Proton Pump Inhibitor Use and Risk of Hip Fracture in Kidney Transplant Recipients

Effect of long-term proton pump inhibitors on phosphocalcium metabolism and bone mineral density

Aim: Although Proton pump inhibitors (PPIs) are well-tolerated, their long-term use may be associated with decreased bone mass. Methods: This is a case-control study including patients treated with PPIs (>1 year) and control subjects who have not received PPIs treatment. Results: A total of 90 patients and 90 matched controls were included. PPIs use was associated with hypocalcemia and hypomagnesemia. Vitamin D3 deficiency and hyperparathyroidism were associated with PPIs use. Long-term PPIs use was significantly associated with decreased bone density. Risk factors of decreased bone mineral density (BMD) included age >50 years, menopause, lack of sun exposure, double PPIs dose, daily intake, post-meal intake and association with a mucoprotective agent. Conclusion: Our results highlight the risk of decreased BMD in patients on long-term PPIs treatment.

Mineral Bone Disorders in Kidney Transplantation

Bone disease after kidney transplantation is associated with an increased risk of fractures, morbidity, and mortality. Its pathophysiology is complex, involving multiple contributors including pretransplant bone disease, immunosuppressive medications, and changes in the parathyroid-bone-kidney axis. Risk scores, bone turnover markers, and noninvasive imaging modalities are only able to partially predict the fracture risk in kidney transplant recipients. The optimal management of bone disease after kidney transplantation has not yet been established, with only a limited number of randomized clinical trials evaluating the efficacy of treatment regimens in kidney transplant recipients. This review focuses on the pathophysiology, evaluation, prevention, and treatment of post-kidney transplant mineral and bone disease as guided by recent evidence.

Proton Pump Inhibitors, But Not H2-receptor Antagonists, Are Associated With Incident Fractures Among Kidney Transplant Recipients

BACKGROUND

Fractures are a common and burdensome problem among kidney transplant recipients (KTRs). Proton pump inhibitors (PPIs) are frequently used after kidney transplantation and have been associated with increased fracture risk in the general population. This study aimed to determine whether PPI use is associated with incidence of major fractures in KTRs.

METHODS

Using the Wisconsin Allograft Recipient Database, we identified 155 KTRs with a major fracture that occurred at least 12 months after transplantation. Controls were selected using incidence-density sampling. Use of PPIs and histamine 2-receptor antagonists (H2RA) during the year before the index date were identified.

RESULTS

A total of 155 cases were matched to 685 controls. Within 1 year before the index date, 68% of cases and 52% of controls used a PPI, and 16% of cases and 11% of controls used an H2RA. PPI use was associated with higher incidence of major fractures in unadjusted analysis (odds ratio [OR], 2.4; 95% CI, 1.6-3.5) and in adjusted analyses controlling for demographic and transplant-related covariates and use of corticosteroids, bisphosphonates, vitamin D and calcium supplements (OR, 1.9; 95% CI, 1.2-3.1). H2RA use was not associated with incidence of major fractures in adjusted analyses (OR, 1.0; 95% CI, 0.5-1.8). The associations between PPI use and fractures remained similar in analyses limited to spine and hip fractures.

CONCLUSIONS

Use of PPIs, but not H2RAs, is associated with a higher risk of major fractures among KTRs. Clinicians should individualize PPI use in KTRs, evaluating the risks and benefits of prescribing and continuing PPIs in KTRs.

Association between proton pump inhibitors use and risk of hip fracture: A general population-based cohort study

Previous studies comparing risk of fracture among Proton Pump Inhibitors (PPIs) users with that among non-users were susceptible to confounding by indication. Epidemiologic studies of this association using an active medication as a comparator would appropriately address this bias. We conducted a propensity-score matched cohort study to compare the risk of incident fracture over five years among initiators of PPIs with initiators of histamine 2 receptor antagonist (H2RA) using data collected from The Health Improvement Network (THIN) database in the United Kingdom (2000-2016). The prevalence of PPIs prescription increased 3.8-fold from 2000 (7.9%) to 2012 (30.3%) and remained stable since then. Of the 50,265 propensity-score matched participants in each cohort (mean age was 65 years, and 57% were women), 370 (1.9/1000 person-years) incident hip fracture occurred in the PPIs initiators and 294 (1.5/1000 person-years) in the H2RA initiators during the follow-up period. The rate difference of incident hip fracture for PPIs initiation was 0.4 (95% confidence interval [CI]: 0.2-0.7)/1000 person-years compared with H2RA initiation and the corresponding hazard ratio (HR) was 1.27 (95%CI: 1.09-1.48). Compared with non-PPI use, multivariable-adjusted odds ratios (ORs) of hip fracture were 1.17 (95%CI: 0.94-1.46), 1.55 (95%CI: 1.23-1.96), and 1.67 (95%CI: 1.33-2.10) for 1-2, 3-9 and ≥ 10 prescriptions of PPIs, respectively (P for trend = 0.001). We found that PPIs prescription has been increasing rapidly over the past decade in the United Kingdom, and the initiation of PPIs was associated with a higher risk of hip fracture than initiation of H2RA.

Bone disease following solid organ transplantation: A narrative review and recommendations for management from The European Calcified Tissue Society

INTRODUCTION

Solid organ transplantation is an established therapy for end-stage organ failure. Both pre-transplantation bone disease and immunosuppressive regimens result in rapid bone loss and increased fracture rates.

METHODS

The European Calcified Tissue Society (ECTS) formed a working group to perform a systematic review of existing literature on the consequences of end-stage kidney, liver, heart, and lung disease on bone health. Moreover, we assessed the characteristics of post-transplant bone disease and the skeletal effects of immunosuppressive agents and aimed to provide recommendations for the prevention and treatment of transplantation-related osteoporosis.

RESULTS

Characteristics of bone disease may differ depending on the organ that fails, but patients awaiting solid organ transplantation frequently depict a wide spectrum of bone and mineral abnormalities. Common features are a decreased bone mass and impaired bone strength with consequent high fracture risk, all of which are aggravated in the early post-transplantation period.

CONCLUSION

Both the underlying disease leading to end-stage organ failure and the immunosuppression regimens implemented after successful organ transplantation have detrimental effects on bone mass, quality and strength. Given existing ample data confirming the high frequency of bone disease in patients awaiting solid organ transplantation, we recommend that all transplant candidates should be assessed for osteoporosis and fracture risk and, if indicated, treated before and after transplantation. Since bone loss in the early post-transplantation period occurs in virtually all solid organ recipients and is associated with glucocorticoid administration, the goal should be to use the lowest possible dose and to taper and withdraw glucocorticoids as early as possible.

Proton Pump Inhibitors and Fracture Risk: A Review of Current Evidence and Mechanisms Involved

The number of patients with gastroesophageal problems taking proton pump inhibitors (PPIs) is increasing. Several studies suggested a possible association between PPIs and fracture risk, especially hip fractures, but the relationship remains contentious. This review aimed to investigate the longitudinal studies published in the last five years on the relationship between PPIs and fracture risk. The mechanism underlying this relationship was also explored. Overall, PPIs were positively associated with elevated fracture risk in multiple studies (n = 14), although some studies reported no significant relationship (n = 4). Increased gastrin production and hypochlorhydria are the two main mechanisms that affect bone remodeling, mineral absorption, and muscle strength, contributing to increased fracture risk among PPI users. As a conclusion, there is a potential relationship between PPIs and fracture risks. Therefore, patients on long-term PPI treatment should pay attention to bone health status and consider prophylaxis to decrease fracture risk.

Proton pump inhibitors use and risk of chronic kidney disease in diabetic patients

AIMS

Chronic kidney disease consumes a huge amount of medical resources and proton pump inhibitors may be a potential factor for the increasing prevalence. This population-based cohort study investigates the risk of chronic kidney disease in a diabetic population using proton pump inhibitors in Taiwan.

METHODS

This study is based on a specific diabetic database obtained from the National Health Insurance Research Database. Individuals with a new diagnosis of diabetes from 2002 to 2013 were enrolled. "Exposure" to proton pump inhibitors was defined as at least one prescription and dosage over 180 DDD (defined daily dose) in one year after the index date. A multivariable Cox proportional hazard model and competing-risk regression model were applied.

RESULTS

There were 5994 patients in the final cohort of proton pump inhibitor users and 23,976 patients in the matched controlled cohort based on 1:4 propensity score matching. Compared with no exposure users, PPIs exposure group had more anemia prevalence, anti-hypertension medication and NSAIDs prescriptions. The multivariable Cox proportional hazard model showed that the adjusted hazard ratio of chronic kidney disease was 1.52 (95% CI 1.40-1.65) in diabetic individuals with PPIs exposure, compared with no exposure users.

CONCLUSIONS

Proton pump inhibitors use is associated with 1.52-fold increased risk of chronic kidney disease in diabetic patients when the dosage is over 180 DDD in one year in Taiwan.

Proton pump inhibitors and risk of hip fracture: a meta-analysis of observational studies

We performed a meta-analysis of relevant studies to quantify the magnitude of the association between proton pump inhibitors (PPIs) and risk of hip fracture. Patients with PPIs had a greater risk of hip fracture than those without PPI therapy (RR 1.20, 95% CI 1.14-1.28, p < 0.0001). These results could be taken into consideration with caution, and patients should also be concerned about the inappropriate use of PPIs.

INTRODUCTION

Proton pump inhibitors (PPIs) are generally considered as first-line medicine with great safety profile, commonly prescribed for gastroesophageal reflux disease (GERD) and peptic ulcer disease. However, several epidemiological studies documented that long-term use of PPIs may be associated with an increased risk of hip fracture. Although, the optimal magnitude of the hip fracture risk is still undetermined. We, therefore, performed a meta-analysis of relevant studies to quantify the magnitude of the association between PPIs and risk of hip fracture.

METHODS

We collected relevant articles using MEDLINE, EMBASE, Google Scholar, and Web of Science from January 1, 1990, to March 31, 2018. We included only the large (n ≥ 500) observational studies with a follow-up duration of at least one year in which the hip fracture patients were identified by a standard procedure. Two of the authors extracted data from each included study independently according to a standardized protocol.

RESULTS

A total of 24 observational studies with 2,103,800 participants (319,568 hip fracture patients) met all the eligibility criteria. Patients with PPIs had a greater risk of hip fracture than those without PPI therapy (RR 1.20, 95% CI 1.14-1.28, p < 0.0001). An increased association was also observed in both low and medium doses of PPI taken and hip fracture risk (RR 1.17, 95% CI 1.05-1.29, p = 0.002; RR 1.28, 95% CI 1.14-1.44, p < 0.0001), but it appeared to be even greater among the patients with higher dose (RR 1.30, 95% CI 1.20-1.40, p < 0.0001). Moreover, the overall pooled risk ratios were 1.20 (95% CI 1.15-1.25, p < 0.0001) and 1.24 (95% CI 1.10-1.40, p < 0.0001) for the patients with short- and long-term PPI therapy, respectively, compared with PPI non-users.

CONCLUSION

Our results suggest that PPI use is significantly associated with an increased risk of hip fracture development, which is not observed in H2RA exposure. Physicians should, therefore, exercise caution when considering a long-term PPI treatment to their patients who already have an elevated risk of hip fracture. In addition, patients should be concerned about the inappropriate use of PPIs; if necessary, then, they should continue to receive it with a clear indication.

Proton pump inhibitors therapy and risk of bone diseases: An update meta-analysis

AIMS

Large observational studies have yielded conflicting results regarding whether the use of proton pump inhibitors (PPI) increases the risk of bone diseases. Here, we performed a meta-analysis to examine the link between PPI and risk of bone fractures, osteoporosis and bone mineral density (BMD) loss.

MATERIALS AND METHODS

We systematically performed a search for published reports on PubMed, EMBASE and the Cochrane Library. We considered articles published in English, and restricted the search to studies on human participants. Studies that reported adjusted Hazard ratio (HR) estimates with 95% confidence intervals (CI) for the associations of interest were included. Data from the articles which can be used to estimate standardized mean difference (SMD) were also obtained and utilized to assess the risk of BMD loss.

KEY FINDINGS

Compared with patients not taking PPI, those taking PPI, had the increased risk of developing any-site fractures (HR: 1.30; 95%CI: 1.16 to 1.45), hip fracture (HR:1.22; 95%CI:1.15 to 1.31), spine fracture (HR:1.49; 95%CI:1.31 to 1.68), and osteoporosis (HR:1.23; 95%CI:1.06 to 1.42) based on a random model, but there was no correlation with developing BMD loss in the femoral (SMD: -0.27; 95%CI: -0.62 to 0.09), or in the spine (SMD: -0.06; 95%CI: -0.54 to 0.41).

SIGNIFICANCE

Results of this meta-analysis suggest that PPI may moderately increase the risk of any-site, hip, spine fracture. Due to the widespread use of PPI and the impact of fractures on human health, clinicians should carefully evaluate the patient condition before prescribing PPI therapy.

Proton-pump Inhibitor Use and Fracture Risk: An Updated Systematic Review and Meta-analysis

Background

This study's objective was to evaluate the association between proton-pump inhibitor (PPI) use and bone fracture incidence and bone mineral density (BMD) by meta-analyzing the estimates reported by epidemiological and cohort studies.

Methods

Data were acquired from studies identified after a literature search in electronic databases. Odds ratios (ORs), hazard ratios (HRs), and risk ratios (RRs) between PPI use and bone fracture incidence were pooled under the random effects model, and meta-analysis of standardized mean differences between PPI users and controls in cross-sectional values and BMD changes was conducted.

Results

Thirty-three studies fulfilled the eligibility criteria. These studies provided data from 2,714,502 individuals with a mean age of 66.91 years (95% confidence interval [CI], 63.37–70.46); 33.21% (95% CI, 30.44–35.99) were males and 64.61% (95% CI, 60.73–68.49) were females. Overall, fracture incidence was 22.04% (95% CI, 16.10–27.97) in PPI users and 15.57% (95% CI, 12.28–18.86) in controls. The overall effect size of the point estimate was 1.28 (95% CI, 1.22–1.35) between PPI use and bone fracture incidence. There was a trend towards increased fracture incidence from short duration use: OR 1.29 (95% CI, 1.19–1.40), medium duration use: OR 1.33 (95% CI, 1.12–1.55) and long duration use: OR 1.62 (95% CI, 1.33–1.90). There was no significant difference in the standardized mean differences between PPI users and controls, either in cross-sectional BMD values or in the BMD change observed in longitudinal studies.

Conclusions

Pooling of ORs, HRs, and RRs suggested that PPI use might increase fracture risk. However, there was no effect of PPI use on BMD.

Proton pump inhibitors' use and risk of hip fracture: a systematic review and meta-analysis

In the last decade, epidemiological studies presented inconsistent findings concerning the proton pump inhibitors (PPI) use and the risk of hip fracture. So, this systematic review and meta-analysis were performed with the aim to quantify the risk of hip fracture associated with PPI use. PubMed^® and Cochrane Central databases were searched from inception to January 2018. The quality of included studies in meta-analysis was assessed using Newcastle-Ottawa scale. Primary outcome of this study was to assess the risk of hip fracture among PPI user. Secondary outcomes include subgroup analysis based on study design, study quality, duration of PPI use, calcium intake, and geographical region. Sensitivity analysis was also performed. Review Manager (RevMan) was used to perform statistical analysis. This meta-analysis was based on seventeen studies. Pooled risk ratio showed a statistically significant association between PPI use and hip fracture risk (RR 1.26 [95% CI 1.17-1.35], p < 0.00001). Subgroup analysis, based on the study design, showed a highly significant association between PPI use and risk of hip fracture (p < 0.0001). The risk of hip fracture persisted even when stratified by calcium adjustment and the duration of PPI use (p < 0.0001). This meta-analysis suggests that PPI user have a 26% increased risk of hip fracture as compared to non-PPI user. Physicians should take caution in prescribing PPI to patients who are at increased risk of hip fracture.

Mineral and Bone Disorders After Kidney Transplantation

The risk of mineral and bone disorders among patients with chronic kidney disease is substantially elevated, owing largely to alterations in calcium, phosphorus, vitamin D, parathyroid hormone, and fibroblast growth factor 23. The interwoven relationship among these minerals and hormones results in maladaptive responses that are differentially affected by the process of kidney transplantation. Interpretation of conventional labs, imaging, and other fracture risk assessment tools are not standardized in the post-transplant setting. Post-transplant bone disease is not uniformly improved and considerable variation exists in monitoring and treatment practices. A spectrum of abnormalities such as hypophosphatemia, hypercalcemia, hyperparathyroidism, osteomalacia, osteopenia, and osteoporosis are commonly encountered in the post-transplant period. Thus, reducing fracture risk and other bone-related complications requires recognition of these abnormalities along with the risk incurred by concomitant immunosuppression use. As kidney transplant recipients continue to age, the drivers of bone disease vary throughout the post-transplant period among persistent hyperparathyroidism, de novo hyperparathyroidism, and osteoporosis. The use of anti-resorptive therapies require understanding of different options and the clinical scenarios that warrant their use. With limited studies underscoring clinical events such as fractures, expert understanding of MBD physiology, and surrogate marker interpretation is needed to determine ideal and individualized therapy.

Gastroesophageal Reflux Characteristics and Patterns in Patients with Idiopathic Subglottic Stenosis

Introduction

Idiopathic subglottic stenosis represents a spectrum of subglottic disease without a clear underlying cause. Prior studies have implicated a pathogenic role of gastroesophageal reflux disease in idiopathic subglottic stenosis. The aim of this study was to examine the presence and pattern of gastroesophageal reflux in a large cohort of patients with idiopathic subglottic stenosis at a tertiary referral center.

Methods

We performed a retrospective review of patients with idiopathic subglottic stenosis from January 2010 to December 2016 who had undergone combined pH impedance testing. Patients with prior gastric or esophageal surgery were excluded. Data obtained included esophageal acid exposure times, number of reflux events, patient position during reflux events (defined as upright, supine, or mixed), body mass index, and the presence of proton pump inhibitor therapy.

Results

159 patients with the idiopathic subglottic stenosis were identified, of whom 41 had undergone esophageal pH impedance testing. 40 (97.6%) were women, with a mean age of 54.8 (range 31-79) years and BMI of 31.0 (range 17-55). Overall, 19 (46.3%) patients were found to reflux as confirmed by abnormal esophageal acid exposure or abnormal number of reflux events. 15 of the 19 patients with reflux had predominantly upright gastroesophageal reflux disease, whereas 2 had supine and 2 mixed reflux.

Discussion

In patients with idiopathic subglottic stenosis who underwent evaluation by combined pH impedance, close to half were found to have gastroesophageal reflux disease. The majority of gastroesophageal reflux occurred while the patients were in the upright position.

Proton pump inhibitor use and the risk of osteoporosis and fracture in stroke patients: a population-based cohort study

A considerable proportion of stroke survivors are prescribed with proton pump inhibitors (PPIs). Our study indicated that PPI use is associated with an increased risk of osteoporosis, hip fracture, and vertebral fracture in stroke patients. The risk tends to increase as the cumulative doses of PPIs increase.

INTRODUCTION

A considerable proportion of stroke survivors are prescribed with proton pump inhibitors (PPIs). Our study investigated the association between PPI use and the risk of osteoporosis and fracture among stroke survivors.

METHODS

A population-based propensity-matched retrospective cohort study was conducted using the National Health Insurance Research Database in Taiwan. Patients diagnosed with a new stroke between 2000 and 2012 were identified. After propensity score matching, 10,596 patients were enrolled, and 5298 patients were each assigned to the PPI user and non-user groups. Hazard ratios (HRs) were calculated for the risk of osteoporosis, hip fracture, and vertebral fractures according to PPI use or non-use. Sensitivity analyses were conducted to evaluate the dose effects of PPI.

RESULTS

PPI use after stroke was associated with an increased risk of osteoporosis, hip fracture, or vertebral fracture, with an adjusted HR (aHR) of 1.28 (P < 0.001). The aHRs were also significant for each outcome: osteoporosis, 1.26 (P < 0.001); hip fracture, 1.18 (P = 0.048); vertebral fracture, 1.33 (P < 0.001). A pattern of dose effect was identified. For any event (osteoporosis/hip fracture/vertebral fracture), the aHR for PPI use of 1-90, 91-365, and > 365 cDDDs was 1.22 (P < 0.001), 1.27 (P < 0.001), and 1.66 (P < 0.001), respectively. For each outcome, the highest dose was associated with the highest risk, with aHR of 1.79 (P < 0.001), 1.41 (P = 0.039), and 1.82 (P < 0.001) for osteoporosis, hip fracture, and vertebral fracture, respectively. Age- and sex-stratified analyses revealed similar patterns.

CONCLUSIONS

PPI use is associated with an increased risk of osteoporosis, hip fracture, and vertebral fracture in stroke patients.

[Proton pump inhibitors and kidney]

Assumed for a long time to be very well tolerated, proton pump inhibitors (PPIs) are widely prescribed for inpatients and outpatients; often beyond their validated indications. Nevertheless, many very varied side effects (pneumopathy, ischemic heart disease, dementia) have been associated with the PPIs during the last decade. Renal toxicity is mainly the occurrence of acute interstitial nephritis (AIN), related to a drug-class effect, involving cellular immunity. AINs, which occur especially in elderly patients, can be difficult to diagnose, with frequently isolated acute kidney injury, appearing with variable delay after the introduction of PPIs. Although sensitive to steroid therapy, patients frequently have an incomplete recovery of the kidney function. Very recently, the risk of chronic kidney disease (CKD) and the risk of progression of CKD among PPIs users have been well demonstrated in several large independent epidemiological studies. It is a low, but a significant side effect because of the millions of PPI prescriptions. Although further studies are needed to investigate the pathophysiological mechanisms leading the use of PPI to CKD, it is appropriate for the physicians to limit PPIs to their correct indications and to monitor renal function during these treatments.