Osteoporosis in chronic kidney disease: A essential challenge

Independent predictors of functional loss and refractures in patients with femur fracture: Follow-up at 6 and 18 months in a Fracture Liaison Service

BACKGROUND

In elderly patients hospitalized for a femur fracture, this study aimed to evaluate the functional evolution, and to estimate the incidence of second fractures at 6 and 18 months after hospital discharge.

PATIENTS AND METHODS

A longitudinal prospective study was designed at an Orthogeriatric Unit after implementing a Fracture Liaison Service (FLS). The variables collected included the baseline demographic and clinical characteristics of the patients, and the outcome variables on discharge, at 6 and 18 months of follow-up. Logistic regressions models were applied to identify independent predictors of functional evolution.

RESULTS

478 patients were admitted. Independent predictors of functional loss at follow-up were institutionalisation, severe dependence either prior to and on discharge, delirium, protein malnutrition, prior acute myocardial infarction, GFR<30ml/min/1.73m2 and not receiving treatment for osteoporosis on discharge. Patients attending follow-up appointments presented improved compliance with osteoporosis treatment both at 6 and 18 months. A lower number of 2nd fractures were recorded at 18 months for patients who attended their appointments (4.8% vs 12.1%, p=0.01). At 6 and 18 months follow-up, a lower rate of readmission was recorded (7% vs 15.3%, p=0.006), (9.6% vs 25.6%, p<0.0001), respectively.

CONCLUSIONS

The independent predictors of functional loss at 6 and 18 months were institutionalisation, severe dependence either prior to and on discharge, delirium, protein malnutrition, prior acute myocardial infarct, GFR<30ml/min/1.73m2 and not receiving treatment for osteoporosis on discharge. A lower incidence of refractures, a lower readmission rate and a better treatment compliance were observed in patients attending follow-up visits.

The Management of Osteoporosis in Chronic Kidney Disease: A Review of Diagnostic and Therapeutic Approaches

Chronic kidney disease (CKD) has shown a growing association with osteoporosis, comprising part of the broader CKD-mineral and bone disorder (CKD-MBD). CKD-MBD is marked by alterations in calcium, phosphorus, parathyroid hormone (PTH), and vitamin D metabolism, significantly elevating fracture risk. While traditional osteoporosis treatments such as bisphosphonates, denosumab, and teriparatide have been adapted for CKD patients, recent innovations have introduced agents aimed at enhancing bone mass and reducing fracture incidence. This study aims to evaluate the pathophysiology, diagnostic methods, and tailored management strategies for osteoporosis in CKD patients. A detailed review of the literature was conducted, involving an in-depth search of PubMed, Medical Literature Analysis and Retrieval System Online (MEDLINE), and the Cochrane Library databases for studies published between 2017 and 2024. Studies were selected based on inclusion criteria focusing on CKD-related osteoporosis, diagnostic criteria, and treatment outcomes. Data extraction and quality assessment were independently performed by multiple reviewers to ensure thoroughness and reduce bias. Findings highlight that conventional treatments, such as bisphosphonates, denosumab, and teriparatide, when tailored to CKD stages, demonstrate variable effectiveness in lowering fracture risk. Additionally, emerging pharmacologic agents hold promise in improving bone density, though evidence on these newer therapies remains limited. Osteoporosis management in CKD patients necessitates a personalized approach guided by the disease's stage and individual profile. This review underscores the potential of emerging therapies and emphasizes the need for further research to refine treatment protocols, aiming to enhance patient outcomes in this complex population.

Vertebral fractures in patients with CKD and the general population: a call for diagnosis and action

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.

Osteoporosis management in patients with chronic kidney disease (ERCOS Study): A challenge in nephrological care

Fracture risk assessment in patients with chronic kidney disease (CKD) has been included in the CKD-MBD ("Chronic Kidney Disease-Mineral and Bone Disorders") complex in international and national nephrology guidelines, suggesting for the first time the assessment of bone mineral density (BMD) if the results can influence therapeutic decision-making. However, there is very little information on actual clinical practice in this population. The main objective of the ERCOS (ERC-Osteoporosis) study is to describe the profile of patients with CKD G3-5D with osteoporosis (OP) and/or fragility fractures treated in specialized nephrology, rheumatology and internal medicine clinics in Spain. Fifteen centers participated and 162 patients (mostly women [71.2%] postmenopausal [98.3%]) with a median age of 77 years were included. Mean estimated glomerular filtration rate (eGFR) was 36 mL/min/1.73 m2 and 38% of the included patients were on dialysis. We highlight the high frequency of prevalent fragility fractures [37.7%), mainly vertebral (52.5%) and hip (24.6%)], the disproportionate history of patients with glomerular disease compared to purely nephrological series (corticosteroids) and undertreatment for fracture prevention, especially in nephrology consultations. This study is an immediate call to action with the dissemination of the new, more proactive, clinical guidelines, and underlines the need to standardize a coordinated and multidisciplinary care/therapeutic approach to these patients in an efficient way to avoid current discrepancies and therapeutic nihilism.

Pathophysiology of bone disease in chronic kidney disease: from basics to renal osteodystrophy and osteoporosis

Chronic kidney disease (CKD) is a highly prevalent disease that has become a public health problem. Progression of CKD is associated with serious complications, including the systemic CKD-mineral and bone disorder (CKD-MBD). Laboratory, bone and vascular abnormalities define this condition, and all have been independently related to cardiovascular disease and high mortality rates. The "old" cross-talk between kidney and bone (classically known as "renal osteodystrophies") has been recently expanded to the cardiovascular system, emphasizing the importance of the bone component of CKD-MBD. Moreover, a recently recognized higher susceptibility of patients with CKD to falls and bone fractures led to important paradigm changes in the new CKD-MBD guidelines. Evaluation of bone mineral density and the diagnosis of "osteoporosis" emerges in nephrology as a new possibility "if results will impact clinical decisions". Obviously, it is still reasonable to perform a bone biopsy if knowledge of the type of renal osteodystrophy will be clinically useful (low versus high turnover-bone disease). However, it is now considered that the inability to perform a bone biopsy may not justify withholding antiresorptive therapies to patients with high risk of fracture. This view adds to the effects of parathyroid hormone in CKD patients and the classical treatment of secondary hyperparathyroidism. The availability of new antiosteoporotic treatments bring the opportunity to come back to the basics, and the knowledge of new pathophysiological pathways [OPG/RANKL (LGR4); Wnt-ß-catenin pathway], also affected in CKD, offers great opportunities to further unravel the complex physiopathology of CKD-MBD and to improve outcomes.

Vitamin D and Chronic Kidney Disease Association with Mineral and Bone Disorder: An Appraisal of Tangled Guidelines

Chronic kidney disease (CKD) is a highly prevalent condition worldwide in which the kidneys lose many abilities, such as the regulation of vitamin D (VD) metabolism. Moreover, people with CKD are at a higher risk of multifactorial VD deficiency, which has been extensively associated with poor outcomes, including bone disease, cardiovascular disease, and higher mortality. Evidence is abundant in terms of the association of negative outcomes with low levels of VD, but recent studies have lowered previous high expectations regarding the beneficial effects of VD supplementation in the general population. Although controversies still exist, the diagnosis and treatment of VD have not been excluded from nephrology guidelines, and much data still supports VD supplementation in CKD patients. In this narrative review, we briefly summarize evolving controversies and useful clinical approaches, underscoring that the adverse effects of VD derivatives must be balanced against the need for effective prevention of progressive and severe secondary hyperparathyroidism. Guidelines vary, but there seems to be general agreement that VD deficiency should be avoided in CKD patients, and it is likely that one should not wait until severe SHPT is present before cautiously starting VD derivatives. Furthermore, it is emphasized that the goal should not be the complete normalization of parathyroid hormone (PTH) levels. New developments may help us to better define optimal VD and PTH at different CKD stages, but large trials are still needed to confirm that VD and precise control of these and other CKD-MBD biomarkers are unequivocally related to improved hard outcomes in this population.