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Hong WK, Kim S, Gong HS. Fracture Management in Chronic Kidney Disease: Challenges and Considerations for Orthopedic Surgeons. Clin Orthop Surg 2024; 16:173-183. [PMID: 38562627 PMCID: PMC10973623 DOI: 10.4055/cios23244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/29/2023] [Accepted: 11/24/2023] [Indexed: 04/04/2024] Open
Abstract
Orthopedic surgeons treating fractures need to consider comorbidities, including chronic kidney disease (CKD), which affects millions worldwide. CKD patients are at elevated risk of fractures due to osteoporosis, especially in advanced stages. In addition, fractures in CKD patients pose challenges due to impaired bone healing and increased post-fracture complications including surgical site infection and nonunion. In this article, we will discuss factors that must be considered when treating fractures in CKD patients. Perioperative management includes careful adjustment of hemodialysis schedules, selection of anesthetic methods, and addressing bleeding tendencies. Tourniquet usage for fractures in limbs with arteriovenous fistulae should be cautious. Pain medication should be administered carefully, with opioids like hydromorphone preferred over nonsteroidal anti-inflammatory drugs. Medical management after fractures should address underlying factors and include physical rehabilitation to reduce the risk of subsequent fractures. A comprehensive approach to fracture management in CKD patients can improve outcomes.
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Affiliation(s)
- Wan Kee Hong
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sejoong Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hyun Sik Gong
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
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Tsai HL, Lin TC, Lin NC, Yang HH, Chang JW. Risk Factors for Fractures in Renal Transplantation: A Population-Based Cohort Study. Am J Nephrol 2023; 54:498-507. [PMID: 37783206 DOI: 10.1159/000533125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 07/17/2023] [Indexed: 10/04/2023]
Abstract
INTRODUCTION Kidney transplant recipients are at an increased risk of fractures, and targeted preventive strategies are needed. Therefore, in this retrospective cohort study, we investigated a large population-based cohort to identify the transplant recipient-specific risk factors for fractures in Taiwanese kidney transplant recipients. METHODS We conducted a retrospective cohort study using the National Health Insurance Research Database. Patients who underwent renal transplantation between 2003 and 2015 were identified and followed until December 31, 2015, to observe the development of fractures. Variables associated with the development of post-transplant fractures were identified by calculating hazard ratios in a Cox regression model. RESULTS 5,309 renal transplant recipients were identified, of whom 553 (10.4%) were diagnosed with post-transplant fractures. Independent predictors of post-transplant fractures included an age at transplant ≥65 years (p < 0.001), female sex (p < 0.001), fractures within 3 years prior to transplantation (p < 0.001), and diabetes mellitus (p < 0.001). In addition, daily prednisolone doses >2.9–5.3 mg/day (p < 0.001), >5.3–8.7 mg/day (p < 0.001), and >8.7 mg/day (p < 0.001) were also independent predictors of post-transplant fractures. Conversely, the use of peritoneal dialysis before renal transplantation (p = 0.021), hypertension (p = 0.005), and the use of tacrolimus (p < 0.001), azathioprine (p = 0.006), mycophenolate mofetil/mycophenolic acid (p = 0.002), mTOR inhibitors (p = 0.004), and calcium supplements (p = 0.009) were inversely correlated with post-transplant fractures. CONCLUSION We recommend minimizing daily glucocorticoids as early and as far as possible in conjunction with immunosuppressive regimens such as tacrolimus, azathioprine, mycophenolate mofetil/mycophenolic acid, mTOR inhibitors, and calcium supplements, especially in older female recipients and in recipients with diabetes and a history of prior fractures.
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Affiliation(s)
- Hsin-Lin Tsai
- Division of Pediatric Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tzu-Ching Lin
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Niang-Cheng Lin
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Transplantation Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hui-Hsin Yang
- Division of Pediatric Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jei-Wen Chang
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Bobillier A, Wagner P, Whittier DE, Ecochard R, Boyd SK, Chapurlat R, Szulc P. Association of Vitamin D and Parathyroid Hormone Status With the Aging-Related Decline of Bone Microarchitecture in Older Men: The Prospective Structure of Aging Men's Bones (STRAMBO) Study. J Bone Miner Res 2022; 37:1903-1914. [PMID: 35880628 DOI: 10.1002/jbmr.4657] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 06/20/2022] [Accepted: 07/21/2022] [Indexed: 11/11/2022]
Abstract
Poor vitamin D status and high parathyroid hormone (PTH) level are associated with impaired bone microarchitecture, but these data are mainly cross-sectional. We studied the association of the baseline PTH and 25-hydroxycholecalciferol (25OHD) levels with the prospectively assessed deterioration of bone microarchitecture and in estimated bone strength in older men. Distal radius and tibia bone microarchitecture was assessed by high-resolution peripheral quantitative computed tomography (HR-pQCT) at baseline, then after 4 and 8 years in 826 men aged 60-87 years. At distal radius, total bone mineral density (Tt.BMD), cortical thickness (Ct.Thd ), cortical area (Ct.Ar), cortical BMD (Ct.BMD), and trabecular BMD (Tb.BMD) decreased, whereas trabecular area (Tb.Ar) increased more rapidly in men with 25OHD ≤20 ng/mL versus the reference group (>30 ng/mL). Men with 25OHD ≤10 ng/mL had faster decrease in reaction force and failure load than men with 25OHD >30 ng/mL. At the distal tibia, Tt.BMD, Ct.Thd , Ct.Ar, Ct.BMD, failure load, and reaction force decreased, whereas Tb.Ar increased more rapidly in men with 25OHD between 10 and 20 ng/mL versus the reference group. The results were similar when 12 ng/mL was used as a threshold of severe vitamin D deficiency. At distal radius, men with PTH levels above the median (>44 pg/mL) had more rapid decrease in Tt.BMD, Ct.Ar, Ct.BMD, Ct.Thd , reaction force, and failure load, and more rapid increase in Tb.Ar versus the lowest quartile (≤34 pg/mL). At the distal tibia, men in the highest PTH quartile had faster decrease in Tt.BMD, Ct.Thd , Ct.Ar, Ct.BMD, reaction force, and failure load and faster increase in Tb.Ar versus the lowest quartile. The results were similar in men with glomerular filtration rate >60 mL/min. The results were similar in men who took no vitamin D or calcium supplements for 8 years. In summary, vitamin D deficiency and secondary hyperparathyroidism are associated with more rapid prospectively assessed cortical and trabecular bone decline in older men. © 2022 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Audrey Bobillier
- Institut National de la Santé et de la Recherche Médicale (INSERM) Unité Mixtes de Recherche (UMR) 1033, University of Lyon, Hôpital Edouard Herriot, Lyon, France
| | - Philippe Wagner
- Institut National de la Santé et de la Recherche Médicale (INSERM) Unité Mixtes de Recherche (UMR) 1033, University of Lyon, Hôpital Edouard Herriot, Lyon, France
| | - Danielle E Whittier
- McCaig Institute for Bone and Joint Health, Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - René Ecochard
- Department of Biostatistics, University of Lyon, Lyon, France
| | - Steven K Boyd
- McCaig Institute for Bone and Joint Health, Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Roland Chapurlat
- Institut National de la Santé et de la Recherche Médicale (INSERM) Unité Mixtes de Recherche (UMR) 1033, University of Lyon, Hôpital Edouard Herriot, Lyon, France
| | - Pawel Szulc
- Institut National de la Santé et de la Recherche Médicale (INSERM) Unité Mixtes de Recherche (UMR) 1033, University of Lyon, Hôpital Edouard Herriot, Lyon, France
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Sharma S, Mehta P, Patil A, Gupta SK, Rajender S, Chattopadhyay N. Meta-analyses of the quantitative computed tomography data in dialysis patients show differential impacts of renal failure on the trabecular and cortical bones. Osteoporos Int 2022; 33:1521-1533. [PMID: 35249146 DOI: 10.1007/s00198-022-06366-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 02/24/2022] [Indexed: 10/18/2022]
Abstract
UNLABELLED Dialysis patients have compromised bone health that increases their fracture risk due to low bone mass and deterioration in bone microarchitecture. Through meta-analyses of published studies, we conclude that dialysis patients suffer from impaired compartmental bone parameters compared with healthy controls. INTRODUCTION We performed meta-analyses to determine the effect of chronic kidney disease (CKD) patients under dialysis on the trabecular and cortical parameters of radius and tibia. METHODS This is a meta-analysis of cross-sectional and prospective clinical studies. PubMed, Web of Science, Google Scholar, and Scopus were searched using various permutation combinations. Dialysis patients were compared with non-CKD healthy controls using quantitative computed tomography. High-resolution peripheral quantitative computed tomography (HR-pQCT) and pQCT data of dialysis patients were dissected from eligible studies for pooled analysis of each parameter. RESULTS Ten studies met the inclusion criteria that included data from 457 dialysis patients and 2134 controls. Pooled analysis showed a significant decrease (a) in total vBMD at distal radius [standard deviation of the mean (SDM) = -0.842, p = 0.000] and tibia (SMD = -0.705, p = 0.000) and (b) in cortical vBMD (SDM = -1.037, p = 0.000) at radius of dialysis patients compared with control. There were strong correlations between total vBMD and microarchitecture parameters at tibia in dialysis patients. CONCLUSIONS At radius and tibia, bone mass, microarchitecture, and geometry at trabecular and cortical envelopes displayed impairments in dialysis patients compared with control. Tibial vBMD may have diagnostic value in dialysis. HR-pQCT and pQCT may be used to further understand the compartmental bones response to CKD-induced loss at different stages of CKD.
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Affiliation(s)
- S Sharma
- Division of Endocrinology and Centre for Research in Anabolic Skeletal Targets in Health and Illness (ASTHI), CSIR-Central Drug Research Institute, Sector 10, Jankipuram Extension, Sitapur Road, Lucknow, 226031, India
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, 201002, India
| | - P Mehta
- Division of Endocrinology and Centre for Research in Anabolic Skeletal Targets in Health and Illness (ASTHI), CSIR-Central Drug Research Institute, Sector 10, Jankipuram Extension, Sitapur Road, Lucknow, 226031, India
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, 201002, India
| | - A Patil
- Division of Endocrinology and Centre for Research in Anabolic Skeletal Targets in Health and Illness (ASTHI), CSIR-Central Drug Research Institute, Sector 10, Jankipuram Extension, Sitapur Road, Lucknow, 226031, India
| | - S K Gupta
- Department of Endocrinology, Sanjay Gandhi Post-graduate Institute of Medical Sciences, Lucknow, India
| | - S Rajender
- Division of Endocrinology and Centre for Research in Anabolic Skeletal Targets in Health and Illness (ASTHI), CSIR-Central Drug Research Institute, Sector 10, Jankipuram Extension, Sitapur Road, Lucknow, 226031, India.
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, 201002, India.
| | - N Chattopadhyay
- Division of Endocrinology and Centre for Research in Anabolic Skeletal Targets in Health and Illness (ASTHI), CSIR-Central Drug Research Institute, Sector 10, Jankipuram Extension, Sitapur Road, Lucknow, 226031, India.
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, 201002, India.
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Malle O, Bergthaler M, Krisper P, Amrein K, Dimai HP, Kirsch AH, Rosenkranz AR, Pieber T, Obermayer-Pietsch B, Fahrleitner-Pammer A. Usefulness of the trabecular bone score in maintenance dialysis patients : A single center observational study. Wien Klin Wochenschr 2022; 134:442-448. [PMID: 35262788 PMCID: PMC9213369 DOI: 10.1007/s00508-022-02011-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 01/25/2022] [Indexed: 02/07/2023]
Abstract
Background The number of dialysis patients is steadily increasing. Associated comorbidities include impaired bone and mineral metabolism, termed chronic kidney disease-mineral and bone disorder (CKD-MBD), leading to a high fracture risk, increased morbidity and mortality and impaired quality of life. While the bone density is assessed with dual-energy X‑ray absorptiometry (DXA), the trabecular bone score (TBS) captures the image texture as a potential index of skeletal microarchitecture. The aim of this study was to evaluate the clinical relevance of DXA and TBS in dialysis patients with and without prevalent fractures. Methods Bone disorders were evaluated in 82 dialysis patients (37% female) at the University Hospital of Graz, Austria, by DXA including the assessment of the TBS based on a patient interview and the local routine patient database software. The patient cohort was stratified by having sustained a fragility fracture in the past or not. Descriptive statistics, t‑tests for continuous variables and χ2-tests for nominal variables including results of DXA and TBS were performed to compare these groups considering the dialysis modality and duration as well as the number of kidney transplantations. Results Of the 82 patients, 32 (39%) had a positive history of fractures. There was a significant association between dialysis duration and fracture prevalence (p < 0.05) as well as musculoskeletal pain (p < 0.01). No significant correlation between DXA/TBS parameters and musculoskeletal pain could be established. The DXA scores did not correlate with fracture prevalence with the exception of DXA radius measurements; however, fracture prevalence significantly correlated inversely with TBS (p < 0.001). Conclusion The use of DXA has a limited role in fracture prediction in dialysis patients; however, the TBS seems to add information as an additional tool for fracture risk estimation in this patient population.
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Affiliation(s)
- Oliver Malle
- Department of Internal Medicine, Div. of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria.
| | - Markus Bergthaler
- Department of Internal Medicine, Div. of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Peter Krisper
- Department of Internal Medicine, Div. of Nephrology, Medical University of Graz, Graz, Austria
| | - Karin Amrein
- Department of Internal Medicine, Div. of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Hans Peter Dimai
- Department of Internal Medicine, Div. of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Alexander H Kirsch
- Department of Internal Medicine, Div. of Nephrology, Medical University of Graz, Graz, Austria
| | - Alexander R Rosenkranz
- Department of Internal Medicine, Div. of Nephrology, Medical University of Graz, Graz, Austria
| | - Thomas Pieber
- Department of Internal Medicine, Div. of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Barbara Obermayer-Pietsch
- Department of Internal Medicine, Div. of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Astrid Fahrleitner-Pammer
- Department of Internal Medicine, Div. of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
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van den Bergh JP, Szulc P, Cheung AM, Bouxsein M, Engelke K, Chapurlat R. The clinical application of high-resolution peripheral computed tomography (HR-pQCT) in adults: state of the art and future directions. Osteoporos Int 2021; 32:1465-1485. [PMID: 34023944 PMCID: PMC8376700 DOI: 10.1007/s00198-021-05999-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 05/06/2021] [Indexed: 12/13/2022]
Abstract
High-resolution peripheral computed tomography (HR-pQCT) was developed to image bone microarchitecture in vivo at peripheral skeletal sites. Since the introduction of HR-pQCT in 2005, clinical research to gain insight into pathophysiology of skeletal fragility and to improve prediction of fractures has grown. Meanwhile, the second-generation HR-pQCT device has been introduced, allowing novel applications such as hand joint imaging, assessment of subchondral bone and cartilage thickness in the knee, and distal radius fracture healing. This article provides an overview of the current clinical applications and guidance on interpretation of results, as well as future directions. Specifically, we provide an overview of (1) the differences and reference data for HR-pQCT variables by age, sex, and race/ethnicity; (2) fracture risk prediction using HR-pQCT; (3) the ability to monitor response of anti-osteoporosis therapy with HR-pQCT; (4) the use of HR-pQCT in patients with metabolic bone disorders and diseases leading to secondary osteoporosis; and (5) novel applications of HR-pQCT imaging. Finally, we summarize the status of the application of HR-pQCT in clinical practice and discuss future directions. From the clinical perspective, there are both challenges and opportunities for more widespread use of HR-pQCT. Assessment of bone microarchitecture by HR-pQCT improves fracture prediction in mostly normal or osteopenic elderly subjects beyond DXA of the hip, but the added value is marginal. The prospects of HR-pQCT in clinical practice need further study with respect to medication effects, metabolic bone disorders, rare bone diseases, and other applications such as hand joint imaging and fracture healing. The mostly unexplored potential may be the differentiation of patients with only moderately low BMD but severe microstructural deterioration, which would have important implications for the decision on therapeutical interventions.
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Affiliation(s)
- J P van den Bergh
- Department of Internal Medicine, VieCuri Medical Center, Venlo, The Netherlands.
- Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands.
- Faculty of Medicine, Hasselt University, Hasselt, Belgium.
| | - P Szulc
- INSERM UMR 1033, Université de Lyon, Hôpital E Herriot, 69437 cedex 03, Lyon, France
| | - A M Cheung
- Department of Medicine and Joint Department of Medical Imaging, University Health Network; and Department of Medicine and Centre of Excellence in Skeletal Health Assessment, University of Toronto, Toronto, Ontario, Canada
| | - M Bouxsein
- Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Center and Department of Orthopedic Surgery, Harvard Medical School, Boston, MA, USA
| | - K Engelke
- Department of Medicine 3, FAU University Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - R Chapurlat
- INSERM UMR 1033, Université de Lyon, Hôpital E Herriot, 69437 cedex 03, Lyon, France
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Pazianas M, Miller PD. Osteoporosis and Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD): Back to Basics. Am J Kidney Dis 2021; 78:582-589. [PMID: 33774081 DOI: 10.1053/j.ajkd.2020.12.024] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 12/29/2020] [Indexed: 02/06/2023]
Abstract
Osteoporosis is defined as a skeletal disorder of compromised bone strength predisposing those affected to an elevated risk of fracture. However, based on bone histology, osteoporosis is only part of a spectrum of skeletal complications that includes osteomalacia and the various forms of renal osteodystrophy of chronic kidney disease-mineral and bone disorder (CKD-MBD). In addition, the label "kidney-induced osteoporosis" has been proposed, even though the changes caused by CKD do not qualify as osteoporosis by the histological diagnosis. It is clear, therefore, that such terminology may not be helpful diagnostically or in making treatment decisions. A new label, "CKD-MBD/osteoporosis" could be a more appropriate term because it brings osteoporosis under the official label of CKD-MBD. Neither laboratory nor noninvasive diagnostic investigations can discriminate osteoporosis from the several forms of renal osteodystrophy. Transiliac crest bone biopsy can make the diagnosis of osteoporosis by exclusion of other kidney-associated bone diseases, but its availability is limited. Recently, a classification of metabolic bone diseases based on bone turnover, from low to high, together with mineralization and bone volume, has been proposed. Therapeutically, no antifracture treatments have been approved by the US Food and Drug Administration for patients with kidney-associated bone disease. Agents that suppress parathyroid hormone (vitamin D analogues and calcimimetics) are used to treat hyperparathyroid bone disease. Antiresorptive and osteoanabolic agents approved for osteoporosis are being used off-label to treat CKD stages 3b-5 in high-risk patients. It has now been suggested that intermittent administration of parathyroid hormone as early as CKD stage 2 could be an effective management strategy. If confirmed in clinical trials, it could mitigate the retention of phosphorus and subsequently the rise in fibroblast growth factor 23 and may be beneficial for coexisting osteoporosis.
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Affiliation(s)
- Michael Pazianas
- Institute of Musculoskeletal Sciences, Oxford University, Oxford, United Kingdom.
| | - Paul D Miller
- University of Colorado Health Sciences Center, Denver, CO; Colorado Center for Bone Health, Lakewood, CO
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Benillouche E, Ostertag A, Marty C, Ureña Torres P, Cohen-Solal M. Cortical Bone Microarchitecture in Dialysis Patients. Am J Nephrol 2020; 51:833-838. [PMID: 32911468 DOI: 10.1159/000510064] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 07/08/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND The incidence of skeletal fractures is high in dialysis patients. Current available tools are insufficient to predict bone fragility. We analyzed the microarchitecture in patients on dialysis therapy using bone biopsies and peripheral microcomputed tomography. METHODS We analyzed 12 trans-iliac bone biopsies of patients with recent fractures. Bone microarchitecture was assessed in the bone cores by histology (2D-), microcomputed tomography (3D-µCT), and high-resolution peripheral quantitative computed tomography (HR-pQCT) at the tibia. RESULTS Trabecular bone volume/tissue volume was similar in 2D histology and 3D-µCT (p = 0.40), while lower in HR-pQCT (p < 0.01). There was no correlation in trabecular microarchitectural indices between 2-histology and 3D-µCT, or HR-pQCT. The 3D-µCT cortical thickness (Ct.Th) were positively correlated with 2D (p < 0.05), but with HR-pQCT (p = 0.33). Ct.Th was lower in patients with ≥2 vertebral fractures than with one fracture. CONCLUSIONS 3D-µCT is a reliable method for the measurement of cortical bone in bone biopsies. Prospective studies are awaited to address its value in discriminating fracture risk.
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Affiliation(s)
- Eva Benillouche
- Department of Rheumatology, Lariboisière Hospital, Paris, France
| | - Agnes Ostertag
- INSERM U1132, Université de Paris, Hôpital Lariboisière (APHP), Paris, France
| | - Caroline Marty
- INSERM U1132, Université de Paris, Hôpital Lariboisière (APHP), Paris, France
| | | | - Martine Cohen-Solal
- Department of Rheumatology, Lariboisière Hospital, Paris, France,
- INSERM U1132, Université de Paris, Hôpital Lariboisière (APHP), Paris, France,
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9
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Boonpheng B, Thongprayoon C, Mao MA, Wijarnpreecha K, Bathini T, Kaewput W, Ungprasert P, Cheungpasitporn W. Risk of hip fracture in patients on hemodialysis versus peritoneal dialysis: A meta-analysis of observational studies. J Evid Based Med 2019; 12:98-104. [PMID: 30701673 DOI: 10.1111/jebm.12341] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 12/31/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Bone and mineral metabolism disorders are common among end-stage renal disease (ESRD) patients, which could lead to hip fracture. It is unclear whether the hip fracture risk is different among patients on hemodialysis (HD) versus peritoneal dialysis (PD). This meta-analysis was conducted to evaluate the hip fracture risk in ESRD patients on HD, when compared to PD. METHODS A literature review was conducted in EMBASE, MEDLINE, and Cochrane databases through January 31, 2018 to identify studies that appraised the rate or risk of hip fracture among patients on HD, when compared to PD. Effect estimates from the individual studies were derived and consolidated utilizing random-effect, generic inverse variance approach of DerSimonian and Laird. RESULTS Five cohort studies with 1 276 677 ESRD patients were enrolled. HD status was associated with a significantly higher risk of hip fracture with the pooled odds ratio (OR) of 1.61 (95% confidence interval [CI] 1.50-1.73, I2 = 10.0%), compared with PD. When the analysis was limited to studies with confounder-adjusted analysis, the pooled OR of hip fracture among HD patients was 1.57 (95% CI 1.43-1.72, I2 = 13.6%). Funnel plots and Egger's regression test demonstrated no significant publication bias in our meta-analysis. CONCLUSIONS Among ESRD patients, HD status is associated with a 61% higher risk of hip fracture compared to PD.
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Affiliation(s)
- Boonphiphop Boonpheng
- Department of Internal Medicine, East Tennessee State University, Johnson City, Tennessee
| | - Charat Thongprayoon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Michael A Mao
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Karn Wijarnpreecha
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Jacksonville, Florida
| | - Tarun Bathini
- Department of Internal Medicine, University of Arizona, Tucson, Arizona
| | - Wisit Kaewput
- Department of Military and Community Medicine, Phramongkutklao College of Medicine, Bangkok, Thailand
| | - Patompong Ungprasert
- Clinical Epidemiology Unit, Department of Research and Development, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Wisit Cheungpasitporn
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
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10
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Wu M, Wu H, Huang X, Ye H, Huang F, Yu X, Yang X. Associations between serum mineral metabolism parameters and mortality in patients on peritoneal dialysis. Nephrology (Carlton) 2019; 24:1148-1156. [PMID: 30565789 DOI: 10.1111/nep.13535] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2018] [Indexed: 11/27/2022]
Abstract
AIM Disturbances in mineral metabolism markers are common in patients with chronic kidney disease but there is no consensus on the association between these markers and clinical outcomes. This study investigated associations between mineral metabolism parameters and mortality in Chinese peritoneal dialysis (PD) patients. METHODS This was a single-centre retrospective cohort study. Incident PD patients between 1 January 2006 and 31 December 2013 with baseline phosphate, albumin-corrected calcium, and calcium-phosphate product data were enrolled. Associations between these parameters and all-cause and cardiovascular mortality were assessed using multivariable-adjusted Cox models. RESULTS Of 1662 patients (mean age: 47.4 ± 15.3 years), 59.3% were male and 23.8% had diabetes. Over a median 38.1 month (interquartile range: 21.3-59.7 months) follow-up period, 382 (23.0%) patients died. After adjusting for confounders, the higher serum phosphate level (>1.78 mmol/L) and calcium-phosphate product level (≥4.4 mmol2 /L2 ) were significantly associated with an increased risk for all-cause mortality (hazards ratio (HR) = 1.818, 95% CI = 1.379-2.396 and HR = 1.735, 95% CI = 1.261-2.386) and cardiovascular mortality (HR = 2.069, 95% CI = 1.428-2.998 and HR = 2.175, 95% CI = 1.450-3.262), respectively. While each 1 mmol/L higher baseline albumin-corrected calcium level was associated with an 14.3% (95% CI = 0.749-0.981) lower risk for all-cause mortality after adjusting for potential confounders. CONCLUSION Abnormalities in mineral metabolism markers, particularly higher serum phosphate and calcium-phosphate product levels, at the commencement of PD were independently associated with increased all-cause and cardiovascular mortality in this cohort of PD patients.
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Affiliation(s)
- Meiju Wu
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University and Key Laboratory of Nephrology, Ministry of Health and Guangdong Province, Guangzhou, China
| | - Haishan Wu
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University and Key Laboratory of Nephrology, Ministry of Health and Guangdong Province, Guangzhou, China
| | - Xuan Huang
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University and Key Laboratory of Nephrology, Ministry of Health and Guangdong Province, Guangzhou, China
| | - Hongjian Ye
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University and Key Laboratory of Nephrology, Ministry of Health and Guangdong Province, Guangzhou, China
| | - Fengxian Huang
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University and Key Laboratory of Nephrology, Ministry of Health and Guangdong Province, Guangzhou, China
| | - Xueqing Yu
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University and Key Laboratory of Nephrology, Ministry of Health and Guangdong Province, Guangzhou, China
| | - Xiao Yang
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University and Key Laboratory of Nephrology, Ministry of Health and Guangdong Province, Guangzhou, China
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11
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Sidibé A, Auguste D, Desbiens L, Fortier C, Wang YP, Jean S, Moore L, Mac‐Way F. Fracture Risk in Dialysis and Kidney Transplanted Patients: A Systematic Review. JBMR Plus 2019; 3:45-55. [PMID: 30680363 PMCID: PMC6339558 DOI: 10.1002/jbm4.10067] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 06/07/2018] [Accepted: 06/14/2018] [Indexed: 12/14/2022] Open
Abstract
Chronic kidney disease is associated with an increased risk of fracture and cardiovascular mortality. The risk of fracture in hemodialysis (HD), peritoneal dialysis (PD) and kidney transplant (KT) patients is higher when compared with the general population. However, there exists a knowledge gap concerning which group has the highest risk of fracture. We aimed to compare the risk of fracture in HD, PD, and KT populations. We conducted a systematic review of observational studies evaluating the risk of fracture in HD, PD, or KT patients. Eligible studies were searched using MEDLINE, Embase, Web of Science, and Cochrane Library from their inception to January 2016, and in grey literature. Incidences (cumulative and rate) of fracture were described together using the median, according to fracture sites, the data source (administrative database or cohort and clinical registry), and fracture diagnosis method. Prevalence estimates were described separately. We included 47 studies evaluating the risk of fracture in HD, PD, and KT populations. In administrative database studies, incidence of hip fracture in HD (median 11.45 per 1000 person-years [p-y]), range: 9.3 to 13.6 was higher than in KT (median 2.6 per 1000 p-y; range 1.5 to 3.8) or in PD (median 5.2 per 1000 p-y; range 4.1 to 6.3). In dialysis (HD+PD), three studies reported a higher incidence of hip fracture than in KT. Prevalent vertebral fracture (assessed by X-rays or questionnaire) reported in HD was in a similar range as that reported in KT. Incidence of overall fracture was similar in HD and KT, from administrative databases studies, but lower in HD compared with KT, from cohorts or clinical registry studies. This systematic review suggests an important difference in fracture risk between HD, PD, and KT population, which vary according to the diagnosis method for fracture identification. © 2018 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Aboubacar Sidibé
- Centre de Recherche du CHU de QuébecHôpital Hôtel‐Dieu de QuébecDivision of Nephrology, Endocrinology, and Nephrology AxisFaculty of MedicineDepartment of Social and Preventive MedicineLaval UniversityQuebecCanada
| | - David Auguste
- Centre de Recherche du CHU de QuébecHôpital Saint‐SacrementFaculty of MedicineDepartment of Social and Preventive MedicineLaval UniversityQuebecCanada
| | - Louis‐Charles Desbiens
- Centre de Recherche du CHU de QuébecHôpital Hôtel‐Dieu de QuébecDivision of Nephrology, Endocrinology, and Nephrology AxisFaculty and Department of MedicineLaval UniversityQuebecCanada
| | - Catherine Fortier
- Centre de Recherche du CHU de QuébecHôpital Hôtel‐Dieu de QuébecDivision of Nephrology, Endocrinology, and Nephrology AxisFaculty and Department of MedicineLaval UniversityQuebecCanada
| | - Yue Pei Wang
- Centre de Recherche du CHU de QuébecHôpital Hôtel‐Dieu de QuébecDivision of Nephrology, Endocrinology, and Nephrology AxisFaculty and Department of MedicineLaval UniversityQuebecCanada
| | - Sonia Jean
- Institut National de Santé Publique du QuébecMedicine FacultyDepartment of Social and Preventive MedicineLaval UniversityQuebecCanada
| | - Lynne Moore
- Centre de Recherche du CHU de QuébecHôpital de l'Enfant‐JésusTraumatology AxisMedicine FacultyDepartment of Social and Preventive MedicineLaval UniversityQuebecCanada
| | - Fabrice Mac‐Way
- Centre de Recherche du CHU de QuébecHôpital Hôtel‐Dieu de QuébecDivision of Nephrology, Endocrinology, and Nephrology AxisFaculty and Department of MedicineLaval UniversityQuebecCanada
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12
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Fang L, Wu J, Luo J, Wen P, Xiong M, Cao J, Chen X, Yang J. Changes in bone mineral density after total parathyroidectomy without autotransplantation in the end-stage renal disease patients with secondary hyperparathyroidism. BMC Nephrol 2018; 19:142. [PMID: 29907149 PMCID: PMC6003160 DOI: 10.1186/s12882-018-0934-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 05/28/2018] [Indexed: 12/17/2022] Open
Abstract
Background The patients with secondary hyperparathyroidism (SHPT) usually had reduced bone mineral density, which might lead to a substantial increase in osteoporosis, fracture and mortality. Although surgical intervention is effective in reducing parathyroid hormone (PTH) levels in suitable candidates refractory to medical therapy, the effect of surgery on bone mass changes still requires further evaluation. Thus, the aim of this study was to evaluate the characteristics of BMD changes after total parathyroidectomy (PTX) without autotransplantation and its associated factors. Methods The records of 34 patients who underwent successful total PTX without autotransplantation with a preoperative and postoperative dual energy X-ray absorptiometry (DEXA) scan in our institution within 4 years of operative intervention were reviewed. Correlation and regression analysis were used to identify factors that independently predict BMD changes. Results At baseline, we found that the prevalence of osteoporosis seemed to be much higher in the load-bearing lumbar spine than in the hip, varying greatly even between different lumbar vertebrae. The bone loss in SHPT had its predilection site in the load-bearing cancellous bone. After curative total PTX without autotransplantation, BMD improved significantly in both lumbar spine and hip overall. The largest increase in BMD occurred at L4 vertebrae with the lowest pre-operative BMD. At the most affected site L4, BMD improved in up to 94.1% of patients: 86.2% had significant improvement, 5.9% moderate improvement, and 5.9% declining bone mineral density. Correlation and regression analysis suggested that percentage changes in BMD were predicted negatively by the preoperative BMD and positively by the preoperative parathyroid mass but not intact PTH levels. Conclusion Total parathyroidectomy without autotransplantation could improve BMD of secondary hyperparathyroidism at L1-L4 and the hip. Furthermore, the large parathyroid glandular mass and the preoperative BMD predicted the BMD changes after surgery. Electronic supplementary material The online version of this article (10.1186/s12882-018-0934-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Li Fang
- Department of Nephrology, Affiliated Hospital of Nantong University, 20 Xisi Road Nantong, Nantong, Jiangsu Province, China.,Department of Nephrology, Second Affiliated Hospital of Nanjing Medical University, 262 Zhongshan North Road, Nanjing, Jiangsu Province, China
| | - Jining Wu
- Department of Nephrology, Second Affiliated Hospital of Nanjing Medical University, 262 Zhongshan North Road, Nanjing, Jiangsu Province, China
| | - Jing Luo
- Department of Nephrology, Second Affiliated Hospital of Nanjing Medical University, 262 Zhongshan North Road, Nanjing, Jiangsu Province, China
| | - Ping Wen
- Department of Nephrology, Second Affiliated Hospital of Nanjing Medical University, 262 Zhongshan North Road, Nanjing, Jiangsu Province, China
| | - Mingxia Xiong
- Department of Nephrology, Second Affiliated Hospital of Nanjing Medical University, 262 Zhongshan North Road, Nanjing, Jiangsu Province, China
| | - Jinlong Cao
- Department of Nephrology, Second Affiliated Hospital of Nanjing Medical University, 262 Zhongshan North Road, Nanjing, Jiangsu Province, China
| | - Xiaolan Chen
- Department of Nephrology, Affiliated Hospital of Nantong University, 20 Xisi Road Nantong, Nantong, Jiangsu Province, China.
| | - Junwei Yang
- Department of Nephrology, Second Affiliated Hospital of Nanjing Medical University, 262 Zhongshan North Road, Nanjing, Jiangsu Province, China.
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13
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The use of bone mineral density measured by dual energy X-ray absorptiometry (DXA) and peripheral quantitative computed microtomography in chronic kidney disease. J Nephrol 2017; 30:635-643. [PMID: 28900872 DOI: 10.1007/s40620-017-0433-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 08/14/2017] [Indexed: 10/18/2022]
Abstract
Chronic kidney disease (CKD) is a risk factor for fractures. The current evaluation of fracture risk is based upon the combination of various clinical factors and quantitative imaging of bone. X-ray-based tools were developed to evaluate bone status and predict fracture risk. Dual energy X-ray absorptiometry (DXA) is available worldwide. Longitudinal studies showed that low areal Bone Mineral Density (BMD) measured by DXA predicts fractures in the CKD population as it does in non uremic populations, with good specificity and moderate sensitivity. Peripheral quantitative computed tomography (pQCT) and high resolution pQCT are research tools which measure volumetric BMD at the tibia and radius. They are able to discriminate between the cortical and trabecular envelopes which are differentially affected by renal osteodystrophy. In CKD, a rapid thinning and increased porosity at the cortex is observed which is associated with increased the risk for fracture.
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14
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Fournie C, Pelletier S, Bacchetta J, Boutroy S, Confavreux C, Drai J, Arkouche W, Fouque D, Chapurlat R, Guebre-Egziabher F. The Relationship Between Body Composition and Bone Quality Measured with HR-pQCT in Peritoneal Dialysis Patients. ARCH ESP UROL 2017; 37:548-555. [PMID: 28765165 DOI: 10.3747/pdi.2016.00239] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 05/09/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Bone is known to be impaired in chronic kidney disease and dialysis patients. Recent studies have shown that body composition (fat mass and lean mass) may impact bone health. Some of these effects may be related to mediators that are secreted by adipose tissue. METHODS The aim of this study was to evaluate the association between body composition (dual x-ray absorptiometry [DEXA]) and adipokines (leptin, adiponectin), with bone density and microarchitecture assessed with high-resolution peripheral quantitative computed tomography (HR-pQCT) in chronic peritoneal dialysis (PD) patients in a single-center prospective study. RESULTS Twenty-three patients with a median age of 61 years and body mass index (BMI) of 27 kg/m2 were recruited. On univariate analysis, age was negatively associated with total volumetric bone mineral density (vBMD) (r = -0.75, p < 0.01), cortical vBMD (r = -0.85, p < 0.01), and cortical thickness (r = -0.71, p < 0.01). There was a negative association between leptin and cortical thickness (r = -0.48, p = 0.021). Fat mass (FM) was negatively correlated with cortical thickness (r = -0.52, p = 0.012). No association was found between bone parameters and dialysis duration, serum insulin, intact parathyroid hormone, osteocalcin, and adiponectin. The short dialysis vintage could in part explain the lack of correlation with bone parameters. In multivariate analysis, FM was significantly and negatively correlated with total vBMD, cortical and trabecular thickness. CONCLUSIONS These data suggest that FM is negatively associated with bone quality in PD patients, supporting a relation between body composition and bone that is independent from other dialysis-associated complications. The relative contribution of the different fat deposits (visceral versus subcutaneous) needs to be assessed in future studies.
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Affiliation(s)
| | - Solenne Pelletier
- Department of Nephrology, Lyon Sud Hospital, Hospices Civils de Lyon, Lyon, France.,INSERM UMR 1033, Lyon, France
| | - Justine Bacchetta
- INSERM UMR 1033, Lyon, France.,Centre de Référence des Maladies Rénales Rares, Women Mother and Children Hospital, Bron, Lyon, France.,Université de Lyon, Lyon, France
| | | | - Cyrille Confavreux
- INSERM UMR 1033, Lyon, France.,Université de Lyon, Lyon, France.,Department of Rheumatology, Hôpital Edouard Herriot, Lyon, France
| | - Jocelyne Drai
- Fédération de Biochimie, Unité de Biochimie Métabolique et Moléculaire, Centre Hospitalier Lyon-Sud, Lyon, France
| | - Walid Arkouche
- Association pour l'Utilisation du Rein Artificiel de la région Lyonnaise, Lyon, France
| | - Denis Fouque
- Department of Nephrology, Lyon Sud Hospital, Hospices Civils de Lyon, Lyon, France.,Université de Lyon, Lyon, France
| | - Roland Chapurlat
- Université de Lyon, Lyon, France.,Department of Rheumatology, Hôpital Edouard Herriot, Lyon, France
| | - Fitsum Guebre-Egziabher
- Department of Nephrology, Hôpital Edouard Herriot, Lyon, France.,Department of Nephrology, Dialysis, and Kidney Transplant, Centre Hospitalier Universitaire de Grenoble Alpes, La Tronche, France
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15
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Marinho S, Carraro Eduardo J, Mafra D. Effect of a resistance exercise training program on bone markers in hemodialysis patients. Sci Sports 2017. [DOI: 10.1016/j.scispo.2017.01.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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Roles of Serum Calcium, Phosphorus, PTH and ALP on Mortality in Peritoneal Dialysis Patients: A Nationwide, Population-based Longitudinal Study Using TWRDS 2005-2012. Sci Rep 2017; 7:33. [PMID: 28232731 PMCID: PMC5428378 DOI: 10.1038/s41598-017-00080-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 01/31/2017] [Indexed: 12/12/2022] Open
Abstract
Biomarkers of chronic kidney disease-mineral and bone disorder (CKD-MBD) correlate with morbidity and mortality in dialysis patients. However, the comparative roles of each CKD-MBD biomarker remained undetermined on long-term peritoneal dialysis (PD) patients. This retrospective study, employing a population-based database, aimed to evaluate the performance and provide the best evidence of each biomarker of CKD-MBD as predictor of all-cause mortality. Throughout the 8-year study period, total 12,116 PD patients were included in this study. Cox proportional regression and Kaplan-Meier method were used for survival analysis. For Cox regression model, baseline measurements and time-varying covariates were used for analysis. In Cox regression model using time-dependent covariates, serum calcium level of ≧9.5 mg/dL was associated with increased mortality. For phosphorus, serum levels of either ≧6.5 mg/dL or <3.5 mg/dL were associated with increased mortality. For parathyroid hormone (PTH), higher serum levels were not associated increased mortality. For alkaline phosphatase (ALP), mortality increased at levels ≧100 IU/L. Our findings suggested that the detrimental effect of ALP on survival was more consistent, while serum calcium, phosphorus and PTH may have a less prominent effect on mortality. This study provided additional information for manipulating CKD-MBD biomarkers in PD patients.
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17
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Marinho SM, Moraes C, Barbosa JEDSM, Carraro Eduardo JC, Fouque D, Pelletier S, Mafra D. Exercise Training Alters the Bone Mineral Density of Hemodialysis Patients. J Strength Cond Res 2016; 30:2918-23. [PMID: 26863587 DOI: 10.1519/jsc.0000000000001374] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Marinho, SM, Moraes, C, Barbosa, JEdSM, Eduardo, JCC, Fouqe, D, Pelletier, S, and Mafra, D. Exercise training alters the bone mineral density of hemodialysis patients. J Strength Cond Res 30(10): 2918-2923, 2016-Patients with chronic kidney disease undergoing hemodialysis (HD) frequently present low bone mineral density (BMD), and exercise may be useful for treating bone loss. This study aimed to assess the effects of an intradialytic resistance exercise training program (RETP) on BMD in HD patients. Twenty-one patients were enrolled into 2 groups; 10 patients performed exercise (80.0% men; 46.9 ± 12.1 years; 27.0 ± 3.4 kg·m) and 11 patients were in the control group (54.5% men; 50.5 ± 11.5 years; 24.1 ± 8.7 kg·m). Dual-energy x-ray absorptiometry was used to measure the BMD, lean mass, and body fat before and after the supervised RETP (performed with elastic bands and ankle cuffs in both lower limbs 3 times a week for 24 weeks-72 sessions). In the exercise group, 30.0% of patients presented with osteopenia and 20.0% osteoporosis and in the control group, 45.5% osteopenia and 36.4% osteoporosis. Only in the exercise group, the osteoporosis percentage was reduced to 10.0% and the femoral neck BMD and T-score improved from 0.89 ± 0.1 to 0.93 ± 0.1 g·cm and from -1.3 ± 0.8 to -1.0 ± 0.8 g·cm (p ≤ 0.05), respectively, after the intervention. In contrast, these parameters were reduced in the control group. The results suggest that resistance exercise may be useful for improving the BMD in HD patients. In summary, 24 weeks of the supervised RETP played a role in improving the BMD of HD patients.
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Affiliation(s)
- Sandra M Marinho
- 1Graduate Program in Medical Sciences, Fluminense Federal University (UFF), Niterói-RJ, Brazil; 2Graduate Program in Cardiovascular Sciences, Fluminense Federal University (UFF), Niterói-RJ, Brazil; 3Fluminense Federal University (UFF), Medicine Faculty, Niterói-RJ, Brazil; and 4Department of Nephrology, Lyon Sud Hospital Center, CARMEN, CENS, University of Lyon, France
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18
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Heaf JG. Chronic Kidney Disease-Mineral Bone Disorder in the Elderly Peritoneal Dialysis Patient. Perit Dial Int 2016; 35:640-4. [PMID: 26702005 DOI: 10.3747/pdi.2014.00339] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE The purpose of this paper was to review the literature concerning the treatment of chronic kidney disease-mineral bone disorder (CKD-MBD) in the elderly peritoneal dialysis (PD) patient. RESULTS Chronic kidney disease-mineral bone disorder is a major problem in the elderly PD patient, with its associated increased fracture risk, vascular calcification, and accelerated mortality fracture risk. Peritoneal dialysis, however, bears a lower risk than hemodialysis (HD). The approach to CKD-MBD prophylaxis and treatment in the elderly PD patient is similar to other CKD patients, with some important differences. Avoidance of hypercalcemia, hyperphosphatemia, and hyperparathyroidism is important, as in other CKD groups, and is generally easier to attain. Calcium-free phosphate binders are recommended for normocalcemic and hypercalcemic patients. Normalization of vitamin D levels to > 75 nmol/L (> 30 pg/L) and low-dose active vitamin D therapy is recommended for all patients. Hyperparathryoidism is to be avoided by using active vitamin D and cinacalcet. Particular attention should be paid to treating protein malnutrition. Fracture prophylaxis (exercise, use of walkers, dwelling modifications) are important. Hypomagnesemia is common in PD and can be treated with magnesium supplements. Vitamin K deficiency is also common and has been identified as a cause of vascular calcification. Accordingly, warfarin treatment for this age group is problematic. CONCLUSION While treatment principles are similar to other dialysis patient groups, physicians should be aware of the special problems of the elderly group.
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Affiliation(s)
- James Goya Heaf
- Department of Medicine, Roskilde Hospital, University of Copenhagen, Copenhagen, Denmark
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19
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Hwang SD, Kim SH, Kim YO, Jin DC, Song HC, Choi EJ, Kim YL, Kim YS, Kang SW, Kim NH, Yang CW, Kim YK. Serum Alkaline Phosphatase Levels Predict Infection-Related Mortality and Hospitalization in Peritoneal Dialysis Patients. PLoS One 2016; 11:e0157361. [PMID: 27310428 PMCID: PMC4911047 DOI: 10.1371/journal.pone.0157361] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 05/28/2016] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Serum alkaline phosphatase (ALP) levels have been reported to be associated with all-cause and cardiovascular mortality in peritoneal dialysis (PD) patients. However, it is unclear whether serum ALP levels predict infection-related clinical outcomes in PD patients. The aim of this study was to determine the relationships between serum ALP levels, infection-related mortality and hospitalization in PD patients. METHODS PD patients from the Clinical Research Center registry for end-stage renal disease, a multicenter prospective observational cohort study in Korea, were included in the present study. Patients were categorized into three groups by serum ALP tertiles as follows: Tertile 1, ALP <78 U/L; Tertile 2, ALP = 78-155 U/L; Tertile 3, ALP >155 U/L. Tertile 1 was used as the reference category. The primary outcomes were infection-related mortality and hospitalization. RESULTS A total of 1,455 PD patients were included. The median follow-up period was 32 months. The most common cause of infection-related mortality and hospitalization was PD-related peritonitis. Multivariate Cox regression analyses showed that patients in the highest tertiles of serum ALP levels were at higher risk of infection-related mortality (HR 2.29, 95% CI, 1.42-5.21, P = 0.008) after adjustment for clinical variables. Higher tertiles of serum ALP levels were associated with higher risk of infection-related hospitalization (Tertile 2: HR 1.56, 95% CI, 1.18-2.19, P = 0.009, tertile 3: HR 1.34, 95% CI, 1.03-2.62, P = 0.031). CONCLUSIONS Our data showed that elevated serum ALP levels were independently associated with a higher risk of infection-related mortality and hospitalization in PD patients.
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Affiliation(s)
- Seun Deuk Hwang
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Su-Hyun Kim
- Department of Internal Medicine, College of Medicine, Chung-Ang University, Seoul, Korea
| | - Young Ok Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong Chan Jin
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ho Chul Song
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Euy Jin Choi
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yong-Lim Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Yon-Su Kim
- Department of Internal Medicine, College of Medicine, Seoul National University, Seoul, Korea
| | - Shin-Wook Kang
- Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Korea
| | - Nam-Ho Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Chul Woo Yang
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yong Kyun Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Cell Death Disease Research Center, The Catholic University of Korea, Seoul, Korea
- * E-mail:
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20
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Chapurlat R. In vivo evaluation of bone microstructure in humans: Clinically useful? BONEKEY REPORTS 2016; 5:813. [PMID: 27347398 DOI: 10.1038/bonekey.2016.40] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 02/13/2016] [Accepted: 02/22/2016] [Indexed: 11/09/2022]
Abstract
In vivo evaluation of bone microstructure with high-resolution peripheral quantitative tomography (HRpQCT) has been used for a decade in research settings. In this review, we examine the value this technique could have in clinical practice. Bone microstructure parameters obtained with HRpQCT are associated with prevalent fracture in men and women. In postmenopausal women, some parameters also predict incident fracture, independently of areal bone mineral density. In specific population groups including patients with diabetes, chronic kidney disease, glucocorticosteroid therapy and rheumatic diseases, abnormal microstructure parameters from HRpQCT have been reported. Findings from HRpQCT studies may also explain ethnic differences in bone fragility. Treatment monitoring has been challenging in the various clinical trials with available HRpQCT data. The improvements were of small magnitude but tended to be proportional to the potency of antiresorptive agents. Microfinite element analysis was a better predictor of treatment efficacy than the microarchitectural parameters. In conclusion, HRpQCT remains a valuable research tool, but more work is needed to be able to use it in clinical practice.
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Affiliation(s)
- Roland Chapurlat
- INSERM UMR 1033, Université de Lyon, Hôpital E Herriot , Lyon, France
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21
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Sharma AK, Masterson R, Holt SG, Toussaint ND. Emerging role of high-resolution imaging in the detection of renal osteodystrophy. Nephrology (Carlton) 2016; 21:801-11. [PMID: 27042945 DOI: 10.1111/nep.12790] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 03/14/2016] [Accepted: 03/25/2016] [Indexed: 12/17/2022]
Abstract
The term renal osteodystrophy refers to changes in bone morphology induced by chronic kidney disease (CKD) and represents the skeletal component of the entity 'chronic kidney disease - mineral and bone disorder'. Changes in turnover, mineralization, mass and microarchitecture impair bone quality, compromising strength and increasing susceptibility to fractures. Fractures are more common in CKD compared with the general population and result in increased morbidity and mortality. Screening for fracture risk and management of renal osteodystrophy are hindered by the complex, and still only partially understood, pathophysiology and the inadequacy of currently available diagnostic methods. Bone densitometry and bone turnover markers, although potentially helpful, have significant limitations in patients with CKD, and the 'gold standard' test of bone biopsy is infrequently performed in routine clinical practice. However, recent advances in high-resolution bone microarchitecture imaging may offer greater potential for quantification and assessment of bone structure and strength and, when used in conjunction with serum biomarkers, may allow non-invasive testing for a diagnostic virtual bone biopsy.
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Affiliation(s)
- Ashish K Sharma
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Victoria, Australia
| | - Rosemary Masterson
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Victoria, Australia
| | - Stephen G Holt
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Victoria, Australia
| | - Nigel D Toussaint
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Victoria, Australia. .,Department of Medicine (RMH), The University of Melbourne, Melbourne, Victoria, Australia.
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de Oliveira RA, Barreto FC, Mendes M, dos Reis LM, Castro JH, Britto ZML, Marques IDB, Carvalho AB, Moysés RM, Jorgetti V. Peritoneal dialysis per se is a risk factor for sclerostin-associated adynamic bone disease. Kidney Int 2014; 87:1039-45. [PMID: 25493951 DOI: 10.1038/ki.2014.372] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 08/30/2014] [Accepted: 09/18/2014] [Indexed: 11/09/2022]
Abstract
Chronic kidney disease--mineral bone disorder (CKD-MBD) is a complex syndrome influenced by various factors, such as age, CKD etiology, uremic toxins, and dialysis modality. Although extensively studied in hemodialysis (HD) patients, only a few studies exist for peritoneal dialysis (PD) patients. Since most of these older studies contain no bone biopsy data, we studied the pattern of renal osteodystrophy in 41 prevalent PD patients. The most common presentation was adynamic bone disease (49%). There was a significant inverse association between serum sclerostin (a Wnt/β-catenin pathway inhibitor that decreases osteoblast action and bone formation) and the bone formation rate. Bone alkaline phosphatase had the best sensitivity and specificity to detect both high- and low-turnover diseases. The comparison between nondiabetic PD and HD patients, matched by age, gender, parathyroid hormone level, and length of dialysis, revealed low 25-hydroxyvitamin D levels, worse bone mineralization, and low bone turnover in the nondiabetic PD group. Thus, adynamic bone disease was the most frequent type of renal osteodystrophy in PD patients. Sclerostin seems to participate in the pathophysiology of adynamic bone disease and bone alkaline phosphatase was the best serum marker of bone turnover in these patients.
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Affiliation(s)
- Rodrigo A de Oliveira
- 1] Department of Internal Medicine, Nephrology Division, Universidade de São Paulo, São Paulo, Brazil [2] Department of Integrated Medicine, Universidade Federal do Rio Grande do Norte, Natal, Brazil
| | - Fellype C Barreto
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, Brazil
| | - Monique Mendes
- Department of Internal Medicine, Nephrology Division, Universidade de São Paulo, São Paulo, Brazil
| | - Luciene M dos Reis
- Department of Internal Medicine, Nephrology Division, Universidade de São Paulo, São Paulo, Brazil
| | - João Henrique Castro
- Department of Internal Medicine, Nephrology Division, Universidade Estadual Paulista, Botucatu, Brazil
| | - Zita Maria L Britto
- Department of Internal Medicine, Nephrology Division, Universidade de São Paulo, São Paulo, Brazil
| | - Igor D B Marques
- Department of Internal Medicine, Nephrology Division, Universidade de São Paulo, São Paulo, Brazil
| | - Aluizio B Carvalho
- Department of Internal Medicine, Nephrology Division, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Rosa M Moysés
- 1] Department of Internal Medicine, Nephrology Division, Universidade de São Paulo, São Paulo, Brazil [2] Medicine Master Degree Program, Universidade Nove de Julho (UNINOVE), São Paulo, Brazil
| | - Vanda Jorgetti
- Department of Internal Medicine, Nephrology Division, Universidade de São Paulo, São Paulo, Brazil
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Chen YJ, Kung PT, Wang YH, Huang CC, Hsu SC, Tsai WC, Hsu HC. Greater risk of hip fracture in hemodialysis than in peritoneal dialysis. Osteoporos Int 2014; 25:1513-8. [PMID: 24557014 DOI: 10.1007/s00198-014-2632-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 10/23/2013] [Indexed: 12/11/2022]
Abstract
UNLABELLED Several differences may have existed between patients treated with peritoneal dialysis and hemodialysis because of the difference in dialysis modality. This nationwide population-based cohort study demonstrated that patients on hemodialysis had an increased risk of hip fracture compared to patients on peritoneal dialysis; the hazard ratio was 1.52. INTRODUCTION Numerous debates on which dialysis modality is "superior" have taken place in recent decades. However, no large-scale study has ever mentioned about the relationship between dialysis modality and risk of hip fracture. METHODS We identified 64,124 incident end-stage renal disease patients from the National Health Insurance Research Database in Taiwan between 1998 and 2008, including 59,457 (92.72%) hemodialysis (HD) and 4,667 (7.28%) peritoneal dialysis (PD) patients. After 8:1 propensity score matching, 31,554 patients, of whom 28,048 were HD and 3,506 were PD patients, were included in the study. We conducted the Cox proportional hazards model to examine the effects of dialysis modality and other variables on hip fracture risk. RESULTS A total of 2,587 hip fractures were identified in 64,124 dialysis patients. The incidence rate of hip fracture was 13.60 per 1000 patient-years in the HD group and 6.25 in the PD group. Dialysis modality, sex, age, presence of cardiovascular disease, diabetes, medication with antiepileptic drugs, diuretics, steroids, and vitamin D had statistically significant associations with hip fracture. Patients on HD had an increased risk of hip fracture compared to patients on PD; the hazard ratio (HR) was 1.52 (95% CI: 1.09-2.12, P = 0.02). CONCLUSIONS In this population-based cohort study, HD had a greater hip fracture risk compared to PD; the HR was 1.52. We should focus more on reducing the risk of hip fractures in hemodialysis patients.
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Affiliation(s)
- Y-J Chen
- Department of Health Services Administration, China Medical University, 91 Hsueh-Shih Road, Taichung, Taiwan, 40402, Republic of China
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Abstract
PURPOSE OF REVIEW Disturbances in calcium-phosphate homeostasis play an important role in children with chronic kidney disease, and not only cause renal osteodystrophy but also result in increased cardiovascular morbidity and mortality. This review outlines the current aspects in the pathogenesis, diagnostic approach and treatment of renal osteodystrophy. RECENT FINDINGS The pathogenesis of renal osteodystrophy is under strong influence of the fibroblast growth factor 23/Klotho system, which is able to enhance phosphate excretion and reduce calcitriol synthesis in the kidney. Fibroblast growth factor 23 increases tissue calcinosis and is cardiotoxic, and is independently associated with mortality. Despite improvement in diagnostic imaging (bone density measurements), determination of biomarkers, mainly parathyroid hormone, still plays a central role. New treatment options resulted in improved bone health and also a reduction in mortality was achieved in adults with calcium-free phosphate binders. Substitution of active and inactive vitamin D is important and also has a beneficial effect on proteinuria. SUMMARY Knowledge about the biochemical and molecular mechanisms of renal osteodystrophy is increasing dramatically and has an impact not only to bone health but also overall morbidity and mortality. This will ultimately translate into further improved diagnostic approaches and novel treatment options.
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Salam SN, Eastell R, Khwaja A. Fragility fractures and osteoporosis in CKD: pathophysiology and diagnostic methods. Am J Kidney Dis 2014; 63:1049-59. [PMID: 24631043 DOI: 10.1053/j.ajkd.2013.12.016] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 12/19/2013] [Indexed: 11/11/2022]
Abstract
Both chronic kidney disease (CKD) and osteoporosis are major public health problems associated with an aging population. Osteoporosis is characterized by reduced bone mineral density, while CKD results in qualitative changes in bone structure; both conditions increase the predisposition to fragility fractures. There is a significant coprevalence of osteoporotic fractures and CKD, particularly in the elderly population. Not only is the risk of fracture higher in the CKD population, but clinical outcomes are significantly worse, with substantial health care costs. Management of osteoporosis in the CKD population is particularly complex given the impact of renal osteodystrophy on bone quality and the limited safety and hard outcome data for current therapy in patients with severe CKD or on dialysis therapy. In this review, we discuss the pathophysiology of osteoporosis, the impact of CKD on bone strength, and the role of novel imaging techniques and biomarkers in predicting underlying renal osteodystrophy on bone histomorphometry in the context of CKD.
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Affiliation(s)
- Syazrah N Salam
- Sheffield Kidney Institute, Northern General Hospital, Sheffield, United Kingdom.
| | - Richard Eastell
- Academic Unit of Bone Metabolism, Metabolic Bone Centre, Northern General Hospital, Sheffield, United Kingdom
| | - Arif Khwaja
- Sheffield Kidney Institute, Northern General Hospital, Sheffield, United Kingdom
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Geusens P, Chapurlat R, Schett G, Ghasem-Zadeh A, Seeman E, de Jong J, van den Bergh J. High-resolution in vivo imaging of bone and joints: a window to microarchitecture. Nat Rev Rheumatol 2014; 10:304-13. [DOI: 10.1038/nrrheum.2014.23] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Liu X, Guo Q, Feng X, Wang J, Wu J, Mao H, Huang F, Yu X, Yang X. Alkaline phosphatase and mortality in patients on peritoneal dialysis. Clin J Am Soc Nephrol 2014; 9:771-8. [PMID: 24458081 DOI: 10.2215/cjn.08280813] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND OBJECTIVES Elevated total serum alkaline phosphatase levels have been associated with higher mortality in the general population, CKD patients, and hemodialysis patients. However, in peritoneal dialysis patients, this association has received little attention. The aim of this study was to evaluate the association between alkaline phosphatase and all-cause and cardiovascular mortality in peritoneal dialysis patients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In this single center retrospective cohort study, 1021 incident peritoneal dialysis patients from January 1, 2006, to December 31, 2010 with baseline serum alkaline phosphatase values were enrolled. Collected baseline data included demographic characteristics and clinical and laboratory measurements. All patients were followed until December 31, 2012. The associations of total serum alkaline phosphatase levels with all-cause and cardiovascular mortality were assessed using multivariable-adjusted Cox models. RESULTS Of 1021 patients, mean age was 47.5 (± 15.5) years, 59.1% of patients were men, and 22.8% of patients were diabetic. The median serum alkaline phosphatase level was 64 U/L (interquartile range=52-82 U/L). During a median 31-month (interquartile range=19-45 months) follow-up period, 203 patients died, of which 109 deaths were caused by cardiovascular disease. After adjusting for demographics, comorbid conditions, liver function, and bone metabolism parameters, the highest alkaline phosphatase quartile was significantly associated with a hazard ratio for all-cause mortality of 1.70 (95% confidence interval, 1.06 to 2.74, P=0.03) and a hazard ratio for cardiovascular mortality of 1.94 (95% confidence interval, 1.02 to 3.72, P=0.04). Each 10 U/L higher baseline alkaline phosphatase level was associated with 4% (95% confidence interval, 1.00 to 1.08, P=0.04) and 7% (95% confidence interval, 1.02 to 1.11, P=0.003) higher risk of all-cause and cardiovascular mortality, respectively. CONCLUSION Higher total serum alkaline phosphatase levels at the commencement of peritoneal dialysis were independently associated with all-cause and cardiovascular mortality in peritoneal dialysis patients.
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Affiliation(s)
- Xinhui Liu
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Key Laboratory of Nephrology, Ministry of Health, Guangdong, China
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[Mineral and bone disorders in renal transplantation]. Nephrol Ther 2013; 9:461-70. [PMID: 24176653 DOI: 10.1016/j.nephro.2013.07.372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 07/23/2013] [Accepted: 07/26/2013] [Indexed: 11/22/2022]
Abstract
The deregulation of bone and mineral metabolism during chronic kidney disease (CKD) is a daily challenge for physicians, its management aiming at decreasing the risk of both fractures and vascular calcifications. Renal transplantation in the context of CKD, with pre-existing renal osteodystrophy as well as nutritional impairment, chronic inflammation, hypogonadism and corticosteroids exposure, represents a major risk factor for bone impairment in the post-transplant period. The aim of this review is therefore to provide an update on the pathophysiology of mineral and bone disorders after renal transplantation.
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