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Matias PJ, Ávila G, Domingos D, Gil C, Ferreira A. Lower serum magnesium levels are associated with a higher risk of fractures and vascular calcifications in hemodialysis patients. Clin Kidney J 2025; 18:sfae381. [PMID: 40008355 PMCID: PMC11852323 DOI: 10.1093/ckj/sfae381] [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: 04/18/2024] [Indexed: 02/27/2025] Open
Abstract
Background Magnesium (Mg) deficiency seems to be associated with altered bone metabolism and vascular calcifications (VC). This study aimed to evaluate the association between serum Mg levels and incident bone fragility fractures and VC in a cohort of prevalent hemodialysis (HD) patients. Methods We performed a retrospective study of 206 patients, with a mean age of 68.3 ± 13.1 years; 121 (59%) were male, and the median follow-up time was 58 months. Results Thirty-seven episodes of fragility fractures were identified with a median HD vintage of 42 months-an incidence rate of 29 per 1000 person-years. Patients with fractures showed lower Mg levels compared with those without fractures (P < .001) and more VC (P = .01). In a Cox regression analysis, time to fragility fracture was independently associated with serum Mg <2.2 mg/dL (P < .001), in a model adjusted to age, female gender, HD vintage, diabetes mellitus, body mass index, albumin, parathyroid hormone, active vitamin D therapy and the presence of VC. Patients with Mg serum levels <2.2 mg/dL had a 1.32-fold higher risk of fragility fractures (P < .001). Conclusions This study showed that the incidence of bone fragility fractures in HD patients is high and is significantly associated with lower Mg levels and with the presence of more VC.
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Affiliation(s)
- Patrícia João Matias
- Dialverca – Dialysis clinic, Forte da Casa, Portugal
- NephroCare Carregado – Dialysis clinic, Carregado, Portugal
- NOVA Medical School and Centro Clínico Académico de Lisboa, Lisboa, Portugal
| | - Gonçalo Ávila
- Dialverca – Dialysis clinic, Forte da Casa, Portugal
| | | | - Célia Gil
- Dialverca – Dialysis clinic, Forte da Casa, Portugal
- NephroCare Carregado – Dialysis clinic, Carregado, Portugal
| | - Aníbal Ferreira
- Dialverca – Dialysis clinic, Forte da Casa, Portugal
- NephroCare Carregado – Dialysis clinic, Carregado, Portugal
- NOVA Medical School and Centro Clínico Académico de Lisboa, Lisboa, Portugal
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2
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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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3
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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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Barrera-Baena P, Rodríguez-García M, Rodríguez-Rubio E, González-Llorente L, Ortiz A, Zoccali C, Locatelli F, Floege J, Cohen-Solal M, Ferreira MA, Ketteler M, London GM, Gorriz-Teruel JL, Sánchez-Álvarez E, Hevia-Suárez MÁ, Fernández-Gómez JM, Martín-Carro B, Gómez-Alonso C, Alonso-Montes C, Cannata-Andía JB, Fernández-Martín JL. Serum phosphate is associated with increased risk of bone fragility fractures in haemodialysis patients. Nephrol Dial Transplant 2024; 39:618-626. [PMID: 37660283 PMCID: PMC10966329 DOI: 10.1093/ndt/gfad190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Indexed: 09/04/2023] Open
Abstract
BACKGROUND Bone fragility fractures are associated with high morbidity and mortality. This study analysed the association between the current biochemical parameters of chronic kidney disease-mineral and bone disorders (CKD-MBD) and bone fragility fractures in the COSMOS (Current management Of Secondary hyperparathyroidism: a Multicentre Observational Study) project. METHODS COSMOS is a 3-year, multicentre, open cohort, prospective, observational study carried out in 6797 haemodialysis patients (227 centres from 20 European countries). The association of bone fragility fractures (outcome) with serum calcium, phosphate and parathyroid hormone (PTH) (exposure), was assessed using standard Cox proportional hazards regression and Cox proportional hazards regression for recurrent events. Additional analyses were performed considering all-cause mortality as a competitive event for bone fragility fracture occurrence. Multivariable models were used in all strategies, with the fully adjusted model including a total of 24 variables. RESULTS During a median follow-up of 24 months, 252 (4%) patients experienced at least one bone fragility fracture (incident bone fragility fracture rate 28.5 per 1000 patient-years). In the fractured and non-fractured patients, the percentage of men was 43.7% and 61.4%, mean age 68.1 and 63.8 years and a haemodialysis vintage of 55.9 and 38.3 months, respectively. Baseline serum phosphate >6.1 mg/dL (reference value 4.3-6.1 mg/dL) was significantly associated with a higher bone fragility fracture risk in both regression models {hazard ratio (HR) 1.53 [95% confidence interval (CI) 1.10-2.13] and HR 1.44 (95% CI 1.02-2.05)}. The significant association persisted after competitive risk analysis [subHR 1.42 (95% CI 1.02-1.98)] but the finding was not confirmed when serum phosphate was considered as a continuous variable. Baseline serum calcium showed no association with bone fragility fracture risk in any regression model. Baseline serum PTH >800 pg/mL was significantly associated with a higher bone fragility fracture risk in both regression models, but the association disappeared after a competitive risk analysis. CONCLUSIONS Hyperphosphatemia was independently and consistently associated with an increased bone fracture risk, suggesting serum phosphate could be a novel risk factor for bone fractures in haemodialysis patients.
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Affiliation(s)
- Pedro Barrera-Baena
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Bone and Mineral Research Unit, REDinREN and RICORS2040 del ISCIII, Oviedo, Spain
- Hospital Universitario de Cabueñes, Department of Nephrology, Gijón, Spain
| | - Minerva Rodríguez-García
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Bone and Mineral Research Unit, REDinREN and RICORS2040 del ISCIII, Oviedo, Spain
- Hospital Universitario Central de Asturias, Department of Nephrology, REDinREN del ISCIII, Oviedo, Spain
| | - Enrique Rodríguez-Rubio
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Bone and Mineral Research Unit, REDinREN and RICORS2040 del ISCIII, Oviedo, Spain
| | - Lucía González-Llorente
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Bone and Mineral Research Unit, REDinREN and RICORS2040 del ISCIII, Oviedo, Spain
| | - Alberto Ortiz
- IIS-Fundacion Jimenez Diaz UAM, Department of Nephrology and Hypertension, Madrid, Spain
- RICORS2040; Madrid, Spain
- Universidad Autónoma de Madrid, Facultad de Medicina, Departamento de Medicina, Madrid, Spain
| | - Carmine Zoccali
- Ospedali Riuniti CNR National Research Council (Italy), Clinical Epidemiology and Physiopathology of Renal Disease and Hypertension and Renal and Transplantation Unit, Foggia, Italy
| | - Francesco Locatelli
- Alessandro Manzoni Hospital, Department of Nephrology, Dialysis and Renal Transplant, ASST Lecco, Italy
| | - Jürgen Floege
- RWTH Aachen University, Div. Nephrology, Aachen, Germany
| | - Martine Cohen-Solal
- Hôpital Lariboisière, Department of Rheumatology, Paris, France
- INSERM U1132 Bioscar & Université Paris-Cité, Paris, France
| | - Manuel Aníbal Ferreira
- Nova Medical School-Vice Dean, Lisboa, Portugal
- Centro Hospitalar Universitário de Lisboa Central – Hospital Curry Cabral, Nephrology Department, Lisboa, Portugal
| | - Markus Ketteler
- Robert-Bosch-Krankenhaus GmbH, Department of General Internal Medicine and Nephrology, Stuttgart, Germany
| | | | - José Luis Gorriz-Teruel
- Hospital Clínico Universitario, Department of Nephrology, Valencia, Spain
- Health Research Institute INCLIVA, University of Valencia, Department of Medicine, Valencia, Spain
| | | | - Miguel Ángel Hevia-Suárez
- Hospital Universitario Central de Asturias, UGC of Urology, Oviedo, Spain
- Universidad de Oviedo, Oviedo, Spain
| | - Jesús María Fernández-Gómez
- Hospital Universitario Central de Asturias, UGC of Urology, Oviedo, Spain
- Universidad de Oviedo, Oviedo, Spain
| | - Beatriz Martín-Carro
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Bone and Mineral Research Unit, REDinREN and RICORS2040 del ISCIII, Oviedo, Spain
| | - Carlos Gómez-Alonso
- Universidad de Oviedo, Oviedo, Spain
- Hospital Universitario Central de Asturias, Bone and Mineral Research Unit, REDinREN and RICORS2040 del ISCIII, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Cristina Alonso-Montes
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Bone and Mineral Research Unit, REDinREN and RICORS2040 del ISCIII, Oviedo, Spain
| | - Jorge Benito Cannata-Andía
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Bone and Mineral Research Unit, REDinREN and RICORS2040 del ISCIII, Oviedo, Spain
- Universidad de Oviedo, Oviedo, Spain
- Hospital Universitario Central de Asturias, Bone and Mineral Research Unit, REDinREN and RICORS2040 del ISCIII, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - José Luis Fernández-Martín
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Bone and Mineral Research Unit, REDinREN and RICORS2040 del ISCIII, Oviedo, Spain
- Hospital Universitario Central de Asturias, Bone and Mineral Research Unit, REDinREN and RICORS2040 del ISCIII, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
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5
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Petrauskiene V, Hellberg M, Svensson P, Zhou Y, Clyne N. Bone mineral density after exercise training in patients with chronic kidney disease stages 3 to 5: a sub-study of RENEXC-a randomized controlled trial. Clin Kidney J 2024; 17:sfad287. [PMID: 38186908 PMCID: PMC10768767 DOI: 10.1093/ckj/sfad287] [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: 06/07/2023] [Indexed: 01/09/2024] Open
Abstract
Background We evaluated the effects of 12 months of exercise training on bone mineral density (BMD) in patients with chronic kidney disease (CKD) stages 3-5 not on kidney replacement therapy (KRT). Methods A total of 151 patients were randomized to 12 months of either balance or strength training, both together with endurance training. Some 112 patients completed and 107 (69 men, 38 women) were analysed, with a mean age 66 ± 13.5 years and 31% having diabetes. The exercise training was self-administered, prescribed and monitored by a physiotherapist. Total body, hip and lumbar BMD, T score and Z score were measured at baseline and after 12 months using dual energy X-ray absorptiometry. Results Both groups showed increased physical performance. The prevalence of osteoporosis and osteopenia was unchanged. The strength group (SG) decreased total body BMD (P < .001), the balance group (BG) increased total body T score (P < .05) and total body Z score (P < .005). Total body ΔT score was negative in the SG and unchanged in the BG (P < .005). Total body ΔZ score was negative in the SG and positive in the BG (P < .001). The proportion of progressors measured by ΔT (P < .05) and ΔZ scores (P < .05) was significantly lower in the BG compared with the SG. In multivariate logistic regression analysis, belonging to the BG was the only factor with a lower risk of deterioration of total body BMD, T and Z scores. Conclusions Twelve months of balance training together with endurance training seemed to be superior to strength training in maintaining and improving BMD in patients with CKD not on KRT.
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Affiliation(s)
- Vaida Petrauskiene
- Lund University, Skåne University Hospital, Faculty of Medicine, Department of Clinical Sciences Lund, Nephrology, Lund, Sweden
| | - Matthias Hellberg
- Lund University, Skåne University Hospital, Faculty of Medicine, Department of Clinical Sciences Lund, Nephrology, Lund, Sweden
| | - Philippa Svensson
- Lund University, Skåne University Hospital, Faculty of Medicine, Department of Clinical Sciences Lund, Nephrology, Lund, Sweden
| | - Yunan Zhou
- Lund University, Skåne University Hospital, Faculty of Medicine, Department of Clinical Sciences Lund, Nephrology, Lund, Sweden
| | - Naomi Clyne
- Lund University, Skåne University Hospital, Faculty of Medicine, Department of Clinical Sciences Lund, Nephrology, Lund, Sweden
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6
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Fusaro M, Barbuto S, Gallieni M, Cossettini A, Re Sartò GV, Cosmai L, Cianciolo G, La Manna G, Nickolas T, Ferrari S, Bover J, Haarhaus M, Marino C, Mereu MC, Ravera M, Plebani M, Zaninotto M, Cozzolino M, Bianchi S, Messa P, Gregorini M, Gasperoni L, Agosto C, Aghi A, Tripepi G. Real-world usage of Chronic Kidney Disease - Mineral Bone Disorder (CKD-MBD) biomarkers in nephrology practices. Clin Kidney J 2024; 17:sfad290. [PMID: 38223338 PMCID: PMC10784916 DOI: 10.1093/ckj/sfad290] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Indexed: 01/16/2024] Open
Abstract
Background Chronic kidney disease mineral bone disorder (CKD-MBD) is a condition characterized by alterations of calcium, phosphate, parathyroid hormone (PTH), and fibroblast growth factor 23 (FGF-23) metabolism that in turn promote bone disorders, vascular calcifications, and increase cardiovascular (CV) risk. Nephrologists' awareness of diagnostic, prognostic, and therapeutic tools to manage CKD-MBD plays a primary role in adequately preventing and managing this condition in clinical practice. Methods A national survey (composed of 15 closed questions) was launched to inquire about the use of bone biomarkers in the management of CKD-MBD patients by nephrologists and to gain knowledge about the implementation of guideline recommendations in clinical practice. Results One hundred and six Italian nephrologists participated in the survey for an overall response rate of about 10%. Nephrologists indicated that the laboratories of their hospitals were able to satisfy request of ionized calcium levels, 105 (99.1%) of both PTH and alkaline phosphatase (ALP), 100 (94.3%) of 25(OH)D, and 61 (57.5%) of 1.25(OH)2D; while most laboratories did not support the requests of biomarkers such as FGF-23 (intact: 88.7% and c-terminal: 93.4%), Klotho (95.3%; soluble form: 97.2%), tartrate-resistant acid phosphatase 5b (TRAP-5b) (92.5%), C-terminal telopeptide (CTX) (71.7%), and pro-collagen type 1 N-terminal pro-peptide (P1NP) (88.7%). As interesting data regarding Italian nephrologists' behavior to start treatment of secondary hyperparathyroidism (sHPT), the majority of clinicians used KDOQI guidelines (n = 55, 51.9%). In contrast, only 40 nephrologists (37.7%) relied on KDIGO guidelines, which recommended referring to values of PTH between two and nine times the upper limit of the normal range. Conclusion Results point out a marked heterogeneity in the management of CKD-MBD by clinicians as well as a suboptimal implementation of guidelines in Italian clinical practice.
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Affiliation(s)
- Maria Fusaro
- National Research Council (CNR), Institute of Clinical Physiology (IFC), Pisa, Italy
- Department of Medicine, University of Padova, Padova, Italy
| | - Simona Barbuto
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Maurizio Gallieni
- Department of Biomedical and Clinical Sciences ‘Luigi Sacco’, Università di Milano, Milano, Italy
- Post-Graduate School of Specialization in Nephrology, University of Milano, Milano, Italy
- Division of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale (ASST) Fatebenefratelli-Sacco, Fatebenefratelli Hospital, Milan, Italy
| | - Althea Cossettini
- Post-Graduate School of Specialization in Nephrology, University of Milano, Milano, Italy
| | | | - Laura Cosmai
- Division of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale (ASST) Fatebenefratelli-Sacco, Fatebenefratelli Hospital, Milan, Italy
| | - Giuseppe Cianciolo
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Gaetano La Manna
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Thomas Nickolas
- Department of Medicine, Division of Nephrology, Columbia University, New York, NY, USA
| | - Serge Ferrari
- Service des Maladies Osseuses, Département de Médecine, HUG, Geneva, Switzerland
| | - Jordi Bover
- Servicio de Nefrología, Hospital Universitario Germans Trias i Pujol, Badalona (Barcelona), Spain
| | - Mathias Haarhaus
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Carmela Marino
- National Research Council (CNR), Institute of Clinical Physiology (IFC), Reggio Calabria, Italy
| | | | - Maura Ravera
- Nephrology, Dialysis, and Transplantation, University of Genoa and Policlinico San Martino, 16132 Genoa, Italy
| | - Mario Plebani
- Laboratory Medicine Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Martina Zaninotto
- Laboratory Medicine Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Mario Cozzolino
- Department of Health Sciences, Renal Division, University of Milan, ASST Santi Paolo e Carlo, Milan, Italy
| | - Stefano Bianchi
- Department of Internal Medicine, Nephrology and Dialysis Complex Operative Unit, Livorno, Italy
| | - Piergiorgio Messa
- Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Lorenzo Gasperoni
- Nephrology and Dialysis Unit, Infermi Hospital, AUSL Romagna, Rimini, Italy
| | - Caterina Agosto
- Pediatric Pain and Palliative Care Service, Department of Women's and Children's Health, Padua University Hospital, Padua, Italy
| | | | - Giovanni Tripepi
- National Research Council (CNR), Institute of Clinical Physiology (IFC), Reggio Calabria, Italy
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7
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Fusaro M, Evenepoel P. Efficacy of vitamin K on bone fragility: puzzling findings from which we should learn how to design a rigorous study. Nephrol Dial Transplant 2023; 38:2105-2108. [PMID: 37279891 PMCID: PMC10539219 DOI: 10.1093/ndt/gfad117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Indexed: 06/08/2023] Open
Affiliation(s)
- Maria Fusaro
- National Research Council (CNR) – Institute of Clinical Physiology (IFC), Pisa Via G. Moruzzi 1, Pisa, Italy
- Department of Medicine, University of Padova, Padova, Italy
| | - Pieter Evenepoel
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium
- Department of Medicine, Division of Nephrology, University Hospitals Leuven, Leuven, Belgium
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8
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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: 21] [Impact Index Per Article: 7.0] [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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9
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Gebre AK, Lewis JR, Leow K, Szulc P, Scott D, Ebeling PR, Sim M, Wong G, Lim WH, Schousboe JT, Kiel DP, Prince RL, Rodríguez AJ. Abdominal aortic calcification, bone mineral density and fractures: a systematic review and meta-analysis of observational studies. J Gerontol A Biol Sci Med Sci 2022:6674525. [PMID: 36000920 DOI: 10.1093/gerona/glac171] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Abdominal aortic calcification (AAC) has been inconsistently associated with skeletal health. We aimed to investigate the association of AAC with bone mineral density (BMD) and fracture risk by pooling the findings of observational studies. METHODS Medline, EMBASE, Web of Science and Google Scholar were searched (August 2021). All clinical studies that assessed the association between AAC and BMD or fracture were included. AAC was categorized into any/advanced (all higher reported groups) vs no/less advanced (lowest reported group). Pooled standardized mean differences (SMDs) and risk ratios (RRs) with 95% confidence intervals (CI) were determined for BMD and fracture, respectively, using random-effects models. RESULTS Of 2,192 articles screened, 86 (61,553 participants) were included in the review, while 42 provided data for meta-analysis. AAC was associated with lower BMD at the total hip [SMD=-1.05 (95%CI: -1.47 to -0.63); 16 studies], femoral neck [-0.25 (-0.46 to - 0.04); 10] and lumbar spine [-0.67 (-1.21 to -0.12); 20]. AAC was associated with a greater risk of any fracture [RR= 1.73 (95%CI: 1.48 to 2.02); 27]. AAC was also associated with vertebral, non-vertebral and hip fractures. In dose-response analysis, the highest AAC group had greater risks of any, vertebral and non-vertebral fractures. CONCLUSIONS AAC is associated with lower BMD and increased fracture risk at multiple sites, underscoring the potential importance of vascular disease on skeletal health. Detection of AAC at the time of BMD testing may provide clinicians with prognostic information about bone health to enhance osteoporosis screening programs and fracture risk prediction.
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Affiliation(s)
- Abadi K Gebre
- Nutrition & Health Innovation Research Institute, School of Medical and Health Sciences, Edith Cowan University, Joondalup, Australia.,School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Tigray
| | - Joshua R Lewis
- Nutrition & Health Innovation Research Institute, School of Medical and Health Sciences, Edith Cowan University, Joondalup, Australia.,Medical School, University of Western Australia, Perth, Australia.,Centre for Kidney Research, Children's Hospital at Westmead School of Public Health, Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Kevin Leow
- Centre for Kidney Research, Children's Hospital at Westmead School of Public Health, Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Pawel Szulc
- INSERM UMR 1033, University of Lyon, Hospices Civils de Lyon, Lyon, France
| | - David Scott
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, VIC, Australia.,Bone and Muscle Health Research Group, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Victoria, Australia
| | - Peter R Ebeling
- Bone and Muscle Health Research Group, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Victoria, Australia
| | - Marc Sim
- Nutrition & Health Innovation Research Institute, School of Medical and Health Sciences, Edith Cowan University, Joondalup, Australia.,Medical School, University of Western Australia, Perth, Australia
| | - Germaine Wong
- Centre for Kidney Research, Children's Hospital at Westmead School of Public Health, Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Wai H Lim
- Medical School, University of Western Australia, Perth, Australia.,Department of Renal Medicine, Sir Charles Gairdner Hospital, Western Australia, Australia
| | - John T Schousboe
- Park Nicollet Osteoporosis Center and HealthPartners Institute, HealthPartners, Minneapolis, MN 55416, USA, and Division of Health Policy and Management, University of Minnesota, Minneapolis, MN 55455, USA
| | - Douglas P Kiel
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Richard L Prince
- Medical School, University of Western Australia, Perth, Australia
| | - Alexander J Rodríguez
- Nutrition & Health Innovation Research Institute, School of Medical and Health Sciences, Edith Cowan University, Joondalup, Australia.,Bone and Muscle Health Research Group, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Victoria, Australia
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10
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Wang L, Cheng H, Zou X, Yuan J, Wu W, Han S, Wang J, Zhang L, He K, Zhao MH, Wang X. Prevalence and Correlates of Cardiovascular Calcification and Its Prognostic Effects Among Patients With Chronic Kidney Disease: Results From the C-STRIDE Study. Front Public Health 2022; 9:762370. [PMID: 35071158 PMCID: PMC8771912 DOI: 10.3389/fpubh.2021.762370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 12/08/2021] [Indexed: 11/16/2022] Open
Abstract
Background and Aims: The purpose of this study was to identify the characteristics and risk factors for cardiovascular calcification, and its relationship to prognosis, in patients with chronic kidney disease (CKD) stages 1–4. Methods: Cardiovascular calcification was evaluated at baseline by lateral abdominal radiography to detect abdominal aortic calcifications (AAC), and by echocardiogram to detect cardiac valvular calcifications (CVC), respectively. Demographic and laboratory data were collected and analyzed. Univariate and multivariable logistic regression model was used to explore the factors associated with the indicators of cardiovascular calcification, while Cox proportional hazards regression was used to examine the association between AAC/CVC and incidence of cardiovascular events and all-cause mortality. Results: A subgroup of 2,235 patients with measurement of AAC in the C-STRIDE study and a subgroup of 2,756 patients with CVC were included in the analysis. AAC was present in 206 patients (9.22%) and CVC was present in 163 patients (5.91%). Age, gender, history of cardiovascular diseases, smoking, hypertension, diabetes, levels of hemoglobin, low-density lipoprotein cholesterol, and uric acid were associated with prevalence of AAC, while only age, history of cardiovascular diseases, levels of serum albumin and low-density lipoprotein cholesterol were associated with prevalence of CVC (all p < 0.05).Survival analyses showed that cardiovascular events and all-cause mortality were significantly greater in patients with AACor with CVC (all p-values for log-rank tests <0.05). After adjustment for age, sex and estimated glomerular filtration rate (eGFR), AAC was associated with increased risk of all-cause mortality (hazard ratio = 1.67[95% confidence interval: 0.99, 2.79]), while CVC associated with that of cardiovascular events only among patients with comparatively normal eGFR (≥45 ml/min/1.73m2) (hazard ratio = 1.99 [0.98, 4.03]). Conclusion: Demographic and traditional cardiovascular risk factors were associated with cardiovascular calcification, especially AAC. AAC may be associated with risk of death for patients CKD of any severity, while CVC as a possible risk factor for cardiovascular disease only among those with mild to moderate CKD. Assessments of vascular calcification are need to be advanced to patients in the early and middle stages of chronic kidney disease and to initiate appropriate preventive measures earlier.
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Affiliation(s)
- Lan Wang
- The First Clinical College, Hubei University of Chinese Medicine, Wuhan, China.,Institute of Chinese Medicine Nephrology, Hubei Provincial Hospital of TCM, Hubei Province Academy of Traditional Chinese Medicine, Wuhan, China
| | - Hong Cheng
- Institute of Chinese Medicine Nephrology, Hubei Provincial Hospital of TCM, Hubei Province Academy of Traditional Chinese Medicine, Wuhan, China
| | - Xinrong Zou
- Institute of Chinese Medicine Nephrology, Hubei Provincial Hospital of TCM, Hubei Province Academy of Traditional Chinese Medicine, Wuhan, China
| | - Jun Yuan
- The First Clinical College, Hubei University of Chinese Medicine, Wuhan, China.,Institute of Chinese Medicine Nephrology, Hubei Provincial Hospital of TCM, Hubei Province Academy of Traditional Chinese Medicine, Wuhan, China
| | - Wenjing Wu
- The First Clinical College, Hubei University of Chinese Medicine, Wuhan, China.,Institute of Chinese Medicine Nephrology, Hubei Provincial Hospital of TCM, Hubei Province Academy of Traditional Chinese Medicine, Wuhan, China
| | - Siping Han
- Institute of Chinese Medicine Nephrology, Hubei Provincial Hospital of TCM, Hubei Province Academy of Traditional Chinese Medicine, Wuhan, China
| | - Jinwei Wang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Renal Disease, National Health Commission of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Luxia Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Renal Disease, National Health Commission of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China.,National Institute of Health Data Science at Peking University, Beijing, China
| | - Kevin He
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, United States
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Renal Disease, National Health Commission of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China.,Peking-Tsinghua Center for Life Sciences, Beijing, China
| | - Xiaoqin Wang
- Institute of Chinese Medicine Nephrology, Hubei Provincial Hospital of TCM, Hubei Province Academy of Traditional Chinese Medicine, Wuhan, China
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11
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Fusaro M, Cianciolo G, Tripepi G, Plebani M, Aghi A, Politi C, Zaninotto M, Nickolas TL, Ferrari S, Ketteler M, La Manna G, Gasperoni L, Messa P, Ravera M, Gallieni M, Cosmai L, Locatelli F, Iervasi G, Vettor R, Mereu MC, Sella S, Arcidiacono G, Giannini S. Oral Calcitriol Use, Vertebral Fractures, and Vitamin K in Hemodialysis Patients: A Cross-Sectional Study. J Bone Miner Res 2021; 36:2361-2370. [PMID: 34622481 DOI: 10.1002/jbmr.4440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 08/26/2021] [Accepted: 08/29/2021] [Indexed: 02/06/2023]
Abstract
Fractures and vascular calcifications (VCs) are common in patients with chronic kidney disease (CKD). They are related to abnormalities in vitamin D metabolism, calcium, phosphorus, parathyroid hormone, and fibroblast growth factor 23 (FGF23)/Klotho that occur with CKD. Impaired vitamin D metabolism and abnormal levels of calcium, phosphate, parathyroid hormone (PTH), and FGF23/Klotho drive bone and vascular changes in CKD. It is unclear if oral calcitriol safely mitigates fracture risk without increasing the burden of calcifications. Therefore, we investigated whether treatment with calcitriol affected the prevalence of fractures and VC progression in hemodialysis (HD) patients. This report is a secondary analysis of the Vitamin K Italian (VIKI) study, a cross-sectional study involving 387 HD patients. We assessed vitamin 25(OH)D, alkaline phosphatase, PTH, calcium, phosphate, osteocalcin or bone Gla protein, matrix Gla protein, and vitamin K levels. Vertebral fractures (VFs) and VCs were determined by spine radiograph. A reduction of >20% of vertebral body height was considered a VF. VCs were quantified by the length of calcific lesions along the arteries. The patients treated with oral calcitriol were 177 of 387 patients (45.7%). The prevalence of VF was lower in patients receiving oral calcitriol than in those untreated (48.6% versus 61.0%, p = 0.015), whereas the presence of aortic and iliac calcifications was similar (aortic: 81.9% versus 79.5%, respectively, p = 0.552; iliac: 52.0% and 59.5%, respectively, p = 0.167). In multivariable logistic regression analysis, oral calcitriol was associated with a 40.2% reduced odds of fracture (OR 0.598; 95% confidence interval [CI], 0.363-0.985; p = 0.043). In conclusion, we found a significant association between oral calcitriol and lower VF in HD patients without an increase in the burden of VC. Further prospective and interventional studies are needed to confirm these findings. © 2021 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Maria Fusaro
- National Research Council (CNR), Institute of Clinical Physiology (IFC), Pisa, Italy.,Department of Medicine, University of Padova, Padova, Italy
| | - Giuseppe Cianciolo
- Nephrology Dialysis and Kidney Transplantation Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Malpighi Hospital, Bologna, Italy
| | - Giovanni Tripepi
- National Research Council-Institute of Clinical Physiology (CNR-IFC), Clinical Epidemiology of Renal Diseases and Hypertension, Ospedali Riuniti, Reggio Calabria, Italy
| | - Mario Plebani
- Laboratory Medicine Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Andrea Aghi
- Department of Medicine, Clinica Medica 1, University of Padua, Padua, Italy
| | - Cristina Politi
- National Research Council-Institute of Clinical Physiology (CNR-IFC), Clinical Epidemiology of Renal Diseases and Hypertension, Ospedali Riuniti, Reggio Calabria, Italy
| | - Martina Zaninotto
- Laboratory Medicine Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Thomas L Nickolas
- Division of Nephrology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Serge Ferrari
- Service des Maladies Osseuses, Département de Médecine, Hôpitaux Universitaires de Genève (HUG), Geneva, Switzerland
| | - Markus Ketteler
- Department of General Internal Medicine and Nephrology, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Gaetano La Manna
- Nephrology Dialysis and Kidney Transplantation Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Malpighi Hospital, Bologna, Italy
| | - Lorenzo Gasperoni
- Nephrology Dialysis and Kidney Transplantation Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Malpighi Hospital, Bologna, Italy
| | - Piergiorgio Messa
- Unit of Nephrology, Dialysis and Kidney Transplantation, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | | | - Maurizio Gallieni
- Nephrology and Dialysis Unit, Azienda Socio-Sanitaria Territoriale (ASST) Fatebenefratelli Sacco, Department of Clinical and Biomedical Sciences 'Luigi Sacco', Università di Milano, Milan, Italy
| | - Laura Cosmai
- Onco-Nephrology Outpatient Clinic, Nephrology and Dialysis Unit, Azienda Socio-Sanitaria Territoriale (ASST) Fatebenefratelli Sacco, Fatebenefratelli Hospital, Milan, Italy
| | - Francesco Locatelli
- Alessandro Manzoni Hospital, Azienda Socio-Sanitaria Territoriale (ASST) Lecco, Lecco, Italy
| | - Giorgio Iervasi
- National Research Council (CNR), Institute of Clinical Physiology (IFC), Pisa, Italy
| | - Roberto Vettor
- Department of Medicine, University of Padova, Padova, Italy
| | | | - Stefania Sella
- Department of Medicine, Clinica Medica 1, University of Padua, Padua, Italy
| | | | - Sandro Giannini
- Department of Medicine, Clinica Medica 1, University of Padua, Padua, Italy
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12
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Cannata-Andía JB, Carrillo-López N, Messina OD, Hamdy NAT, Panizo S, Ferrari SL, on behalf of the International Osteoporosis Foundation (IOF) Working Group on Bone and Cardiovascular Diseases. Pathophysiology of Vascular Calcification and Bone Loss: Linked Disorders of Ageing? Nutrients 2021; 13:3835. [PMID: 34836090 PMCID: PMC8623966 DOI: 10.3390/nu13113835] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 10/20/2021] [Accepted: 10/22/2021] [Indexed: 02/07/2023] Open
Abstract
Vascular Calcification (VC), low bone mass and fragility fractures are frequently observed in ageing subjects. Although this clinical observation could be the mere coincidence of frequent age-dependent disorders, clinical and experimental data suggest that VC and bone loss could share pathophysiological mechanisms. Indeed, VC is an active process of calcium and phosphate precipitation that involves the transition of the vascular smooth muscle cells (VSMCs) into osteoblast-like cells. Among the molecules involved in this process, parathyroid hormone (PTH) plays a key role acting through several mechanisms which includes the regulation of the RANK/RANKL/OPG system and the Wnt/ß-catenin pathway, the main pathways for bone resorption and bone formation, respectively. Furthermore, some microRNAs have been implicated as common regulators of bone metabolism, VC, left ventricle hypertrophy and myocardial fibrosis. Elucidating the common mechanisms between ageing; VC and bone loss could help to better understand the potential effects of osteoporosis drugs on the CV system.
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Affiliation(s)
- Jorge B. Cannata-Andía
- Bone and Mineral Research Unit, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Retic REDinREN-ISCIII, Hospital Universitario Central de Asturias, 33011 Oviedo, Spain; (N.C.-L.); (S.P.)
| | - Natalia Carrillo-López
- Bone and Mineral Research Unit, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Retic REDinREN-ISCIII, Hospital Universitario Central de Asturias, 33011 Oviedo, Spain; (N.C.-L.); (S.P.)
| | - Osvaldo D. Messina
- Investigaciones Reumatológicas y Osteológicas (IRO), Buenos Aires 1114, Argentina;
| | - Neveen A. T. Hamdy
- Center for Bone Quality, Division Endocrinology, Department of Medicine, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands;
| | - Sara Panizo
- Bone and Mineral Research Unit, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Retic REDinREN-ISCIII, Hospital Universitario Central de Asturias, 33011 Oviedo, Spain; (N.C.-L.); (S.P.)
| | - Serge L. Ferrari
- Service and Laboratory of Bone Diseases, Department of Medicine, Faculty of Medicine, Geneva University Hospital, 1211 Geneva, Switzerland;
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13
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Fusaro M, Tripepi G, Plebani M, Politi C, Aghi A, Taddei F, Schileo E, Zaninotto M, La Manna G, Cianciolo G, Gallieni M, Cosmai L, Messa P, Ravera M, Nickolas TL, Ferrari S, Ketteler M, Iervasi G, Mereu MC, Vettor R, Giannini S, Gasperoni L, Sella S, Brandi ML, Cianferotti L, De Caterina R. The Vessels-Bone Axis: Iliac Artery Calcifications, Vertebral Fractures and Vitamin K from VIKI Study. Nutrients 2021; 13:nu13103567. [PMID: 34684568 PMCID: PMC8539275 DOI: 10.3390/nu13103567] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 10/06/2021] [Accepted: 10/09/2021] [Indexed: 01/07/2023] Open
Abstract
Vascular calcification and fragility fractures are associated with high morbidity and mortality, especially in end-stage renal disease. We evaluated the relationship of iliac arteries calcifications (IACs) and abdominal aortic calcifications (AACs) with the risk for vertebral fractures (VFs) in hemodialysis patients. The VIKI study was a multicenter cross-sectional study involving 387 hemodialysis patients. The biochemical data included bone health markers, such as vitamin K levels, vitamin K-dependent proteins, vitamin 25(OH)D, alkaline phosphatase, parathormone, calcium, and phosphate. VF, IACs and AACs was determined through standardized spine radiograms. VF was defined as >20% reduction of vertebral body height, and VC were quantified by measuring the length of calcium deposits along the arteries. The prevalence of IACs and AACs were 56.1% and 80.6%, respectively. After adjusting for confounding variables, the presence of IACs was associated with 73% higher odds of VF (p = 0.028), whereas we found no association (p = 0.294) for AACs. IACs were associated with VF irrespective of calcification severity. Patients with IACs had lower levels of vitamin K2 and menaquinone 7 (0.99 vs. 1.15 ng/mL; p = 0.003), and this deficiency became greater with adjustment for triglycerides (0.57 vs. 0.87 ng/mL; p < 0.001). IACs, regardless of their extent, are a clinically relevant risk factor for VFs. The association is enhanced by adjusting for vitamin K, a main player in bone and vascular health. To our knowledge these results are the first in the literature. Prospective studies are needed to confirm these findings both in chronic kidney disease and in the general population.
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Affiliation(s)
- Maria Fusaro
- National Research Council (CNR), Institute of Clinical Physiology (IFC), 56124 Pisa, Italy
- Department of Medicine, University of Padova, 35128 Padova, Italy; (G.I.); (R.V.)
- Correspondence:
| | - Giovanni Tripepi
- CNR-IFC, Clinical Epidemiology of Renal Diseases and Hypertension, Ospedali Riuniti, 89124 Reggio Calabria, Italy; (G.T.); (C.P.)
| | - Mario Plebani
- Laboratory Medicine Unit, Department of Medicine, University of Padua, 35129 Padua, Italy; (M.P.); (M.Z.)
| | - Cristina Politi
- CNR-IFC, Clinical Epidemiology of Renal Diseases and Hypertension, Ospedali Riuniti, 89124 Reggio Calabria, Italy; (G.T.); (C.P.)
| | - Andrea Aghi
- Clinica Medica 1, Department of Medicine, University of Padua, 35128 Padua, Italy; (A.A.); (S.G.); (S.S.)
| | - Fulvia Taddei
- Bioengineering and Computing Laboratory, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.T.); (E.S.)
| | - Enrico Schileo
- Bioengineering and Computing Laboratory, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.T.); (E.S.)
| | - Martina Zaninotto
- Laboratory Medicine Unit, Department of Medicine, University of Padua, 35129 Padua, Italy; (M.P.); (M.Z.)
| | - Gaetano La Manna
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS—Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, 40126 Bologna, Italy; (G.L.M.); (G.C.); (L.G.)
| | - Giuseppe Cianciolo
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS—Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, 40126 Bologna, Italy; (G.L.M.); (G.C.); (L.G.)
| | - Maurizio Gallieni
- Department of Biomedical and Clinical Sciences ‘Luigi Sacco’, Università di Milano, 20157 Milano, Italy;
| | - Laura Cosmai
- Nephrology Unit, ASST Fate Bene Fratelli Sacco, 20157 Milano, Italy;
| | - Piergiorgio Messa
- Unit of Nephrology, Dialysis and Kidney Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, 20157 Milan, Italy;
- Department of Clinical Sciences and Community Health, University of Milan, 20157 Milan, Italy
| | | | - Thomas L. Nickolas
- Division of Nephrology, Department of Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA;
| | - Serge Ferrari
- Service des Maladies Osseuses, Département de Médecine, HUG, 1205 Genève, Switzerland;
| | - Markus Ketteler
- Department of General Internal Medicine and Nephrology, Robert-Bosch-Krankenhaus, 70376 Stuttgart, Germany;
| | - Giorgio Iervasi
- Department of Medicine, University of Padova, 35128 Padova, Italy; (G.I.); (R.V.)
| | | | - Roberto Vettor
- Department of Medicine, University of Padova, 35128 Padova, Italy; (G.I.); (R.V.)
| | - Sandro Giannini
- Clinica Medica 1, Department of Medicine, University of Padua, 35128 Padua, Italy; (A.A.); (S.G.); (S.S.)
| | - Lorenzo Gasperoni
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS—Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, 40126 Bologna, Italy; (G.L.M.); (G.C.); (L.G.)
| | - Stefania Sella
- Clinica Medica 1, Department of Medicine, University of Padua, 35128 Padua, Italy; (A.A.); (S.G.); (S.S.)
| | - Maria Luisa Brandi
- Department of Surgery and Translational Medicine, University of Florence, Viale Pieraccini 6, 50139 Florence, Italy; (M.L.B.); (L.C.)
| | - Luisella Cianferotti
- Department of Surgery and Translational Medicine, University of Florence, Viale Pieraccini 6, 50139 Florence, Italy; (M.L.B.); (L.C.)
| | - Raffaele De Caterina
- Cardiology, Cardiovascular Division, Pisa University Hospital, University of Pisa, Via Paradisa 2, 56126 Pisa, Italy;
- Fondazione Villa Serena per la Ricerca, Città Sant’Angelo, 65013 Pescara, Italy
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14
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Fusaro M, Holden R, Lok C, Iervasi G, Plebani M, Aghi A, Gallieni M, Cozzolino M. Phosphate and bone fracture risk in chronic kidney disease patients. Nephrol Dial Transplant 2021; 36:405-412. [PMID: 31620773 DOI: 10.1093/ndt/gfz196] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 08/29/2019] [Indexed: 01/25/2023] Open
Abstract
In chronic kidney disease (CKD), phosphate homoeostasis plays a central role in the development of mineral and bone disorder (MBD) together with decreased serum calcium and elevated serum parathyroid hormone, fibroblast growth factor 23 and sclerostin levels. Today there are only a few data exploring the direct role of abnormal phosphate homoeostasis and hyperphosphataemia in the development of CKD-MBD. On the other hand, several studies have looked at the link between hyperphosphataemia and cardiovascular morbidity and mortality in CKD, but there is a lack of evidence to indicate that lowering phosphate levels improves cardiovascular outcomes in this population. Furthermore, the impact of liberalizing phosphate targets on CKD-MBD progression and bone fracture is currently not known. In this review we discuss the central role of phosphate in the pathogenesis of CKD-MBD and how it may be associated with fracture risk, both in hyper- and hypophosphataemia.
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Affiliation(s)
- Maria Fusaro
- National Research Council, Institute of Clinical Physiology, Pisa, Italy.,Department of Medicine, University of Padova, Padova, Italy
| | - Rachel Holden
- Department of Medicine, Division of Nephrology, Queen's University, Kingston, Ontario, Canada
| | - Charmaine Lok
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Giorgio Iervasi
- National Research Council, Institute of Clinical Physiology, Pisa, Italy
| | - Mario Plebani
- Department of Medicine, Laboratory Medicine Unit, University of Padova, Padova, Italy
| | - Andrea Aghi
- Department of Medicine, Clinica Medica 1, University of Padova, Padova, Italy
| | - Maurizio Gallieni
- Department of Biomedical and Clinical Sciences 'L. Sacco', Nephrology and Dialysis Unit, ASST Fatebenefratelli-Sacco, Università di Milano, Milan, Italy
| | - Mario Cozzolino
- Department of Health Sciences, ASST Santi Paolo and Carlo, University of Milan and Renal Division, Milan, Italy
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15
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Evenepoel P, Cunningham J, Ferrari S, Haarhaus M, Javaid MK, Lafage-Proust MH, Prieto-Alhambra D, Torres PU, Cannata-Andia J. European Consensus Statement on the diagnosis and management of osteoporosis in chronic kidney disease stages G4-G5D. Nephrol Dial Transplant 2021; 36:42-59. [PMID: 33098421 DOI: 10.1093/ndt/gfaa192] [Citation(s) in RCA: 100] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Indexed: 12/16/2022] Open
Abstract
Controlling the excessive fracture burden in patients with chronic kidney disease (CKD) Stages G4-G5D remains an impressive challenge. The reasons are 2-fold. First, the pathophysiology of bone fragility in patients with CKD G4-G5D is complex and multifaceted, comprising a mixture of age-related (primary male/postmenopausal), drug-induced and CKD-related bone abnormalities. Second, our current armamentarium of osteoporosis medications has not been developed for, or adequately studied in patients with CKD G4-G5D, partly related to difficulties in diagnosing osteoporosis in this specific setting and fear of complications. Doubts about the optimal diagnostic and therapeutic approach fuel inertia in daily clinical practice. The scope of the present consensus paper is to review and update the assessment and diagnosis of osteoporosis in patients with CKD G4-G5D and to discuss the therapeutic interventions available and the manner in which these can be used to develop management strategies for the prevention of fragility fracture. As such, it aims to stimulate a cohesive approach to the management of osteoporosis in patients with CKD G4-G5D to replace current variations in care and treatment nihilism.
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Affiliation(s)
- Pieter Evenepoel
- Department of Nephrology, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - John Cunningham
- Centre for Nephrology, UCL Medical School, Royal Free Campus, London, UK
| | - Serge Ferrari
- Service of Bone Diseases, Geneva University Hospital, Switzerland
| | - Mathias Haarhaus
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Diaverum Sweden, Stockholm, Sweden
| | | | | | | | - Pablo Ureña Torres
- Department of Dialysis, AURA Nord Saint Ouen, Saint Ouen, France.,Department of Renal Physiology, Necker Hospital, University of Paris Descartes, Paris, France
| | - Jorge Cannata-Andia
- Bone and Mineral Research Unit (ISPA) (REDinREN), Hospital Universitario Central Asturias, Oviedo University, Spain
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16
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Fusaro M, Cozzolino M, Plebani M, Iervasi G, Ketteler M, Gallieni M, Aghi A, Locatelli F, Cunningham J, Salam S, Zaninotto M, Ravera M, Russo D, Mereu MC, Giannini S, Brandi ML, Ferrari S, Sella S, Egan CG, Bellasi A, Di Lullo L, Tripepi G, Nickolas T. Sevelamer Use, Vitamin K Levels, Vascular Calcifications, and Vertebral Fractures in Hemodialysis Patients: Results from the VIKI Study. J Bone Miner Res 2021; 36:500-509. [PMID: 33188702 DOI: 10.1002/jbmr.4214] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 10/11/2020] [Accepted: 11/04/2020] [Indexed: 12/22/2022]
Abstract
Hyperphosphatemia is a risk factor for vascular calcifications (VCs), which are part of the chronic kidney disease-mineral and bone disorders (CKD-MBD). Vitamin K-dependent proteins such as matrix Gla protein (MGP) and bone Gla proteins (BGP, or osteocalcin) can inhibit VCs and regulate bone mineralization. In this analysis of the Vitamin K Italian (VIKI) study, the relationship between vitamin K status, vertebral fractures (VFs) and VCs in 387 hemodialysis (HD) patients with (N = 163; 42.1%) or without N = 224; 57.9%) sevelamer was evaluated. Levels of vitamin K vitamers K1 and K2 or menaquinones (MK; MK4-7), total and undercarboxylated (uc) forms for both BGP and MGP were determined. Although no differences in clinical characteristics were noted, lower levels of MK4 (0.45 versus 0.6 ng/mL, p = .01) and a greater MK4 deficiency was observed in sevelamer-treated patients (13.5% versus 5.4%, p = .005). Multivariate logistic regression revealed that MK4 deficiency was associated with sevelamer use (odds ratio [OR] = 2.64, 95% confidence interval [CI] 1.25-5.58, p = .011) and aortic calcification (OR = 8.04, 95% CI 1.07-60.26, p = .04). In the same logistic model, sevelamer amplified the effect of total BGP levels on the odds of VFs in patients with total BGP <150 μg/L compared with those with total BGP ≥150 μg/L (OR = 3.15, 95% CI 1.46-6.76, p = .003). In contrast, there was no such effect in those untreated (total BGP <150 μg/L versus total BGP ≥150 μg/L: OR = 1.21, 95% CI 0.66-2.23, p = .54]; p = .049 for effect modification by sevelamer). Sevelamer may interfere with MK4 levels in HD patients and interact with low BGP levels to increase bone fractures in CKD patients. © 2020 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Maria Fusaro
- National Research Council (CNR)-Institute of Clinical Physiology (IFC), Pisa, Italy.,Department of Medicine, University of Padua, Padua, Italy
| | - Mario Cozzolino
- Renal Division, Department of Health Sciences, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Mario Plebani
- Department of Laboratory Medicine, University Hospital of Padova, Padova, Italy
| | - Giorgio Iervasi
- National Research Council (CNR)-Institute of Clinical Physiology (IFC), Pisa, Italy
| | - Markus Ketteler
- Department of General Internal Medicine and Nephrology, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Maurizio Gallieni
- Nephrology and Dialysis Unit, Azienda Socio-Sanitaria Territoriale (ASST) Fatebenefratelli Sacco, Department of Clinical and Biomedical Sciences 'Luigi Sacco', Università di Milano, Milan, Italy
| | - Andrea Aghi
- Department of Medicine, Clinica Medica 1, University of Padova, Padova, Italy
| | | | | | - Syazrah Salam
- Sheffield Kidney Institute, Sheffield Teaching Hospitals National Health Service Foundation Trust, and Academic Unit of Bone Metabolism and Mellanby Centre for Bone Research, Medical School-University of Sheffield, Sheffield, UK
| | | | - Maura Ravera
- Clinica Nefrologica, Dialisi e Trapianto, Universita' di Genova e Policlinico San Martino, Genoa, Italy
| | - Domenico Russo
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | | | - Sandro Giannini
- Department of Medicine, Clinica Medica 1, University of Padova, Padova, Italy
| | - Maria Luisa Brandi
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Serge Ferrari
- Service des Maladies Osseuses, Département de Médecine, HUG, Genève, Switzerland
| | - Stefania Sella
- Department of Medicine, Clinica Medica 1, University of Padova, Padova, Italy
| | | | - Antonio Bellasi
- UOC Ricerca, Innovazione, Brand Reputation, ASST-Papa Giovanni XXIII, Bergamo, Italy
| | - Luca Di Lullo
- Department of Nephrology and Dialysis, L. Parodi, Delfino Hospital, Rome, Italy
| | - Giovanni Tripepi
- CNR-IFC, Clinical Epidemiology and Pathophysiology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Thomas Nickolas
- Division of Nephrology, Department of Medicine, Columbia University Irving Medical Center, New York City, NY, USA
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Expression of Circulating MicroRNAs Linked to Bone Metabolism in Chronic Kidney Disease-Mineral and Bone Disorder. Biomedicines 2020; 8:biomedicines8120601. [PMID: 33322822 PMCID: PMC7764659 DOI: 10.3390/biomedicines8120601] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 12/06/2020] [Accepted: 12/08/2020] [Indexed: 12/12/2022] Open
Abstract
The pathophysiology of chronic kidney disease-mineral and bone disorder (CKD-MBD) is complex and multifactorial. Recent studies have identified a link between microRNAs (miRNAs) and bone loss. In this study, we investigated the expression of miRNAs in CKD-MBD. In this case-control study, we included thirty patients with CKD-MBD (cases) and 30 age- and gender-matched healthy individuals (controls). Bone mineral density (BMD) and trabecular bone score (TBS) evaluation was performed with dual X-ray absorptiometry. The selected panel of miRNAs included: hsa-miRNA-21-5p; hsa-miRNA-23a-3p; hsa-miRNA-24-2-5p; hsa-miRNA-26a-5p; hsa-miRNA-29a-3; hsa-miRNA-124-3p; hsa-miRNA-2861. The majority of cases had low BMD values. The relative expression of miRNA-21-5p was 15 times lower [fold regulation (FR): -14.7 ± 8.1, p = 0.034), miRNA-124-3p, 6 times lower (FR: -5.9 ± 4, p = 0.005), and miRNA-23a-3p, 4 times lower (FR: -3.8 ± 2.0, p = 0.036) in cases compared to controls. MiRNA-23a-3p was significantly and inversely correlated with TBS, adjusted for calcium metabolism and BMD values (beta = -0.221, p = 0.003, 95% CI -0.360, -0,081) in cases. In a receiver operating characteristic (ROC) analysis, expression of miRNA-124-3p demonstrated 78% sensitivity and 83% specificity in identifying CKD patents with osteoporosis. Serum expression of miRNAs related to osteoblasts (miRNA-23a-3p) and osteoclasts (miRNA-21-5p, miRNA-124-3p) is significantly altered in patients with CKD-MBD.
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18
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Runesson B, Trevisan M, Iseri K, Qureshi AR, Lindholm B, Barany P, Elinder CG, Carrero JJ. Fractures and their sequelae in non-dialysis-dependent chronic kidney disease: the Stockholm CREAtinine Measurement project. Nephrol Dial Transplant 2020; 35:1908-1915. [PMID: 31361316 PMCID: PMC7643673 DOI: 10.1093/ndt/gfz142] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 06/03/2019] [Indexed: 01/11/2023] Open
Abstract
Introduction People undergoing maintenance dialysis are at high risk for fractures, but less is known about fracture incidence and associated outcomes in earlier stages of chronic kidney disease (CKD). Methods We conducted an observational analysis from the Stockholm Creatinine Measurement project, a Swedish health care utilization cohort during 2006–11. We identified all adults with confirmed CKD Stages 3–5 and no documented history of fractures and extracted information on comorbid history, ongoing medication, cardiovascular events and death. We studied incidence rates of fractures (overall and by location), with the estimated glomerular filtration rate (eGFR) as time-dependent exposure. We then studied hazard ratios [HRs and 95% confidence intervals (CIs)] for the events of death and major adverse cardiac events (MACE) using Cox regression with fracture as time-varying exposure. Results We identified 68 764 individuals with confirmed CKD (mean age 79 years, 56% women). During a median follow-up of 2.7 years, 9219 fractures occurred, of which 3105 were hip fractures. A more severe CKD stage was associated with a higher risk of fractures, particularly hip fractures: compared with CKD Stage 3a, the adjusted HR was 1.10 (95% CI 1.02–1.19), 1.32 (1.17–1.49) and 2.47 (1.94–3.15) for CKD Stage 3b, 4 and 5, respectively. Spline curves suggested a linear association with fracture risk with an eGFR <30 mL/min/1.73 m2. Compared with non-fracture periods, incident fracture was associated with a 4-fold increased mortality within 90 days [HR 4.21 (95% CI 3.95–4.49)]. The risk remained elevated beyond 90 days [HR 1.47 (95% CI 1.40–1.54)] and was stronger after hip fractures. Post-fracture MACE risk was also highest in the first 90 days [HR 4.02 (95% CI 3.73–4.33)], particularly after hip fractures, and persisted beyond 90 days [HR 1.20 (95% CI 1.10–1.30)]. Conclusion Our findings highlight the commonness of fractures and the increased risk for subsequent adverse outcomes in CKD patients. These results may inform clinical decisions regarding post-fracture clinical surveillance and fracture prevention strategies.
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Affiliation(s)
- Björn Runesson
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Marco Trevisan
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Ken Iseri
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan.,Division of Renal Medicine and Baxter Novum, Karolinska Institutet, Stockholm, Sweden
| | - Abdul Rashid Qureshi
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.,Division of Renal Medicine and Baxter Novum, Karolinska Institutet, Stockholm, Sweden
| | - Bengt Lindholm
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.,Division of Renal Medicine and Baxter Novum, Karolinska Institutet, Stockholm, Sweden
| | - Peter Barany
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Carl Gustaf Elinder
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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19
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Kwon YE, Choi HY, Oh HJ, Ahn SY, Ryu DR, Kwon YJ. Vertebral fracture is associated with myocardial infarction in incident hemodialysis patients: a Korean nationwide population-based study. Osteoporos Int 2020; 31:1965-1973. [PMID: 32394062 DOI: 10.1007/s00198-020-05423-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 04/14/2020] [Indexed: 10/24/2022]
Abstract
UNLABELLED Chronic kidney disease (CKD)-mineral and bone disorder suggests that fragile bone and vascular disorder might be connected closely in CKD patients. In this study, fracture event was significantly associated with myocardial infarction (MI) in end-stage renal disease patients on hemodialysis (HD), especially for vertebral fractures. INTRODUCTION CKD-mineral and bone disorder is characterized by biochemical abnormalities, bone disorders, and vascular calcification. We aimed to verify the association between fracture and MI in CKD patients. METHODS Records for incident CKD stage 3 to 5 patients and patients who initiated HD between July 2014 and June 2018 were retrieved from the Korean Health Insurance Review & Assessment Service Database. Fractures were defined using diagnostic codes and were classified into vertebral, femoral, and other site fractures. MI was defined using a combination of MI diagnostic codes and related procedure codes. Multiple logistic regressions and 1:1 propensity score matching analysis were conducted. RESULTS A total of 38,935 patients (HD, 11,379; pre-dialysis CKD, 27,556) were included in this study. A total of 5,057 (13.0%) patients experienced fracture, and 1,431 (3.7%) patients had MI. Multiple logistic regression analysis showed that fracture was significantly associated with MI in the HD group (odds ratio (OR) 1.34, P = 0.024), but not in the pre-dialysis CKD group (OR 1.04, P = 0.701). After propensity score matching for age, gender, and diabetes mellitus between patients with and without fracture, fracture still significantly correlated with MI in HD patients (OR 1.47, P = 0.034) but not in patients with pre-dialysis CKD (OR 1.04, P = 0.751). Subgroup analysis by fracture site found that vertebral fracture was associated with MI in HD patients (OR 2.11, P = 0.024), but femoral or other site fractures were not. CONCLUSION In HD patients, fracture was significantly associated with MI, especially for vertebral fractures patients.
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Affiliation(s)
- Y E Kwon
- Department of Internal Medicine, Hanyang University College of Medicine, Myongji Hospital, Goyang-si, South Korea
| | - H Y Choi
- The Korean Society of Nephrology, Seoul, South Korea
| | - H J Oh
- Ewha Institute of Convergence Medicine and Research Institute for Human Health Information, Ewha Womans University, Seoul, South Korea
| | - S Y Ahn
- Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea
| | - D-R Ryu
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, South Korea.
| | - Y J Kwon
- Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea.
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20
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Gómez-Islas VE, García-Fong KR, Aguilar-Fuentes RE, Hernández-Castellanos S, Pherez-Farah A, Méndez-Bribiesca SA, López-Navarro JM, Osorio-Landa HK, Carbajal-Morelos SL, Zúñiga-Guzmán AM, Pérez-Díaz I. Evaluation of bone densitometry by dual-energy x-ray absorptiometry as a fracture prediction tool in women with chronic kidney disease. Bone Rep 2020; 13:100298. [PMID: 32743028 PMCID: PMC7387779 DOI: 10.1016/j.bonr.2020.100298] [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: 05/19/2020] [Revised: 06/27/2020] [Accepted: 07/13/2020] [Indexed: 11/22/2022] Open
Abstract
Background The 2017 KDIGO guidelines establish a 2B grade recommendation in favor of testing Bone Mineral Density (BMD) by DXA to assess osteoporotic fracture (OPF) risk in patients with CKD G3a-G5D. Still, controversy remains because large studies evaluating it for this particular population are lacking. Aim To establish the clinical performance of BMD measured by DXA in the evaluation of fracture risk in women with CKD. Methods We conducted a 43 year retrospective cohort study with 218 women ≥18 years-old with CKD and BMD measurement by DXA of total hip and lumbar spine. Clinical (age, year of CKD onset, comorbidities, BMI, transplant status, treatment), and biochemical (PTH, corrected calcium, phosphate, vitamin D [25 (OH) D3], creatinine, and albumin), parameters were collected from hospital records. All osteoporotic fractures (as defined by the WHO) found in the clinical and radiologic files were registered. Results 218 women with a median age of 60 years (40–73 IQ range) and a CKD evolution time of 12 years (7–18 IQ range) were evaluated. Forty-eight (28.23%) presented an OPF. These women were older (57 vs 69 years, p =0.0072) and had a lower BMD. CKD stage did not influence fracture incidence. In the multivariate analysis we found that for each standard deviation decrease in hip and lumbar spine T-Score, the overall fracture risk was 2.7 and 2.04 times higher, respectively. More than 50% of fractures took place within the first ten years of follow-up, especially with GFR <30 mL/min/m2 and osteoporosis. Diabetes and hypothyroidism accelerated fracture onset, while renal transplant delayed it. In the ROC analysis, the AUC was largest with the total hip (0.7098, p =0.000) and lumbar spine (0.6916, p = 0.000). Conclusions BMD measured by DXA is a useful fracture prediction tool for women with CKD, having a sensibility and specificity similar to that in the general population. It seems to be appropriate for the diagnosis, treatment decisions, and follow-up of patients with renal failure.
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Affiliation(s)
- Valeria E. Gómez-Islas
- Department of Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Mexico City Campus, Mexico
| | - Kevin R. García-Fong
- Department of Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Rosa E. Aguilar-Fuentes
- Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Mexico City Campus, Mexico
| | | | - Alfredo Pherez-Farah
- Department of Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Mexico City Campus, Mexico
| | - Sofía A. Méndez-Bribiesca
- Department of Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Mexico City Campus, Mexico
| | - Juan M. López-Navarro
- Department of Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Hillary K. Osorio-Landa
- Department of Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Mexico City Campus, Mexico
| | - Sergio L. Carbajal-Morelos
- Department of Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Mexico City Campus, Mexico
| | - Areli M. Zúñiga-Guzmán
- Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Mexico City Campus, Mexico
| | - Iván Pérez-Díaz
- Department of Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Mexico City Campus, Mexico
- Corresponding author at: Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, Avenida Vasco de Quiroga 15, Colonia Belisario Domínguez Sección XVI, PC. 14080, Tlalpan, Mexico City, Mexico.
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Trabecular bone score may indicate chronic kidney disease-mineral and bone disorder (CKD-MBD) phenotypes in hemodialysis patients: a prospective observational study. BMC Nephrol 2020; 21:299. [PMID: 32711466 PMCID: PMC7382149 DOI: 10.1186/s12882-020-01944-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 07/12/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND In the general population, the trabecular bone score (TBS) represents the bone microarchitecture and predicts fracture risk independent of bone mineral density (BMD). A few studies reported that TBS is significantly reduced in dialysis patients. Chronic kidney disease-mineral and bone disorder (CKD-MBD) are accompanied by increased fracture risk, cardiovascular morbidity, and mortality. We investigated whether TBS is associated with comorbidity related to CKD-MBD or frailty in hemodialysis patients. METHODS In this prospective observational study, TBS was obtained using the TBS iNsight software program (Med-Imaps) with BMD dual energy x-ray absorptiometry (DXA) images (L1-L4) from prevalent hemodialysis patients. A Tilburg frailty indicator was used to evaluate frailty, and hand grip strength and bio-impedance (InBody) were measured. A patient-generated subjective global assessment (PG-SGA) was used for nutritional assessment. The history of cardiovascular events (CVE) and demographic, clinical, laboratory, and biomarker data were collated. We then followed up patients for the occurrence of CKD-MBD related complications. RESULTS We enrolled 57 patients in total. The mean age was 56.8 ± 15.9 years (50.9% female). Prevalence of Diabetes mellitus (DM) was 40.4% and CVE was 36.8%. Mean TBS was 1.44 ± 0.10. TBS significantly reduced in the CVE group (1.38 ± 0.08 vs. 1.48 ± 0.10, p < 0.001). Multivariable regression analysis was conducted adjusting for age, sex, dialysis vintage, DM, CVE, albumin, intact parathyroid hormone, fibroblast growth factor 23, handgrip strength, and phosphate binder dose. Age (ß = - 0.030; p = 0.001) and CVE (ß = - 0.055; p = 0.024) were significant predictors of TBS. During the follow up period after TBS measurements (about 20 months), four deaths, seven incident fractures, and six new onset CVE were recorded. Lower TBS was associated with mortality (p = 0.049) or new onset fracture (p = 0.007, by log-rank test). CONCLUSION Lower TBS was independently associated with increased age and CVE prevalence in hemodialysis patients. Mortality and fracture incidence were significantly higher in patients with lower TBS values. These findings suggest that TBS may indicate a phenotype of frailty and also a CKD-MBD phenotype reciprocal to CVE.
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22
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Dusceac R, Niculescu DA, Dobre R, Sorohan MC, Caragheorgheopol A, Tacu C, David C, Poiana C. Bone turnover correlates with bone quantity but not bone microarchitecture in chronic hemodialysis. J Bone Miner Metab 2020; 38:597-604. [PMID: 32144577 DOI: 10.1007/s00774-020-01094-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 02/11/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION In chronic hemodialysis, high-turnover bone disease was associated with decreased bone mineral density (BMD), poor bone quality (chemical and structural), and increased fracture risk. Our aim was to correlate bone turnover markers (BTMs) with bone microarchitecture measured by trabecular bone score (TBS) before and after correction for BMD. MATERIALS AND METHODS We measured lumbar spine (LS), femoral neck, and 1/3 radius BMD and LS TBS by dual X-ray absorptiometry in 81 patients on permanent hemodialysis. Bone turnover was assessed using serum parathyroid hormone, osteocalcin, C-terminal crosslaps of type 1 collagen, procollagen 1 N-terminal propeptide (P1NP), and alkaline phosphatase (ALP). No patient had any partial or total parathyroidectomy and no previous or current treatment with anti-osteoporotic drugs. RESULTS All BTMs correlated significantly with each other. Univariate regressions showed significant negative correlations between BTMs and BMD (best r = - 0.53, between P1NP and 1/3 radius Z-score) or BTMs and TBS (best r = - 0.27, p < 0.05 between ALP and TBS T-score). TBS correlated significantly with BMD at all three sites (best r = 0.5, between LS BMD and TBS T-score). Multivariate regression showed that TBS, crude or adjusted, correlated with LS BMD. No model retained any of the BTMs as independent variables due to the better prediction of BMD and multicollinearity. CONCLUSION We showed a progressively impaired bone microarchitecture with increasing bone turnover in chronic hemodialysis. However, this correlation is no longer present when controlling for bone mass. This suggests that impaired bone microarchitecture and increased fracture risk are dependent upon factors other than high bone turnover.
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Affiliation(s)
- Roxana Dusceac
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, 34-38 Aviatorilor blvd, 011863, Bucharest, Romania
| | - Dan Alexandru Niculescu
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, 34-38 Aviatorilor blvd, 011863, Bucharest, Romania.
| | - Ramona Dobre
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, 34-38 Aviatorilor blvd, 011863, Bucharest, Romania
| | - Madalina Cristina Sorohan
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, 34-38 Aviatorilor blvd, 011863, Bucharest, Romania
| | - Andra Caragheorgheopol
- Research Laboratory, C. I. Parhon National Institute of Endocrinology, 34-38 Aviatorilor blvd, 011863, Bucharest, Romania
| | - Catalin Tacu
- Diaverum Dialysis Center, 2N Industiilor blvd, 032895, Bucharest, Romania
| | - Cristiana David
- Department of Nephrology, Carol Davila University of Medicine and Pharmacy, 13 Vitan-Barzesti rd, 042122, Bucharest, Romania
| | - Catalina Poiana
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, 34-38 Aviatorilor blvd, 011863, Bucharest, Romania
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Panuccio VA, Tripepi R. Paget's Disease and Secondary Hyperparathyroidism: Is Healing Possible? Front Cell Dev Biol 2020; 8:399. [PMID: 32548119 PMCID: PMC7273920 DOI: 10.3389/fcell.2020.00399] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 04/29/2020] [Indexed: 11/13/2022] Open
Abstract
Paget bone disease (PDB) is often asymptomatic and incidentally diagnosed. It is a cause of osteoporosis and bone fragility and exposes patients to a high incidence of bone fractures. In Europe the prevalence varies according to the geographical area of origin, and increases with age. In patients with chronic renal disease, the prevalence is unknown and only few cases with PDB have been reported. We present a challenging case in an elderly patient with chronic kidney disease on peritoneal dialysis treatment. Our patients presented extremely high levels of alkaline phosphatase, suggesting a Paget bone disease. Secondary hyperparathyroidism was confirmed by the bone histological examination. The surprising biochemical and clinical response to active vitamin D confirms the well-known role on hyperparathyroidism and may indicate an additional role in the pathogenesis of Paget’s disease.
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Affiliation(s)
- Vincenzo Antonio Panuccio
- Nephrology, Dialysis and Transplantation Unit G.O.M. "Bianchi Melacrino Morelli", Reggio Calabria, Italy
| | - Rocco Tripepi
- Institute of Clinical Physiology (IFC-CNR), Research Unit of Reggio Calabria, Reggio Calabria, Italy
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24
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Nickolas TL, Chen N, McMahon DJ, Dempster D, Zhou H, Dominguez J, Aponte MA, Sung J, Evenepoel P, D'Haese PC, Mac-Way F, Moyses R, Moe S. A microRNA Approach to Discriminate Cortical Low Bone Turnover in Renal Osteodystrophy. JBMR Plus 2020; 4:e10353. [PMID: 32490328 PMCID: PMC7254487 DOI: 10.1002/jbm4.10353] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 01/31/2020] [Accepted: 02/18/2020] [Indexed: 01/03/2023] Open
Abstract
A main obstacle to diagnose and manage renal osteodystrophy (ROD) is the identification of intracortical bone turnover type (low, normal, high). The gold standard, tetracycline‐labeled transiliac crest bone biopsy, is impractical to obtain in most patients. The Kidney Disease Improving Global Outcomes Guidelines recommend PTH and bone‐specific alkaline phosphatase (BSAP) for the diagnosis of turnover type. However, PTH and BSAP have insufficient diagnostic accuracy to differentiate low from non‐low turnover and were validated for trabecular turnover. We hypothesized that four circulating microRNAs (miRNAs) that regulate osteoblast (miRNA‐30b, 30c, 125b) and osteoclast development (miRNA‐155) would provide superior discrimination of low from non‐low turnover than biomarkers in clinical use. In 23 patients with CKD 3‐5D, we obtained tetracycline‐labeled transiliac crest bone biopsy and measured circulating levels of intact PTH, BSAP, and miRNA‐30b, 30c, 125b, and 155. Spearman correlations assessed relationships between miRNAs and histomorphometry and PTH and BSAP. Diagnostic test characteristics for discriminating low from non‐low intracortical turnover were determined by receiver operator curve analysis; areas under the curve (AUC) were compared by χ2 test. In CKD rat models of low and high turnover ROD, we performed histomorphometry and determined the expression of bone tissue miRNAs. Circulating miRNAs moderately correlated with bone formation rate and adjusted apposition rate at the endo‐ and intracortical envelopes (ρ = 0.43 to 0.51; p < 0.05). Discrimination of low versus non‐low turnover was 0.866, 0.813, 0.813, and 0.723 for miRNA‐30b, 30c, 125b, and 155, respectively, and 0.509 and 0.589 for PTH and BSAP, respectively. For all four miRNAs combined, the AUC was 0.929, which was superior to that of PTH and BSAP alone and together (p < 0.05). In CKD rats, bone tissue levels of the four miRNAs reflected the findings in human serum. These data suggest that a panel of circulating miRNAs provide accurate noninvasive identification of bone turnover in ROD. © 2020 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Thomas L Nickolas
- Department of Medicine Columbia University Medical Center New York NY USA
| | - Neal Chen
- Division of Nephrology Indiana University School of Medicine Indianapolis IN USA
| | - Donald J McMahon
- Department of Medicine Columbia University Medical Center New York NY USA
| | - David Dempster
- Department of Pathology and Cell Biology Columbia University New York NY USA.,Regional Bone Center Helen Hayes Hospital New York NY USA
| | - Hua Zhou
- Regional Bone Center Helen Hayes Hospital New York NY USA
| | - James Dominguez
- Division of Nephrology Indiana University School of Medicine Indianapolis IN USA
| | - Maria A Aponte
- Department of Medicine Columbia University Medical Center New York NY USA
| | - Joshua Sung
- Department of Medicine Columbia University Medical Center New York NY USA
| | - Pieter Evenepoel
- Department of Microbiology and Immunology, Laboratory of Nephrology Katholieke Universiteit Leuven, University of Leuven Leuven Belgium
| | - Patrick C D'Haese
- Department of Biomedical Sciences, Laboratory of Pathophysiology Antwerp University Wilrijk Belgium
| | - Fabrice Mac-Way
- CHU de Québec Research Center, L'Hôtel-Dieu de Québec Hospital, Endocrinology and Nephrology Axis, Faculty and Department of Medicine Université Laval Quebec City Canada
| | - Rosa Moyses
- Laboratório de Investigação Médica 16 Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo Sao Paulo Brazil
| | - Sharon Moe
- Division of Nephrology Indiana University School of Medicine Indianapolis IN USA.,Department of Medicine Roudebush Veterans Administration Medical Center Indianapolis IN USA
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25
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Jansz TT, Goto NA, van Ballegooijen AJ, Willems HC, Verhaar MC, van Jaarsveld BC. The prevalence and incidence of vertebral fractures in end-stage renal disease and the role of parathyroid hormone. Osteoporos Int 2020; 31:515-524. [PMID: 31728605 PMCID: PMC7076061 DOI: 10.1007/s00198-019-05187-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 10/09/2019] [Indexed: 11/17/2022]
Abstract
UNLABELLED The risk of vertebral fracture is unclear in end-stage renal disease. We report a high vertebral fracture prevalence and incidence in transplantation-eligible patients on dialysis, suggesting that these patients may benefit from radiographic screening for vertebral fractures. Parathyroid hormone had a U-shaped association with vertebral fracture risk. INTRODUCTION Vertebral fractures are often overlooked, but even undiagnosed vertebral fractures negatively impact physical functioning, quality of life, and mortality. The risk of vertebral fractures in end-stage renal disease (ESRD) patients is unclear, and parathyroid hormone (PTH) might play a role in the development of vertebral fractures. We therefore determined vertebral fracture prevalence and incidence in ESRD patients and assessed associations of vertebral trabecular bone mineral density (BMD) and PTH with vertebral fracture. METHODS In 146 transplantation-eligible patients on dialysis, we determined vertebral fractures on lateral chest radiographs, which image the thoracic and upper lumbar spine. We determined incident vertebral fractures in 70 patients with follow-up radiographs (23 received a kidney transplant) after median 1.8 years. Vertebral trabecular BMD was measured with computed tomography, and PTH measured with 2-site immunoassays, categorized in tertiles with the middle tertile as reference. We used Poisson regression to assess associations of vertebral trabecular BMD and PTH with vertebral fracture. RESULTS Mean age of the study population was 52 ± 13 years, and 98 (67%) were male. Median dialysis duration was 26 (IQR 13-55) months. Vertebral fractures were present in 50/146 patients (34%) and incident vertebral fractures occurred in 20/70 patients (29%). Vertebral trabecular BMD was not associated with vertebral fracture prevalence (relative risk 0.97, 95% CI 0.89 to 1.04). For the lowest PTH tertile (< 11 pmol/L), the relative risk of vertebral fracture was greater although not significant (2.28, 95% CI 0.97 to 5.97) and was significantly greater for the highest PTH tertile (≥ 30 pmol/L; 2.82, 95% CI 1.22 to 7.27) after adjustment for potential confounders. CONCLUSIONS The prevalence and incidence of vertebral fractures is high even in relatively young and healthy ESRD patients. Vertebral trabecular BMD is not associated with vertebral fracture, and the association of PTH with vertebral fracture risk appears U-shaped. Nevertheless, our study did not measure vertebral BMD using DXA and assessed vertebral fractures using lateral chest radiographs and not spine radiographs.
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Affiliation(s)
- T T Jansz
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Dianet Dialysis Centers, Utrecht, the Netherlands
| | - N A Goto
- Dianet Dialysis Centers, Utrecht, the Netherlands
- Department of Geriatrics, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - A J van Ballegooijen
- Department of Nephrology and Cardiovascular Sciences (ACS), Amsterdam UMC, Vrije Universiteit Amsterdam, P.O. box 7507, 1007 MB, Amsterdam, the Netherlands
- Department of Epidemiology and Biostatistics, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - H C Willems
- Department of Geriatrics, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - M C Verhaar
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - B C van Jaarsveld
- Dianet Dialysis Centers, Utrecht, the Netherlands.
- Department of Nephrology and Cardiovascular Sciences (ACS), Amsterdam UMC, Vrije Universiteit Amsterdam, P.O. box 7507, 1007 MB, Amsterdam, the Netherlands.
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Matias PJ, Laranjinha I, Azevedo A, Raimundo A, Navarro D, Jorge C, Aires I, Mendes M, Ferreira C, Amaral T, Gil C, Ferreira A. Bone fracture risk factors in prevalent hemodialysis patients. J Bone Miner Metab 2020; 38:205-212. [PMID: 31489503 DOI: 10.1007/s00774-019-01041-9] [Citation(s) in RCA: 20] [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: 02/19/2019] [Accepted: 07/31/2019] [Indexed: 12/21/2022]
Abstract
Bone fractures are an important cause of morbidity and mortality in hemodialysis (HD) patients. The aim of this study was to quantify the incidence of fractures in a cohort of prevalent HD patients and evaluate its relationship with possible risk factors. We performed a retrospective analysis of 341 patients, since they started HD (median of 51 months). Demographic, clinical, and biochemical parameters as well as vascular calcifications (VC) were evaluated. Fifty-seven episodes of fracture were identified with a median HD vintage of 47 months (incidence rate of 31 per 1000 person-years). Age (p < 0.001), female gender (p < 0.001), lower albumin (p = 0.02), and higher VC score (p < 0.001) were independently associated with increased risk of fracture, while active vitamin D therapy (p = 0.03) was associated with decreased risk. A significantly higher risk of incident fracture was also associated with higher values of bone-specific alkaline phosphatase (bALP) (p = 0.01) and intact parathyroid hormone (iPTH) levels either < 300 pg/mL (p = 0.02) or > 800 pg/mL (p < 0.001) compared with 300-800 pg/mL. In conclusion, bone fracture incidence in HD patients is high and its risk increases with age, female gender, lower serum albumin, and with the presence of more VC. Prevalent HD patients with low or high iPTH levels or increased bALP also had a higher fracture risk. Therapy with active vitamin D seems to have a protective role. Assessment of fracture risk and management in dialysis patients at greatest risk requires further study.
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Affiliation(s)
- Patrícia João Matias
- Dialysis Unit, Nephrocare Vila Franca de Xira, Praça Bartolomeu Dias, lote 3 r/c, 2600-063, Vila Franca de Xira, Portugal.
- Dialysis Unit, Dialverca, Forte da Casa, Portugal.
- NIDAN, Lisbon, Portugal.
- Faculdade de Ciências Médicas, NOVA Medical School, Lisbon, Portugal.
| | - Ivo Laranjinha
- Dialysis Unit, Dialverca, Forte da Casa, Portugal
- NIDAN, Lisbon, Portugal
- Faculdade de Ciências Médicas, NOVA Medical School, Lisbon, Portugal
| | - Ana Azevedo
- Dialysis Unit, Dialverca, Forte da Casa, Portugal
- NIDAN, Lisbon, Portugal
| | - Ana Raimundo
- Dialysis Unit, Nephrocare Vila Franca de Xira, Praça Bartolomeu Dias, lote 3 r/c, 2600-063, Vila Franca de Xira, Portugal
- NIDAN, Lisbon, Portugal
| | - David Navarro
- Dialysis Unit, Nephrocare Vila Franca de Xira, Praça Bartolomeu Dias, lote 3 r/c, 2600-063, Vila Franca de Xira, Portugal
- NIDAN, Lisbon, Portugal
| | - Cristina Jorge
- Dialysis Unit, Nephrocare Vila Franca de Xira, Praça Bartolomeu Dias, lote 3 r/c, 2600-063, Vila Franca de Xira, Portugal
- Dialysis Unit, Dialverca, Forte da Casa, Portugal
- NIDAN, Lisbon, Portugal
| | - Inês Aires
- Dialysis Unit, Nephrocare Vila Franca de Xira, Praça Bartolomeu Dias, lote 3 r/c, 2600-063, Vila Franca de Xira, Portugal
- Dialysis Unit, Dialverca, Forte da Casa, Portugal
- NIDAN, Lisbon, Portugal
- Faculdade de Ciências Médicas, NOVA Medical School, Lisbon, Portugal
| | - Marco Mendes
- Dialysis Unit, Nephrocare Vila Franca de Xira, Praça Bartolomeu Dias, lote 3 r/c, 2600-063, Vila Franca de Xira, Portugal
- NIDAN, Lisbon, Portugal
| | - Carina Ferreira
- Dialysis Unit, Dialverca, Forte da Casa, Portugal
- NIDAN, Lisbon, Portugal
- Faculdade de Ciências Médicas, NOVA Medical School, Lisbon, Portugal
| | - Tiago Amaral
- Dialysis Unit, Dialverca, Forte da Casa, Portugal
- NIDAN, Lisbon, Portugal
| | - Célia Gil
- Dialysis Unit, Nephrocare Vila Franca de Xira, Praça Bartolomeu Dias, lote 3 r/c, 2600-063, Vila Franca de Xira, Portugal
- Dialysis Unit, Dialverca, Forte da Casa, Portugal
- NIDAN, Lisbon, Portugal
| | - Aníbal Ferreira
- Dialysis Unit, Nephrocare Vila Franca de Xira, Praça Bartolomeu Dias, lote 3 r/c, 2600-063, Vila Franca de Xira, Portugal
- Dialysis Unit, Dialverca, Forte da Casa, Portugal
- NIDAN, Lisbon, Portugal
- Faculdade de Ciências Médicas, NOVA Medical School, Lisbon, Portugal
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Lin R, Toussaint ND, Gallagher M, Cass A, Kotwal S. Hospitalized fracture rates amongst patients with chronic kidney disease in Australia using data linkage. Nephrology (Carlton) 2019; 25:475-482. [PMID: 31743530 DOI: 10.1111/nep.13681] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 10/27/2019] [Accepted: 11/11/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Renal osteodystrophy leading to fractures in chronic kidney disease (CKD) is associated with significant hospitalization, morbidity, mortality and health care costs. There is a paucity of data on fractures in the CKD population in Australia. AIM To describe the trends and impact of hospitalized fractures in an Australian population of non-dialysis CKD patients. METHODS Retrospective observational data derived using data linkage. Fracture rates, trends in hospital admissions, comorbidity burden and mortality were analysed in a non-dialysis CKD population between 2000 and 2010 in the Australian state of New South Wales. Hospitalized patients with CKD and fractures were compared with CKD patients without fracture. RESULTS A total of 149 839 hospitalized patients with CKD were included, of whom 9898 (6.6%) experienced one or more fractures. Patients with fracture were older, more likely to be female with a higher comorbidity burden than those without. Hospital admissions involving fracture were longer than non-fracture admissions (14.3 vs 5.9 days, P < .0001) and patients were less likely to be discharged home (28.3% vs 80.9%, P < .0001). The 12-month mortality rate was high at 41%. CONCLUSION Australian non-dialysis CKD patients with hospitalized fractures were older, had a greater burden of disease, and have similar rates of fracture and associated mortality compared to international CKD cohorts. Implications of fracture requiring hospitalization are considerable, with longer admissions, greater healthcare costs, lower likelihood of discharge home and significant mortality. As fracture prevention in the CKD population evolves, treatment algorithms should account for those at greatest risk.
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Affiliation(s)
- Raymond Lin
- Renal and Metabolic Divisions, The George Institute for Global Health, Newtown, New South Wales, Australia
| | - Nigel D Toussaint
- Department of Nephrology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medicine (RMH), University of Melbourne, Melbourne, Victoria, Australia
| | - Martin Gallagher
- Renal and Metabolic Divisions, The George Institute for Global Health, Newtown, New South Wales, Australia.,Concord Clinical School, Faculty of Medicine & Health, University of Sydney, Sydney, New South Wales, Australia
| | - Alan Cass
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Sradha Kotwal
- Renal and Metabolic Divisions, The George Institute for Global Health, Newtown, New South Wales, Australia.,Department of Nephrology, Prince of Wales Hospital, Sydney, New South Wales, Australia
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Cozzolino M, Fusaro M, Ciceri P, Gasperoni L, Cianciolo G. The Role of Vitamin K in Vascular Calcification. Adv Chronic Kidney Dis 2019; 26:437-444. [PMID: 31831122 DOI: 10.1053/j.ackd.2019.10.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 10/25/2019] [Accepted: 10/28/2019] [Indexed: 12/28/2022]
Abstract
Vascular calcification (VC) is common in advanced chronic kidney disease (CKD), contributes to cardiovascular disease (CVD), and associates with increased mortality. Major risk factors for VC in CKD are increasing age, dialysis vintage, and positive net calcium-phosphate balance. To date, no specific therapy that prevents progression or facilitates regression of VC beyond careful attention to calcium and phosphate balance exists. Accumulating evidence demonstrates that CKD patients may incur subclinical vitamin K deficiency. This deficiency may be induced by exhaustion of vitamin K due to its high requirement by vitamin K-dependent proteins to inhibit VC. This review analyzes the pathophysiological mechanisms and clinical consequences of vitamin K deficiency with emphasis on its involvement on vascular calcification in CKD and end-stage renal disease and its relationship to the bone-vascular axis.
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29
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Khairallah P, Nickolas TL, Fusaro M. How and when to assess bone mineral density and bone quality in chronic kidney disease patients? Nephrol Dial Transplant 2019; 36:774-776. [PMID: 31665427 DOI: 10.1093/ndt/gfz198] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Indexed: 01/26/2023] Open
Affiliation(s)
- Pascale Khairallah
- Division of Nephrology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Thomas L Nickolas
- Division of Nephrology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Maria Fusaro
- National Research Council (CNR), Institute of Clinical Physiology (IFC), Pisa, Italy.,Department of Medicine, University of Padova, Padova, Italy
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Sidibé A, Auguste D, Desbiens L, Fortier C, Wang YP, Jean S, Moore L, Mac‐Way F. Fracture Risk in Dialysis and Kidney Transplanted Patients: A Systematic Review. JBMR Plus 2019; 3:45-55. [PMID: 30680363 PMCID: PMC6339558 DOI: 10.1002/jbm4.10067] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 06/07/2018] [Accepted: 06/14/2018] [Indexed: 12/14/2022] Open
Abstract
Chronic kidney disease is associated with an increased risk of fracture and cardiovascular mortality. The risk of fracture in hemodialysis (HD), peritoneal dialysis (PD) and kidney transplant (KT) patients is higher when compared with the general population. However, there exists a knowledge gap concerning which group has the highest risk of fracture. We aimed to compare the risk of fracture in HD, PD, and KT populations. We conducted a systematic review of observational studies evaluating the risk of fracture in HD, PD, or KT patients. Eligible studies were searched using MEDLINE, Embase, Web of Science, and Cochrane Library from their inception to January 2016, and in grey literature. Incidences (cumulative and rate) of fracture were described together using the median, according to fracture sites, the data source (administrative database or cohort and clinical registry), and fracture diagnosis method. Prevalence estimates were described separately. We included 47 studies evaluating the risk of fracture in HD, PD, and KT populations. In administrative database studies, incidence of hip fracture in HD (median 11.45 per 1000 person-years [p-y]), range: 9.3 to 13.6 was higher than in KT (median 2.6 per 1000 p-y; range 1.5 to 3.8) or in PD (median 5.2 per 1000 p-y; range 4.1 to 6.3). In dialysis (HD+PD), three studies reported a higher incidence of hip fracture than in KT. Prevalent vertebral fracture (assessed by X-rays or questionnaire) reported in HD was in a similar range as that reported in KT. Incidence of overall fracture was similar in HD and KT, from administrative databases studies, but lower in HD compared with KT, from cohorts or clinical registry studies. This systematic review suggests an important difference in fracture risk between HD, PD, and KT population, which vary according to the diagnosis method for fracture identification. © 2018 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Aboubacar Sidibé
- Centre de Recherche du CHU de QuébecHôpital Hôtel‐Dieu de QuébecDivision of Nephrology, Endocrinology, and Nephrology AxisFaculty of MedicineDepartment of Social and Preventive MedicineLaval UniversityQuebecCanada
| | - David Auguste
- Centre de Recherche du CHU de QuébecHôpital Saint‐SacrementFaculty of MedicineDepartment of Social and Preventive MedicineLaval UniversityQuebecCanada
| | - Louis‐Charles Desbiens
- Centre de Recherche du CHU de QuébecHôpital Hôtel‐Dieu de QuébecDivision of Nephrology, Endocrinology, and Nephrology AxisFaculty and Department of MedicineLaval UniversityQuebecCanada
| | - Catherine Fortier
- Centre de Recherche du CHU de QuébecHôpital Hôtel‐Dieu de QuébecDivision of Nephrology, Endocrinology, and Nephrology AxisFaculty and Department of MedicineLaval UniversityQuebecCanada
| | - Yue Pei Wang
- Centre de Recherche du CHU de QuébecHôpital Hôtel‐Dieu de QuébecDivision of Nephrology, Endocrinology, and Nephrology AxisFaculty and Department of MedicineLaval UniversityQuebecCanada
| | - Sonia Jean
- Institut National de Santé Publique du QuébecMedicine FacultyDepartment of Social and Preventive MedicineLaval UniversityQuebecCanada
| | - Lynne Moore
- Centre de Recherche du CHU de QuébecHôpital de l'Enfant‐JésusTraumatology AxisMedicine FacultyDepartment of Social and Preventive MedicineLaval UniversityQuebecCanada
| | - Fabrice Mac‐Way
- Centre de Recherche du CHU de QuébecHôpital Hôtel‐Dieu de QuébecDivision of Nephrology, Endocrinology, and Nephrology AxisFaculty and Department of MedicineLaval UniversityQuebecCanada
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Dusceac R, Niculescu DA, Dobre R, Dragne MC, Tacu C, Peride I, David C, Checherita I, Poiana C. Chronic hemodialysis is associated with lower trabecular bone score, independent of bone mineral density: a case-control study. Arch Osteoporos 2018; 13:125. [PMID: 30426286 DOI: 10.1007/s11657-018-0541-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 11/07/2018] [Indexed: 02/03/2023]
Abstract
UNLABELLED We measured trabecular bone score (TBS) in 98 patients on permanent hemodialysis (HD) and 98 subjects with similar bone mineral density and normal kidney function. TBS was significantly lower in HD patients, indicating deteriorated bone microarchitecture, independent of bone mass. This might partially explain the increased fracture risk in HD. PURPOSE In the general population, trabecular bone score (TBS) was shown to predict fracture independent of bone mineral density (BMD). In end-stage renal disease patients on hemodialysis (HD), the value of TBS is beyond that of BMD in currently unclear. Our aim was to assess lumbar spine (LS) TBS in HD patients compared with subjects with normal kidney function matched for age, sex, and LS BMD. METHODS We assessed TBS and LS and femoral neck (FN) BMD in 98 patient on permanent HD (42.8% males; mean age 57.5 ± 11.3 years; dialysis vintage 5.5 ± 3.8 years) and 98 control subjects (glomerular filtration rate > 60 mL/min) using DXA. We simultaneously controlled for sex, age (± 3 years), and LS BMD (± 0.03 g/cm2). RESULTS HD patients had significantly lower LS TBS (0.07 [95% CI 0.03-0.1]; p = 0.0004), TBS T-score (0.83 SD [95% CI 0.42-1.24]; p = 0.0001)) and TBS Z-score (0.81 SD [95% CI 0.41-1.20]; p = 0.0001) than matched controls. TBS significantly correlated with LS BMD in both HD patients (r = 0.382; p = 0.001) and controls (r = 0.36; p = 0.002). The two regression lines had similar slopes (0.3 vs. 0.28; p = 0.84) with different intercepts (0.88 vs. 0.98). TBS adjustment significantly increased the 10-year fracture risk from 3.7 to 5.3 for major osteoporotic fracture and from 0.9 to 1.5 for hip fracture. CONCLUSIONS HD patients have lower TBS than controls matched for LS BMD, indicating altered bone microarchitecture. Also, the magnitude of TBS reduction in HD patients is constant at any LS BMD. Adjustment for TBS partially corrects the absolute 10-year fracture risk.
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Affiliation(s)
- Roxana Dusceac
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, 34-38 Aviatorilor blvd, 011863, Bucharest, Romania
| | - Dan Alexandru Niculescu
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, 34-38 Aviatorilor blvd, 011863, Bucharest, Romania.
| | - Ramona Dobre
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, 34-38 Aviatorilor blvd, 011863, Bucharest, Romania
| | - Madalina Cristina Dragne
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, 34-38 Aviatorilor blvd, 011863, Bucharest, Romania
| | - Catalin Tacu
- Diaverum Dialysis Center, 2N Industiilor blvd, 032895, Bucharest, Romania
| | - Ileana Peride
- Department of Nephrology, Carol Davila University of Medicine and Pharmacy, 13 Vitan-Barzesti rd, 042122, Bucharest, Romania
| | - Cristiana David
- Department of Nephrology, Carol Davila University of Medicine and Pharmacy, 13 Vitan-Barzesti rd, 042122, Bucharest, Romania
| | - Ionel Checherita
- Department of Nephrology, Carol Davila University of Medicine and Pharmacy, 13 Vitan-Barzesti rd, 042122, Bucharest, Romania
| | - Catalina Poiana
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, 34-38 Aviatorilor blvd, 011863, Bucharest, Romania
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Przedlacki J, Buczyńska-Chyl J, Koźmiński P, Niemczyk E, Wojtaszek E, Gieglis E, Żebrowski P, Podgórzak A, Wściślak J, Wieliczko M, Matuszkiewicz-Rowińska J. The utility of FRAX® in predicting bone fractures in patients with chronic kidney disease on hemodialysis: a two-year prospective multicenter cohort study. Osteoporos Int 2018; 29:1105-1115. [PMID: 29411069 DOI: 10.1007/s00198-018-4406-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 01/23/2018] [Indexed: 01/05/2023]
Abstract
UNLABELLED We assessed the FRAX® method in 718 hemodialyzed patients in estimating increased risk of bone major and hip fractures. Over two prospective years, statistical analysis showed that FRAX® enables a better assessment of bone major fracture risk in these patients than any of its components and other risk factors considered in the analysis. INTRODUCTION Despite the generally increased risk of bone fractures among patients with end-stage renal disease, no prediction models for identifying individuals at particular risk have been developed to date. The goal of this prospective, multicenter observational study was to assess the usefulness of the FRAX® method in comparison to all its elements considered separately, selected factors associated with renal disease and the history of falls, in estimating increased risk of low-energy major bone and hip fractures in patients undergoing chronic hemodialysis. METHODS The study included a total of 1068 hemodialysis patients, who were followed for 2 years, and finally, 718 of them were analyzed. The risk analysis included the Polish version of the FRAX® calculator (without bone mineral density), dialysis vintage, mineral metabolism disorders (serum calcium, phosphate, and parathyroid hormone), and the number of falls during the last year before the study. RESULTS Over 2 years, low-energy 30 major bone fractures were diagnosed and 13 of hip fractures among them. Area under the curve for FRAX® was 0.76 (95% CI 0.69-0.84) for major fractures and 0.70 (95% CI 0.563-0.832) for hip fractures. The AUC for major bone fractures was significantly higher than for all elements of the FRAX® calculator. In logistic regression analysis FRAX® was the strongest independent risk factor of assessment of the major bone fracture risk. CONCLUSIONS FRAX® enables a better assessment of major bone fracture risk in ESRD patients undergoing hemodialysis than any of its components and other risk factors considered in the analysis.
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Affiliation(s)
- J Przedlacki
- Department of Nephrology, Dialysis and Internal Diseases, Medical University of Warsaw, Warsaw, Poland.
| | | | | | - E Niemczyk
- Department of Internal Diseases, John Paul II Western Hospital, Grodzisk Mazowiecki, Poland
- Fresenius Dialysis Center, Płońsk, Poland
| | - E Wojtaszek
- Department of Nephrology, Dialysis and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - E Gieglis
- Fresenius Dialysis Center, Otwock, Poland
| | - P Żebrowski
- Department of Nephrology, Dialysis and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - A Podgórzak
- Department of Nephrology, Mazovia Regional Hospital, Siedlce, Poland
| | - J Wściślak
- Department of Nephrology, Mazovia Regional Hospital, Siedlce, Poland
| | - M Wieliczko
- Department of Nephrology, Dialysis and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - J Matuszkiewicz-Rowińska
- Department of Nephrology, Dialysis and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
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Bover J, Ureña-Torres P, Torregrosa JV, Rodríguez-García M, Castro-Alonso C, Górriz JL, Laiz Alonso AM, Cigarrán S, Benito S, López-Báez V, Lloret Cora MJ, daSilva I, Cannata-Andía J. Osteoporosis, bone mineral density and CKD-MBD complex (I): Diagnostic considerations. Nefrologia 2018; 38:476-490. [PMID: 29703451 DOI: 10.1016/j.nefro.2017.12.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 12/21/2017] [Accepted: 12/31/2017] [Indexed: 01/10/2023] Open
Abstract
Osteoporosis (OP) and chronic kidney disease (CKD) independently influence bone and cardiovascular health. A considerable number of patients with CKD, especially those with stages 3a to 5D, have a significantly reduced bone mineral density leading to a high risk of fracture and a significant increase in associated morbidity and mortality. Independently of classic OP related to age and/or gender, the mechanical properties of bone are also affected by inherent risk factors for CKD ("uraemic OP"). In the first part of this review, we will analyse the general concepts regarding bone mineral density, OP and fractures, which have been largely undervalued until now by nephrologists due to the lack of evidence and diagnostic difficulties in the context of CKD. It has now been proven that a reduced bone mineral density is highly predictive of fracture risk in CKD patients, although it does not allow a distinction to be made between the causes which generate it (hyperparathyroidism, adynamic bone disease and/or senile osteoporosis, etc.). Therefore, in the second part, we will analyse the therapeutic indications in different CKD stages. In any case, the individual assessment of factors which represent a higher or lower risk of fracture, the quantification of this risk (i.e. using tools such as FRAX®) and the potential indications for densitometry in patients with CKD could represent an important first step pending new clinical guidelines based on randomised studies which do not exclude CKD patients, all the while avoiding therapeutic nihilism in an area of growing importance.
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Affiliation(s)
- Jordi Bover
- Fundació Puigvert, Servicio de Nefrología, IIB Sant Pau, REDinREN, Barcelona, España.
| | - Pablo Ureña-Torres
- Ramsay-Générale de Santé, Clinique du Landy, Department of Nephrology and Dialysis and Department of Renal Physiology, Necker Hospital, University of Paris Descartes, París, Francia
| | - Josep-Vicent Torregrosa
- Servicio de Nefrología, Hospital Clinic, IDIBAPS, Universidad de Barcelona, Barcelona, España
| | - Minerva Rodríguez-García
- Servicio de Nefrología, Hospital Universitario Central de Asturias, REDinREN, Universidad de Oviedo, Oviedo, España
| | | | - José Luis Górriz
- Servicio de Nefrología, Hospital Clínico Universitario de Valencia, INCLIVA, Universidad de Valencia, Valencia, España
| | | | | | - Silvia Benito
- Fundació Puigvert, Servicio de Nefrología, IIB Sant Pau, REDinREN, Barcelona, España
| | - Víctor López-Báez
- Fundació Puigvert, Servicio de Nefrología, IIB Sant Pau, REDinREN, Barcelona, España
| | | | - Iara daSilva
- Fundació Puigvert, Servicio de Nefrología, IIB Sant Pau, REDinREN, Barcelona, España
| | - Jorge Cannata-Andía
- Unidad de Gestión Clínica de Servicio de Metabolismo Óseo, Hospital Universitario Central de Asturias, Instituto de Investigación del Principado de Asturias, REDinREN, Universidad de Oviedo, Oviedo, España
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Fusaro M, Cannata-Andía JB, Nickolas TL, Plebani M, Mereu MC, Aghi A, Gallieni M. Clinical relevance and future perspective of fractures in patients with chronic kidney disease. Kidney Int 2018; 93:1248. [PMID: 29680025 DOI: 10.1016/j.kint.2018.02.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 02/15/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Maria Fusaro
- National Research Council (CNR)-Institute of Clinical Physiology (IFC), Pisa, Italy; Department of Medicine, University of Padova Italy; Padova, Italy.
| | - Jorge B Cannata-Andía
- Servicio de Metabolismo Óseo y Mineral, Instituto Reina Sofía de Investigación, REDinREN del ISCIII, Hospital Universitario Central de Asturias, Universidad de Oviedo, Oviedo (Asturias), España
| | - Thomas L Nickolas
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA
| | - Mario Plebani
- Laboratory Medicine Unit, Department of Medicine, University of Padova, Padova, Italy
| | | | - Andrea Aghi
- Department of Medicine, Clinica Medica 1, University of Padova, Padova, Italy
| | - Maurizio Gallieni
- Nephrology and Dialysis Unit, Ospedale San Carlo Borromeo, Department of Clinical and Biomedical Sciences "Luigi Sacco," University of Milan, Milan, Italy
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Dey V, Farrah TE, Traynor JP, Spalding EM, Robertson SE, Geddes CC. Symptomatic fracture risk in the renal replacement therapy population. Nephrol Dial Transplant 2018; 32:1211-1216. [PMID: 27257273 DOI: 10.1093/ndt/gfw222] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 04/27/2016] [Indexed: 11/13/2022] Open
Abstract
Background Bone fractures are an important cause of morbidity and mortality in patients on renal replacement therapy (RRT). The aim of this multicentre observational study was to quantify the incidence of radiologically proven bone fracture by anatomical site in prevalent RRT groups and study its relationship to potential risk factors. Methods We performed a retrospective analysis of electronic records of all 2096 adults prevalent on RRT in the West of Scotland on 7 July 2010 across all hospitals (except one where inception was 1 August 2011) to identify all subsequent radiologically proven fractures during a median 3-year follow-up. Results There were 340 fractures, with an incidence of 62.8 per 1000 patient-years. The incidences were 37.6, 99.2 and 57.6 per 1000 patient-years in the transplant, haemodialysis (HD) and peritoneal dialysis (PD) groups, respectively (P < 0.05). In the multivariable model, age and HD (relative to transplant or PD) were independently associated with increased risk of fractures, while primary glomerular disease, increasing serum albumin and taking alfacalcidol or lanthanum were associated with decreased risk. In a multivariable model of only HD patients, age was independently associated with an increased risk of fractures, while glomerular disease, high serum albumin and being on alfacalcidol and lanthanum were associated with decreased risk. In a multivariable model in transplant patients, there were no significant independent predictors of fracture. Conclusions The risk of symptomatic bone fracture is high in RRT patients and is ∼2.5 times higher in HD than in renal transplant patients, with the increased risk being independent of baseline factors. Fracture risk increases with age and lower serum albumin and is reduced if the primary renal diagnosis is glomerular disease. The possible protective role of alfacalcidol and lanthanum in HD patients deserves further exploration.
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Affiliation(s)
- Vishal Dey
- Renal Unit, University Hospital Crosshouse, Kilmarnock, UK
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Cai MMX, Smith ER, Tan SJ, Hewitson TD, Holt SG. The Role of Secondary Calciprotein Particles in the Mineralisation Paradox of Chronic Kidney Disease. Calcif Tissue Int 2017; 101:570-580. [PMID: 28861648 DOI: 10.1007/s00223-017-0313-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 08/09/2017] [Indexed: 12/12/2022]
Abstract
Mineralisation paradox is prevalent in chronic kidney disease and ageing where increased vascular calcification is accompanied by reduced bone mineralisation and osteopenia. Secondary calciprotein particles (CPP2), colloidal nanoparticles containing hydroxyapatite crystal stabilised by a protein shell, have been implicated in vascular calcification in chronic kidney disease. Here, we describe the effect of CPP2 on osteoblasts and vascular smooth muscle cells (VSMC) mineralisation in an in vitro model system. The mineralisation paradox can be simulated in vitro by the addition of phosphate ions (Pi, 3 mM) and CPP2 (10 µg/ml of Ca equivalent). Pi alone induced osteoblast mineralisation but had no effect on VSMC mineralisation. CPP2 alone had no effect on mineralisation in either cell line, but when combined with elevated Pi, reduced osteoblast-like mineralisation (P < 0.001) whilst induced VSMC mineralisation (P < 0.001). These results suggest that in an in vitro system the synergistic interaction between Pi and CPP2 could mimic the mineralisation paradox, and may provide a potential mechanistic link to explain these clinical observations.
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Affiliation(s)
- Michael M X Cai
- Department of Nephrology, Royal Melbourne Hospital, Parkville, VIC, Australia.
- Department of Medicine (RMH), University of Melbourne, Parkville, VIC, Australia.
| | - Edward R Smith
- Department of Nephrology, Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Medicine (RMH), University of Melbourne, Parkville, VIC, Australia
| | - Sven-Jean Tan
- Department of Nephrology, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Timothy D Hewitson
- Department of Nephrology, Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Medicine (RMH), University of Melbourne, Parkville, VIC, Australia
| | - Stephen G Holt
- Department of Nephrology, Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Medicine (RMH), University of Melbourne, Parkville, VIC, Australia
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Abstract
Osteoporosis is defined simply as "a skeletal disorder characterized by compromised bone strength predisposing to an increased risk of fracture. Thus, any bone lesion that causes fragility fracture is osteoporosis, which has quite heterogeneous backgrounds. Chronic kidney disease-related bone and mineral disease (CKD-MBD) is defined as "a systemic disorder of mineral and bone metabolism due to CKD, which is manifested by abnormalities in bone and mineral metabolism and/or extra-skeletal calcification". Although CKD-MBD is one of the possible causes of osteoporosis, we do not have evidences that CKD-MBD is the only or crucial determinant of bone mechanical strength in CKD patients. The risk of hip fracture is considerably high in CKD patients. Drugs that intervene in systemic mineral metabolism, indeed, lead to the improvement on bone histology in CKD patients. However, it remains unclear whether the intervention in systemic mineral metabolism also improves bone strength, today. Thus, the use of drugs that directly act on bone and the introduction of fracture liaison concept are promising strategies for fragility fracture prevention among CKD patients, as well as treatment for CKD-MBD.
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Affiliation(s)
- Junichiro James Kazama
- Department of Nephrology and Hypertension, Fukushima Medical University, 1 Hikarigaoka, Fukushima, Fukushima, 960-1295, Japan.
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Atteritano M, Di Mauro E, Canale V, Bruzzese AM, Ricciardi CA, Cernaro V, Lacquaniti A, Buemi M, Santoro D. Higher serum sclerostin levels and insufficiency of vitamin D are strongly associated with vertebral fractures in hemodialysis patients: a case control study. Osteoporos Int 2017; 28:577-584. [PMID: 27682249 DOI: 10.1007/s00198-016-3770-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 09/08/2016] [Indexed: 10/20/2022]
Abstract
UNLABELLED In hemodialysis patients, vertebral fractures were associated with elevated sclerostin levels, suggesting that sclerostin could reflect bone fragility in these patients. INTRODUCTION Fragility fractures are common in hemodialysis patients. The aims of our study were to determine the prevalence of vertebral fracture and analyze associations between sclerostin serum levels and vertebral fractures in hemodialysis patients. METHODS Ninety-two hemodialysis patients and 100 controls matched for age and sex were studied. Bone mineral density was measured by ultrasonography at non-dominant heel. The markers of bone turnover included serum osteocalcin, C-terminal telopeptide, and sclerostin. All participants underwent radiography of the thoracic and lumbar spine to ascertain the presence of vertebral fractures. RESULTS Bone ultrasound parameters at calcaneus were significantly lower in hemodialysis patients compared with controls; bone turnover markers and parathyroid hormone level were significantly higher, while serum of 25-OH-D3 was significantly lower in hemodialysis group. One or more moderate or severe vertebral fractures were found in 38 hemodialysis patients, whereas in control group, 10 patients had a vertebral fracture. In hemodialysis group, the comparison between patients with and without vertebral fractures showed that the patients with vertebral fractures had the serum sclerostin levels statistically higher than patients without vertebral, while serum levels of 25-OH-D3 was significantly lower in patients with vertebral fractures compared to the patients without vertebral fractures. Multivariate analysis disclosed that sclerostin levels were associated with an increased risk of vertebral fractures in hemodialysis patients after adjusting for multiple variables. CONCLUSIONS Our data shows high prevalence of vertebral fractures in hemodialysis patients and that it is associated with elevated sclerostin levels, reflecting bone fragility in these patients.
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Affiliation(s)
- M Atteritano
- Department of Clinical and Experimental Medicine, University of Messina, Pad. B, 2nd floor, A.O.U. Policlinico "G. Martino" Via C. Valeria, 98125, Messina, Italy.
| | - E Di Mauro
- Department of Clinical and Experimental Medicine, University of Messina, Pad. B, 2nd floor, A.O.U. Policlinico "G. Martino" Via C. Valeria, 98125, Messina, Italy
| | - V Canale
- Department of Clinical and Experimental Medicine, University of Messina, Pad. B, 2nd floor, A.O.U. Policlinico "G. Martino" Via C. Valeria, 98125, Messina, Italy
| | - A M Bruzzese
- Department of Clinical and Experimental Medicine, University of Messina, Pad. B, 2nd floor, A.O.U. Policlinico "G. Martino" Via C. Valeria, 98125, Messina, Italy
| | - C A Ricciardi
- Department of Clinical and Experimental Medicine, University of Messina, Pad. B, 2nd floor, A.O.U. Policlinico "G. Martino" Via C. Valeria, 98125, Messina, Italy
| | - V Cernaro
- Department of Clinical and Experimental Medicine, University of Messina, Pad. B, 2nd floor, A.O.U. Policlinico "G. Martino" Via C. Valeria, 98125, Messina, Italy
| | - A Lacquaniti
- Department of Clinical and Experimental Medicine, University of Messina, Pad. B, 2nd floor, A.O.U. Policlinico "G. Martino" Via C. Valeria, 98125, Messina, Italy
| | - M Buemi
- Department of Clinical and Experimental Medicine, University of Messina, Pad. B, 2nd floor, A.O.U. Policlinico "G. Martino" Via C. Valeria, 98125, Messina, Italy
| | - D Santoro
- Department of Clinical and Experimental Medicine, University of Messina, Pad. B, 2nd floor, A.O.U. Policlinico "G. Martino" Via C. Valeria, 98125, Messina, Italy
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Abstract
OBJECTIVE The objective of this meta-analysis was to systematically assess the association between aortic calcification (AC) and fractures. METHOD Relevant studies were identified through searching PubMed, EMBASE and Cochrane databases before August 2014. Two investigators extracted data independently from the included studies. A random-effects model was derived to composite the pooled HRs or ORs for association of aortic calcification with fractures. RESULTS A total of 15 articles (21927 subjects) were included in the final meta-analyses. Comparing with non-calcification subjects, patients with aortic calcification were associated with increased risk of fractures (OR = 2.97, 95% CI: 1.98-4.42). Stratified analysis indicated that patients with aortic calcification showed a higher risk of fractures in hemodialysis patients (OR = 1.89, 95% CI: 1.33-2.67; I2 = 0.0%, p= 0.781) and general population (OR = 2.90, 95% CI: 1.80-4.80; I2 = 33.0%, p= 0.225), respectively. Similar significant association between severe aortic calcification and fractures were also observed. CONCLUSIONS Patients with aortic calcification or severe aortic calcification were associated with higher risk of fractures.
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Affiliation(s)
- Zexin Chen
- Department of Clinical Epidemiology & Biostatistics, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yunxian Yu
- Department of Epidemiology & Health Statistics, School of Public Health, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
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Hansen D, Olesen JB, Gislason GH, Abrahamsen B, Hommel K. Risk of fracture in adults on renal replacement therapy: a Danish national cohort study. Nephrol Dial Transplant 2016; 31:1654-62. [DOI: 10.1093/ndt/gfw073] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 02/22/2016] [Indexed: 11/13/2022] Open
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Lin JCF, Liang WM. Mortality and complications after hip fracture among elderly patients undergoing hemodialysis. BMC Nephrol 2015; 16:100. [PMID: 26149489 PMCID: PMC4492013 DOI: 10.1186/s12882-015-0099-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 06/28/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Osteoporotic hip fractures cause high mortality and morbidity in elderly adults. Compared to the general population, subjects with end-stage renal disease and hemodialysis often develop mineral bone disorders and have a higher risk for hip fractures. METHODS We conducted a matched cohort study design and used competing risk analysis to estimate the cumulative incidence of the complication rate. Subjects aged greater than 60 years with hip fracture were selected from Taiwan's National Health Insurance Research Database covering a period from 1997 to 2007, and these subjects were followed up until 2009. We used the Kaplan-Meier method to estimate the overall survival and used the log-rank test and multiple Cox proportional hazards model to explore the risk factors for survival. The cumulative incidence of the first complication was estimated using competing risk analysis. RESULTS Among hemodialysis subjects, the three-month, one-year, two-year and five-year mortality rates were 17.3 %, 37.2 %, 51.5 %, and 80.5 %, respectively; the one-year and five-year cumulative incidences of the first surgical complication were 14.2 % and 20.6 %, respectively; and the three-month cumulative incidence of the first medical complication was 24.1 %. Hemodialysis subjects presented a 2.32 times (95 % CI: 2.16-2.49) higher hazard ratio of overall death, 1.15 times (95 % CI: 1.01-1.30) higher sub-hazard ratio (sub-HR) of surgical complications, and 1.35 times (95 % CI: 1.21-1.52) higher sub-HR of the first medical complication than non-hemodialysis controls. CONCLUSIONS The overall mortality and complication rates of hemodialysis subjects after surgery for hip fracture were significantly higher than those of non-hemodialysis subjects. Further prospective studies which include important risk factors are necessary to more precisely quantify the adjusted effect of hemodialysis.
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Affiliation(s)
- Jeff Chien-Fu Lin
- Department of Statistics, National Taipei University, Taipei, Taiwan. .,Department of Orthopedic Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.
| | - Wen-Miin Liang
- Graduate Institute of Biostatistics, Biostatistics Center, Department of Public Health, China Medical University, Taichung, Taiwan.
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Fractures in chronic kidney disease: neglected, common, and associated with sickness and death. Kidney Int 2014; 85:20-2. [PMID: 24380905 DOI: 10.1038/ki.2013.302] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Bone fractures in dialysis patients have been poorly studied in the past. Tentori et al. partially fill this gap, assessing the incidence of post-fracture morbidity and mortality in patients of the Dialysis Outcomes and Practice Patterns Study (DOPPS). A high frequency of fractures and increased adverse outcomes following a fracture were observed. The nephrology community should pay more attention to bone fractures in dialysis patients.
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