Kidney function and its association to imminent, short- and long-term fracture risk-a longitudinal study in older women

Predicting Osteoporotic Fracture in Patients With Early-Stage Diabetic Kidney Disease Using a Radiomic Model: A Longitudinal Cohort Study

OBJECTIVE

There is an urgent need for effective predictive strategies to accurately evaluate the risk of fragility fractures in elderly patients in the early stages of diabetic kidney disease (DKD).

METHODS

This longitudinal cohort study included 715 older patients in the early stages of DKD diagnosed between January 2015 and August 2019. Patients were randomly allocated to a training cohort (n = 499) and a validation cohort (n = 216). The least absolute shrinkage and selection operator method was used to select key features for dual-energy x-ray absorptiometry-based radiomic analysis. A radiomic model was constructed using Cox proportional hazards regression. The performance of the radiomic model was compared with that of traditional fracture assessment tools through a receiver operating characteristic curve, calibration curve, and decision curve analysis.

RESULTS

Over a mean follow-up period of 4.72 ± 1.60 years, 65 participants (9.09%) experienced incident fragility fractures. Seventeen features were ultimately selected to create the radiomic model. The calibration plots of this model demonstrated satisfactory agreement between the observed and predicted outcomes. Moreover, the radiomic model outperformed traditional fracture assessment tools in both the training and validation cohorts according to the area under the receiver operating characteristic curve and decision curve analysis.

CONCLUSIONS

The novel radiomic model has demonstrated a more effective prediction of fragility fracture in elderly patients in the early stages of DKDcompared to traditional fracture assessment tools.

Analysis on fluid intake and urination behaviors among the elderly in five cities in China: a cross-sectional study

Background

Fluid intake in the elderly may influence urination behaviors and further influence their health status. This study investigated the behaviors of fluid intake, urination and their relationships among the elderly in China.

Methods

Stratified random sampling was used to recruit the elderly participants who met the inclusion criteria from five cities in China. Participants' total fluid intake (TFI) level was investigated using a validated 7-day 24 h fluid intake questionnaire. Their urination behaviors in real time were also recorded using a validated 7-day 24 h urination behavior record.

Results

A total of 524 participants completed the study, including 233 males and 291 females. The average age was 69.7 years. The median daily TFI was 1,241 mL, with a frequency of 8.1 times per day. Approximately 73.3% of the participants did not reach the amount of adequate fluid intake (1.7 L for males and 1.5 L for females) recommended in China. Fluid intake in the morning, afternoon, and evening among participants was 594 mL, 305 mL and 342 mL, with a frequency of 3.0 times, 1.7 times, and 2.0 times, respectively. The median urination frequency was 7.4 times per day. The percentage of participants who urinated >7 times during the day was 44.3%. The percentage of participants who urinated ≥1 time at night was 77.5%. Age and BMI were not the main influence factors for fluid intake and urination behaviors. The preliminary analysis showed that higher TFI, plain water intake, dairy products intake, and fluid intake frequency were significantly associated with higher urination frequency (t = 6.553, p < 0.05; t = 5.291, p < 0.05; t = 4.667, p < 0.05; t = 13.413, p < 0.05). Higher fluid intake per time was significantly associated with lower urination frequency (t = -3.562, p < 0.05). Correlations between TFI, fluid intake frequency, fluid intake in night, fluid intake frequency in night and urination at night were also found (r = 0.114, p < 0.05; r = 0.091, p < 0.05; r = 0.146, p < 0.05; r = 0.331, p < 0.05).

Conclusion

Fluid intake was inadequate in terms of the elderly participants. Participants with higher fluid intake and frequency in night had a greater incidence of nocturia. Thus, correcting fluid intake behaviors can improve urination behavior and promote health.

Clinical trial registration

https://www.chictr.org.cn/searchprojEN.html, identifier CTR1900023355.

Executive summary: Italian guidelines for diagnosis, risk stratification, and care continuity of fragility fractures 2021

Background

Fragility fractures are a major public health concern owing to their worrying and growing burden and their onerous burden upon health systems. There is now a substantial body of evidence that individuals who have already suffered a fragility fracture are at a greater risk for further fractures, thus suggesting the potential for secondary prevention in this field.

Purpose

This guideline aims to provide evidence-based recommendations for recognizing, stratifying the risk, treating, and managing patients with fragility fracture. This is a summary version of the full Italian guideline.

Methods

The Italian Fragility Fracture Team appointed by the Italian National Health Institute was employed from January 2020 to February 2021 to (i) identify previously published systematic reviews and guidelines on the field, (ii) formulate relevant clinical questions, (iii) systematically review literature and summarize evidence, (iv) draft the Evidence to Decision Framework, and (v) formulate recommendations.

Results

Overall, 351 original papers were included in our systematic review to answer six clinical questions. Recommendations were categorized into issues concerning (i) frailty recognition as the cause of bone fracture, (ii) (re)fracture risk assessment, for prioritizing interventions, and (iii) treatment and management of patients experiencing fragility fractures. Six recommendations were overall developed, of which one, four, and one were of high, moderate, and low quality, respectively.

Conclusions

The current guidelines provide guidance to support individualized management of patients experiencing non-traumatic bone fracture to benefit from secondary prevention of (re)fracture. Although our recommendations are based on the best available evidence, questionable quality evidence is still available for some relevant clinical questions, so future research has the potential to reduce uncertainty about the effects of intervention and the reasons for doing so at a reasonable cost.

Bone health as a co-morbidity of chronic kidney disease

Chronic kidney disease and osteoporosis commonly co-exist in aged patients. Chronic kidney disease affects bone health because of its effect on mineral metabolism in the syndrome, Chronic Kidney Disease Mineral and Bone Disorder, resulting in an increased risk of fractures. Hip fracture risk may be as much as four-fold higher in the worst affected. Tools to estimate fracture risk such as FRAX® and measuring bone density can be used in patients with chronic kidney disease; however, bone density may underestimate fracture risk in this population as it does not give information on bone quality. While osteoporosis treatment in patients with chronic kidney disease stage 1-3 does not differ from the general population, in the absence of Chronic Kidney Disease Mineral and Bone Disorder, patients with disease stage 4-5 require special consideration. It is, however, of the utmost importance that these patients receive pharmacological treatment because of their high risk of fractures.

Risk Factors for Fracture in Patients with Coexisting Chronic Kidney Disease and Type 2 Diabetes: An Observational Analysis from the CREDENCE Trial

BACKGROUND

The fracture pathophysiology associated with type 2 diabetes and chronic kidney disease (CKD) is incompletely understood. We examined individual fracture predictors and prediction sets based on different pathophysiological hypotheses, testing whether any of the sets improved prediction beyond that based on traditional osteoporotic risk factors.

METHODS

Within the CREDENCE cohort with adjudicated fracture outcomes, we assessed the association of individual factors with fracture using Cox regression models. We used the Akaike information criteria (AIC) and Schwartz Bayes Criterion (SBC) to assess six separate variable sets based on hypothesized associations with fracture, namely, traditional osteoporosis, exploratory general population findings, cardiovascular risk, CKD-mineral and bone disorder, diabetic osteodystrophy, and an all-inclusive set containing all variables.

RESULTS

Fracture occurred in 135 (3.1%) participants over a median 2.35 [1.88-2.93] years. Independent fracture predictors were older age (hazard ratio [HR] 1.04, confidence interval [CI] 1.01-1.06), female sex (HR 2.49, CI 1.70-3.65), previous fracture (HR 2.30, CI 1.58-3.34), Asian race (HR 1.74, CI 1.09-2.78), vitamin D therapy requirement (HR 2.05, CI 1.31-3.21), HbA1c (HR 1.14, CI 1.00-1.32), prior cardiovascular event (HR 1.60, CI 1.10-2.33), and serum albumin (HR 0.41, CI 0.23-0.74) (lower albumin associated with greater risk). The goodness of fit of the various hypothesis sets was similar (AIC range 1870.92-1849.51, SBC range 1875.60-1948.04).

CONCLUSION

Independent predictors of fracture were identified in the CREDENCE participants with type 2 diabetes and CKD. Fracture prediction was not improved by models built on alternative pathophysiology hypotheses compared with traditional osteoporosis predictors.

Causal Effects of Genetically Predicted Cystatin C on Osteoporosis: A Two-Sample Mendelian Randomization Study

Objectives: Although it has long been reported that high levels of cystatin C could contribute to the development of osteoporosis in some studies, no evidence has established a causal association between them thus far. Methods: A Mendelian randomization (MR) study was conducted to determine the causal effect of cystatin C on osteoporosis based on public databases obtained from separately published genome-wide association studies (GWASs). The single-nucleotide polymorphisms (SNPs) for cystatin C were extracted from the MR-Base (CKDGen, 33,152 participants), and the SNPs for osteoporosis were extracted from the United Kingdom Biobank project (United Kingdom Biobank, including 5,266 osteoporosis cases and 331,893 controls). We defined the odds ratio (OR) of IVW methods as the primary outcome. In addition, weighted median and MR-Egger regressions were used in the sensitivity analysis. Results: In IVW, we found that genetically predicted cystatin C was causally associated with the risk of osteoporosis with an OR of 1.02 [95% confidence interval (CI) = 1.003-1.025, p = 0.01]. In the further sensitivity analysis, weighted median regression also showed directionally similar estimates (OR = 1.02, 95% CI = 1.005-1.03, p = 0.005), and MR-Egger regression (OR = 1.02, 95% CI = 1.000-1.036, p = 0.15) revealed similar estimates but with lower precision. The funnel plot, MR-Egger intercept, and MR-PRESSO all indicate that no directional pleiotropic effect was observed. Conclusion: In conclusion, our MR study showed evidence of a causal association between serum cystatin C levels and osteoporosis, which also needs to be verified by studies with larger sample sizes in the future. Early monitoring of cystatin C may enable us to prevent osteoporosis-related diseases.