between bone mineral density and T-scores of total femur and femoral neck were the ones that best correlated with bone volume assessed by a bone biopsy. The sensitivity of DXA for osteoporosis diagnosis was 47.0%, and the specificity was 81.2%. The positive predictive value was 50.0%, and the negative predictive value (NPV) was 80.0%. DXA parameters also correlated with klotho and sclerostin serum levels. In this population, a normal examination excluded the presence of osteoporosis, helping in identifying patients that would not benefit from therapy. Overall, densitometry in total femur and femoral neck correlated well with bone volume measured by bone biopsy.
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Affiliation(s)
- Ana Carina Ferreira
- Nephrology Department, Hospital Curry Cabral, CHULC, Lisbon, Portugal.,Nova Medical School, Lisbon, Portugal
| | - Marco Mendes
- Nephrology Department, Hospital Curry Cabral, CHULC, Lisbon, Portugal
| | - Cecília Silva
- Nephrology Department, Hospital Curry Cabral, CHULC, Lisbon, Portugal
| | - Patrícia Cotovio
- Nephrology Department, Hospital Curry Cabral, CHULC, Lisbon, Portugal
| | - Inês Aires
- Nephrology Department, Hospital Curry Cabral, CHULC, Lisbon, Portugal.,Nova Medical School, Lisbon, Portugal
| | - David Navarro
- Nephrology Department, Hospital Curry Cabral, CHULC, Lisbon, Portugal
| | - Fernando Caeiro
- Nephrology Department, Hospital Curry Cabral, CHULC, Lisbon, Portugal
| | - Rute Salvador
- Tissue Repair and Inflammation Lab, CEDOC, Lisbon, Portugal
| | - Bruna Correia
- Tissue Repair and Inflammation Lab, CEDOC, Lisbon, Portugal
| | | | - Fernando Nolasco
- Nephrology Department, Hospital Curry Cabral, CHULC, Lisbon, Portugal.,Nova Medical School, Lisbon, Portugal
| | - Aníbal Ferreira
- Nephrology Department, Hospital Curry Cabral, CHULC, Lisbon, Portugal.,Nova Medical School, Lisbon, Portugal
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Aleksova J, Milat F, Kotowicz MA, Pasco JA, Schultz C, Wong P, Ebeling PR, Elder GJ. Patients with end-stage kidney disease have markedly abnormal cortical hip parameters by dual-energy X-ray absorptiometry. Nephrol Dial Transplant 2021; 36:543-550. [PMID: 31697355 DOI: 10.1093/ndt/gfz195] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 08/01/2019] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Patients with end-stage kidney disease (ESKD) have higher fracture rates and post-fracture mortality than the general population, but bone mineral density by dual-energy X-ray absorptiometry (DXA) is less predictive of fracture in this patient group. Bone biopsy and high-resolution imaging indicate that cortical thickness (CT) is reduced and cortical porosity is increased in ESKD. The aim of this study was to assess cortical parameters using DXA in patients with ESKD. It was hypothesized that these parameters would show deterioration and be associated with fracture. METHODS Using advanced hip analysis, normal age-related ranges were determined from 752 female and 861 male femur scans and were compared with scans of 226 patients with ESKD at the time of transplantation. RESULTS Compared with controls, female patients had lower mean±SD CT (mms) at the femoral neck (FN) (2.59 ± 1.42 versus 5.23 ± 1.85), calcar (3.46 ± 1.07 versus 5.09 ± 1.30) and shaft (4.42 ± 1.21 versus 7.44 ± 2.07; P < 0.001 for each), and buckling ratios were higher (8.21 ± 4.6 versus 3.63 ± 1.42; P < 0.001), indicating greater FN instability. All findings were similar for men. Prevalent fracture was documented in 28.8% of patients; 12.4% vertebral only, 8.4% non-vertebral only and 8% vertebral plus non-vertebral. In adjusted models, each 1 SD reduction in FN CT and increase in the buckling ratio was associated with a respective 1.73 (1.22-2.46)- and 1.82 (1.49-2.86)-fold increase in the risk of prevalent vertebral fracture. CONCLUSIONS In patients with ESKD, DXA-derived cortical parameters are markedly abnormal compared with age- and sex-matched controls. These parameters should be assessed for incident fracture prediction and targeting treatment.
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Affiliation(s)
- Jasna Aleksova
- Hudson Institute for Medical Research, Clayton, Australia.,Department of Medicine, Monash University, Clayton, Australia.,Department of Endocrinology, Monash Health, Clayton, Australia
| | - Frances Milat
- Hudson Institute for Medical Research, Clayton, Australia.,Department of Medicine, Monash University, Clayton, Australia.,Department of Endocrinology, Monash Health, Clayton, Australia
| | - Mark A Kotowicz
- Deakin University, Geelong, Australia.,Barwon Health, University Hospital, Geelong, Australia.,Department of Medicine-Western Health, University of Melbourne, St Albans, Australia
| | - Julie A Pasco
- Deakin University, Geelong, Australia.,Barwon Health, University Hospital, Geelong, Australia.,Department of Medicine-Western Health, University of Melbourne, St Albans, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Chris Schultz
- Department of Nuclear Medicine, PET and Bone Densitometry, Royal Adelaide Hospital, Adelaide, Australia
| | - Phillip Wong
- Hudson Institute for Medical Research, Clayton, Australia.,Department of Medicine, Monash University, Clayton, Australia.,Department of Endocrinology, Monash Health, Clayton, Australia
| | - Peter R Ebeling
- Department of Medicine, Monash University, Clayton, Australia.,Department of Endocrinology, Monash Health, Clayton, Australia
| | - Grahame J Elder
- Department of Renal Medicine, Westmead Hospital, Sydney, Australia.,Osteoporosis and Bone Biology Division, Garvan Institute of Medical Research, Sydney, Australia
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Bushinsky DA, Raggi P, Bover J, Ketteler M, Bellasi A, Rodriguez M, Sinha S, Garg R, Perelló J, Gold A, Chertow GM. Effects of Myo-inositol Hexaphosphate (SNF472) on Bone Mineral Density in Patients Receiving Hemodialysis: An Analysis of the Randomized, Placebo-Controlled CaLIPSO Study. Clin J Am Soc Nephrol 2021; 16:736-745. [PMID: 33835939 PMCID: PMC8259477 DOI: 10.2215/cjn.16931020] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 01/22/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES In the CaLIPSO study, intravenous administration of SNF472 (300 or 600 mg) during hemodialysis significantly attenuated progression of coronary artery and aortic valve calcification. SNF472 selectively inhibits formation of hydroxyapatite, the final step in cardiovascular calcification. Because bone mineral is predominantly hydroxyapatite, we assessed changes in bone mineral density in CaLIPSO. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Patients with coronary artery calcification at screening (Agatston score of 100-3500 U) were randomized 1:1:1 to receive placebo, 300 mg SNF472, or 600 mg SNF472 as an intravenous infusion during hemodialysis three times weekly for 52 weeks. Dual-energy x-ray absorptiometry (DXA) scans were obtained at baseline (screening) and end of treatment, and between-group changes from baseline were compared using analysis of covariance. RESULTS Among 274 randomized patients, 202 had evaluable DXA scans at baseline and postrandomization (the DXA-modified intention-to-treat population). Mean (95% confidence interval) changes in total-hip bone mineral density from baseline to week 52 were -1.5% (-2.7% to -0.3%), -1.5% (-2.7% to -0.4%), and -2.5% (-3.8% to -1.2%) in the placebo, 300 mg SNF472, and 600 mg SNF472 groups, respectively. Mean (95% confidence interval) changes in femoral-neck bone mineral density from baseline to week 52 were -0.3% (-1.6% to 1.0%), -1.0% (-2.3% to 0.2%), and -2.6% (-4.0% to -1.3%), respectively. Regression analyses showed no correlation between change in coronary artery calcium volume and change in bone mineral density at either location. Changes in serum alkaline phosphatase, calcium, magnesium, phosphate, and intact parathyroid hormone levels were similar across treatment groups. Clinical fracture events were reported for four of 90, three of 92, and six of 91 patients in the placebo, 300 mg SNF472, and 600 mg SNF472 groups, respectively. CONCLUSIONS Bone mineral density decreased modestly in all groups over 1 year. In the 600 mg SNF472 group, the reduction appeared more pronounced. Reported fractures were infrequent in all groups. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER Effect of SNF472 on Progression of Cardiovascular Calcification in End-Stage-Renal-Disease (ESRD) Patients on Hemodialysis (HD), NCT02966028.
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Affiliation(s)
- David A. Bushinsky
- Department of Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Paolo Raggi
- Department of Medicine, Mazankowski Alberta Heart Institute and University of Alberta, Edmonton, Alberta, Canada
| | - Jordi Bover
- Department of Nephrology, Puigvert Foundation/Autonoma University, Sant Pau Biomedical Research Institute, Red de Investigacion Renal (REDinREN), Barcelona, Spain
| | - Markus Ketteler
- Department of General Internal Medicine and Nephrology, Robert Bosch Hospital, Stuttgart, Germany
| | - Antonio Bellasi
- Research, Innovation and Brand Reputation Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Mariano Rodriguez
- Nephrology Unit, Reina Sofia University Hospital, Maimonides Biomedical Research Institute of Córdoba (IMIBIC), Red de Investigacion Renal (REDinREN), Córdoba, Spain
| | - Smeeta Sinha
- Department of Renal Medicine, Salford Royal National Health Service Foundation Trust, Salford, United Kingdom
| | - Rekha Garg
- Research and Development, Sanifit Therapeutics, San Diego, California
| | - Joan Perelló
- Research and Development, Sanifit Therapeutics, Palma, Spain,University Institute of Health Sciences Research (IUNICS-IDISBA), University of the Balearic Islands, Palma, Spain
| | - Alex Gold
- Research and Development, Sanifit Therapeutics, San Diego, California,Department of Medicine, Stanford University, Palo Alto, California
| | - Glenn M. Chertow
- Department of Medicine, Stanford University, Palo Alto, California
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The Use of Imaging Techniques in Chronic Kidney Disease-Mineral and Bone Disorders (CKD-MBD)-A Systematic Review. Diagnostics (Basel) 2021; 11:diagnostics11050772. [PMID: 33925796 PMCID: PMC8146279 DOI: 10.3390/diagnostics11050772] [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] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/11/2021] [Accepted: 04/20/2021] [Indexed: 02/07/2023] Open
Abstract
Although frequently silent, mineral and bone disease (MBD) is one of the most precocious complication of chronic kidney disease (CKD) and is omnipresent in patients with CKD stage 5. Its pathophysiology is complex, but basically, disturbances in vitamin D, phosphate, and calcium metabolism lead to a diverse range of clinical manifestations with secondary hyperparathyroidism usually being the most frequent. With the decline in renal function, CKD-MBD may induce microstructural changes in bone, vascular system and soft tissues, which results in macrostructural lesions, such as low bone mineral density (BMD) resulting in skeletal fractures, vascular and soft tissue calcifications. Moreover, low BMD, fractures, and vascular calcifications are linked with increased risk of cardiovascular mortality and all-cause mortality. Therefore, a better characterization of CKD-MBD patterns, beyond biochemical markers, is helpful to adapt therapies and monitor strategies as used in the general population. An in-depth characterization of bone health is required, which includes an evaluation of cortical and trabecular bone structure and density and the degree of bone remodeling through bone biomarkers. Standard radiological imaging is generally used for the diagnosis of fracture or pseudo-fractures, vascular calcifications and other features of CKD-MBD. However, bone fractures can also be diagnosed using computed tomography (CT) scan, magnetic resonance (MR) imaging and vertebral fracture assessment (VFA). Fracture risk can be predicted by bone densitometry using dual-energy X-ray absorptiometry (DXA), quantitative computed tomography (QTC) and peripheral quantitative computed tomography (pQTC), quantitative ultrasound (QUS) and most recently magnetic resonance micro-imaging. Quantitative methods to assess bone consistency and strength complete the study and adjust the clinical management when integrated with clinical factors. The aim of this review is to provide a brief and comprehensive update of imaging techniques available for the diagnosis, prevention, treatment and monitoring of CKD-MBD.
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Bover J, Ureña-Torres P, Cozzolino M, Rodríguez-García M, Gómez-Alonso C. The Non-invasive Diagnosis of Bone Disorders in CKD. Calcif Tissue Int 2021; 108:512-527. [PMID: 33398414 DOI: 10.1007/s00223-020-00781-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 11/17/2020] [Indexed: 12/14/2022]
Abstract
Abnormal bone metabolism is an integral part of the chronic kidney disease-mineral bone disorder (CKD-MBD). For several reasons, the difficult bone compartment was neglected for some time, but there has been renewed interest as a result of the conception of bone as a new endocrine organ, the increasing recognition of the cross-talk between bone and vessels, and, especially, the very high risk of osteoporotic fractures (and associated mortality) demonstrated in patients with CKD. Therefore, it has been acknowledged in different guidelines that action is needed in respect of fracture risk assessment and the diagnosis and treatment of osteoporosis in the context of CKD and CKD-MBD, even beyond renal osteodystrophy. These updated guidelines clearly underline the need to improve a non-invasive approach to these bone disorders in order to guide treatment decisions aimed at not only controlling CKD-MBD but also decreasing the risk of fracture. In this report, we review the current role of the most often clinically used or promising biochemical circulating biomarkers such as parathyroid hormone, alkaline phosphatases, and other biochemical markers of bone activity as alternatives to some aspects of bone histomorphometry. We also mention the potential role of classic and new imaging techniques for CKD patients. Information on many aspects is still scarce and heterogeneous, but many of us consider that it is indeed time for action, recognizing our definitely limited ability to base certain treatment decisions only on our current non-comprehensive knowledge.
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Affiliation(s)
- Jordi Bover
- Department of Nephrology, Fundació Puigvert and Universitat Autònoma, IIB Sant Pau, REDinREN, C. Cartagena 340-350, 08025, Barcelona, Catalonia, Spain.
| | - Pablo Ureña-Torres
- Department of Dialysis, AURA Nord Saint Ouen and Department of Renal Physiology, Necker Hospital, University of Paris Descartes, Paris, France
| | - Mario Cozzolino
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Milan, Italy
| | - Minerva Rodríguez-García
- Unidad de Gestión Clínica de Nefrología, Hospital Universitario Central de Asturias, REDinREN, Universidad de Oviedo, Oviedo, Spain
| | - Carlos Gómez-Alonso
- Unidad de Gestión Clínica de Metabolismo Óseo y Mineral, Instituto de Investigación Sanitaria del Principado de Asturias, Hospital Universitario Central de Asturias, Oviedo, Spain
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Leal DV, Ferreira A, Watson EL, Wilund KR, Viana JL. Muscle-Bone Crosstalk in Chronic Kidney Disease: The Potential Modulatory Effects of Exercise. Calcif Tissue Int 2021; 108:461-475. [PMID: 33388899 DOI: 10.1007/s00223-020-00782-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 11/25/2020] [Indexed: 02/06/2023]
Abstract
Chronic kidney disease (CKD) is a prevalent worldwide public burden that increasingly compromises overall health as the disease progresses. Two of the most negatively affected tissues are bone and skeletal muscle, with CKD negatively impacting their structure, function and activity, impairing the quality of life of these patients and contributing to morbidity and mortality. Whereas skeletal health in this population has conventionally been associated with bone and mineral disorders, sarcopenia has been observed to impact skeletal muscle health in CKD. Indeed, bone and muscle tissues are linked anatomically and physiologically, and together regulate functional and metabolic mechanisms. With the initial crosstalk between the skeleton and muscle proposed to explain bone formation through muscle contraction, it is now understood that this communication occurs through the interaction of myokines and osteokines, with the skeletal muscle secretome playing a pivotal role in the regulation of bone activity. Regular exercise has been reported to be beneficial to overall health. Also, the positive regulatory effect that exercise has been proposed to have on bone and muscle anatomical, functional, and metabolic activity has led to the proposal of regular physical exercise as a therapeutic strategy for muscle and bone-related disorders. The detection of bone- and muscle-derived cytokine secretion following physical exercise has strengthened the idea of a cross communication between these organs. Hence, this review presents an overview of the impact of CKD in bone and skeletal muscle, and narrates how these tissues intrinsically communicate with each other, with focus on the potential effect of exercise in the modulation of this intercommunication.
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Affiliation(s)
- Diogo V Leal
- Research Center in Sports Sciences, Health Sciences and Human Development, CIDESD, University Institute of Maia, ISMAI, Maia, Portugal
| | - Aníbal Ferreira
- Department of Nephrology, Curry Cabral Hospital, Hospital Centre of Central Lisbon, Lisbon, Portugal
- Nova Medical School, Lisbon, Portugal
| | - Emma L Watson
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Kenneth R Wilund
- Department of Kinesiology and Community Health, University of Illinois At Urbana-Champaign, Champaign, IL, USA
| | - João L Viana
- Research Center in Sports Sciences, Health Sciences and Human Development, CIDESD, University Institute of Maia, ISMAI, Maia, Portugal.
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Pimentel A, Ureña-Torres P, Bover J, Luis Fernandez-Martín J, Cohen-Solal M. Bone Fragility Fractures in CKD Patients. Calcif Tissue Int 2021; 108:539-550. [PMID: 33219822 PMCID: PMC8052229 DOI: 10.1007/s00223-020-00779-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 11/04/2020] [Indexed: 12/14/2022]
Abstract
Chronic kidney diseases (CKD) are associated with mineral and bone diseases (MBD), including pain, bone loss, and fractures. Bone fragility related to CKD includes the risk factors observed in osteoporosis in addition to those related to CKD, resulting in a higher risk of mortality related to fractures. Unawareness of such complications led to a poor management of fractures and a lack of preventive approaches. The current guidelines of the Kidney Disease Improving Global Outcomes (KDIGO) recommend the assessment of bone mineral density if results will impact treatment decision. In addition to bone density, circulating biomarkers of mineral, serum bone turnover markers, and imaging techniques are currently available to evaluate the fracture risk. The purpose of this review is to provide an overview of the epidemiology and pathogenesis of CKD-associated bone loss. The contribution of the current tools and other techniques in development are discussed. We here propose a current view of how to better predict bone fragility and the therapeutic options in CKD.
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Affiliation(s)
| | - Pablo Ureña-Torres
- AURA Paris-Nord, Saint-Ouen, France
- Necker Hospital, University of Paris Descartes, Department of Renal Physiology, Paris, France
| | - Jordi Bover
- Fundació Puigvert, Universitat Autònoma, IIB Sant Pau, REDinREN, Nephrology Department, Barcelona, Catalonia, Spain
| | - Jose Luis Fernandez-Martín
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), REDinREN del ISCIII, Hospital Universitario Central de Asturias. Universidad de Oviedo, Bone and Mineral Research Unit, Oviedo, Asturias, Spain
| | - Martine Cohen-Solal
- INSERM U1132 & Université de Paris, Hôpital Lariboisière, Department of Rheumatology, Paris, France.
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Abstract
Introduction Chronic kidney disease (CKD) exposes to an increased incidence of fragility fractures. International guidelines recommend performing bone mineral density (BMD) if the results will impact treatment decisions. It remains unknown where bone loss occurs and what would preclude the longitudinal loss in patients with CKD. Here, we aimed to investigate factors influencing BMD and to analyze the longitudinal BMD changes. Methods In the NephroTest cohort, we measured BMD at the femoral neck, total hip, lumbar spine, and proximal radius, together with circulating biomarkers and standardized measured glomerular filtration rate (mGFR) by 51Cr-EDTA in a subset of patients with CKD stage 1 to 5 followed during 4.3 ± 2.0 years. A linear mixed model explored the longitudinal bone loss and the relationship of associated factors with BMD changes. A total of 858 patients (mean age 58.9 ± 15.2 years) had at least 1 and 477 had at least 2 BMD measures. Results At baseline, cross-sectional analysis showed a significantly lower BMD at femoral neck and total hip and a significant higher serum parathyroid hormone (PTH) along with CKD stages. Baseline age, gender, tobacco, low body mass index (BMI), and high PTH levels were significantly associated with low BMD. Longitudinal analysis during the mean 4.3 years revealed a significant bone loss at the radius only. BMD changes at the femoral neck were associated with BMI, but not CKD stages or basal PTH levels. Conclusions CKD is associated with low BMD and high PTH in the cross-sectional analysis. Longitudinal bone loss occurred at the proximal radius after 4.3 years.
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