Bone mineral density and mortality in end-stage renal disease patients

Effect of kidney function on 30 day post-operative complications and mortality following ankle fracture ORIF

BACKGROUND

Estimated glomerular filtration rate (eGFR) is commonly used to evaluate kidney function before surgery, but research on its impact on outcomes after ankle fracture open reduction and internal fixation (ORIF) is limited. This study aims to analyze how eGFR affects short-term complications and mortality following ankle fracture ORIF.

METHODS

The American College of Surgeons (ACS) NSQIP database was queried from 2005 to 2019 to identify 44,755 patients who underwent ankle fracture ORIF using specific CPT codes. Patients were excluded for missing demographic data or preoperative eGFR exceeding 3 standard deviations above the mean (91.1 mL/min/1.73 m²). Patients were categorized by eGFR: end stage renal disease (ESRD) (<15 mL/min/1.73 m2 [1.39 %]), severe loss of kidney function (15-30 mL/min/1.73 m2 [2.32 %]), moderate loss of kidney function (30-60 mL/min/1.73 m2 [15.45 %]), mild loss of kidney function (60-90 mL/min/1.73 m2 [33.78 %]), normal kidney function (90-120 mL/min/1.73 m2 [29.47 %]), and hyperfiltration (>120 mL/min/1.73 m2 [17.57 %]). Demographics, hospital length of stay, 30-day complications, surgical site infections (SSI), Clavien-Dindo grade IV complications, readmissions, reoperations, and mortality rates were compared. The cohort was primarily female (64.5 %), with a mean age of 55.41 years (range, 16-89).

RESULTS

A total of 21,815 patients were included, with about 30 % having an eGFR of 90-120 mL/min/1.73 m², indicating "normal" kidney function. As eGFR decreased, patient age (p < .001), BMI (p < .001), female sex rate (p < .001), and comorbidities significantly increased. Multivariate regression analysis showed that compared to normal eGFR (>90), patients with ESRD or moderate to severe kidney loss had a significantly higher risk of complications (ESRD: OR=1.576; p = .028)(15-30: 1.978; p < .001), reoperation (ESRD: OR=1.872; p = .039)(30-60: 1.523; p = .012), and readmission (ESRD: OR=1.784; p = .013)(30-60: 1.389; p = .012).

CONCLUSION

In patients undergoing ankle fracture ORIF, worse kidney function, as indicated by eGFR, was significantly linked to higher rates of postoperative complications, reoperation, and readmission. Surgeons and patients should take these findings into account for those with reduced kidney function.

LEVEL OF EVIDENCE

Level III, Retrospective Cohort Study.

Synbiotics as a novel therapeutic approach for hyperphosphatemia and hyperparathyroidism in chronic kidney disease rats

Hyperphosphatemia and secondary hyperparathyroidism (SHPT) are the common complications found in CKD that lead to severe complications including mineral bone disease (MBD), vascular calcification (VC), and cardiovascular mortality. To mitigate hyperphosphatemia, SHPT and uremic toxemia, we supplemented cisplatin-induced CKD rats with a synbiotic composed of Lactobacillus salivarius LBR228, Bifidobacterium longum BFS309, fructo-oligosaccharide and chitosan oligosaccharide, with Lactobacillus casei as a standard probiotic control. After the 12 weeks experiment, rats supplemented with the synbiotic had lower serum phosphate, calcium-phosphorus product, serum parathyroid hormone, and indoxyl sulfate levels than untreated rats. The expression of type 1 RNA and protein expression were increased in rats treated with the synbiotics. Our result showed that synbiotic treatment alleviates hyperphosphatemia and SHPT, which are the main risks of MBD and VC. The mode of the synbiotic action is hypothesized to associate with the improvement of the tight junction and gut barrier, leading to the suppression of intestinal paracellular phosphate transport. This study demonstrated the beneficial effects of synbiotic treatment in the control of serum phosphate and parathyroid hormone in an animal model with CKD.

Super-high levels of serum intact-parathyroid hormone and bone turnover markers descended with recuperating allograft function and a short-term high-dose methylprednisolone during preoperative period of renal transplantation: a retrospective cohort study

Background

Secondary hyperparathyroidism is an important factor of chronic kidney disease-mineral and bone disorder (CKD-MBD), which frequently results in maintenance dialysis patients having super-high levels of serum intact-parathyroid hormone (iPTH) and bone turnover markers (BTMs). This study aimed to investigate the immediate changes of iPTH and BTMs levels after renal transplantation during the perioperative period, and to explore the allograft function rapid recovery and the effect of high-dose glucocorticoids on serum iPTH and BTMs.

Methods

Between April 2018 and August 2021, a total of 346 Chinese kidney transplantation (KT) recipients (median age, 34.0 years; 236 males and 110 females; median dialysis duration, 12 months) were enrolled in this retrospective cohort study. The included patients had been undergoing maintenance dialysis for at least three months before transplant, and all of them accepted short-term high-dose methylprednisolone (MP) to prevent allograft rejection in the perioperative period. Allograft functions were evaluated and divided into different groups accorded to the CKD staging on the postoperative fifth day. Serum beta C-terminal crosslinking telopeptide of type I collagen (β-CTX), type 1N-terminal propeptide (P1NP), osteocalcin (OC), and iPTH were measured from fasting morning blood samples before surgery and on the postoperative fifth day with an electro-chemiluminescence immunoassay analyzer (2012; Roche Diagnostics).

Results

Among the participants, the graft functions were in CKD-II (n=134), CKD-III (n=137), CKD-IV (n=24), and CKD-V (n=51) after the postoperative fifth day. The changes of P1NP level [-95.8 (-84.0 to -2.4) ng/mL] and the OC level [-88.0 (-96.9 to -42.9) ng/mL] were significantly greater than those of the β-CTX level [-62.3 (-73.6 to 0) pg/mL] and the iPTH level [-57.6 (-15.6 to 11.9) pg/mL] (P<0.001). In the CKD-V group, the changes of β-CTX level [-0.7 (-43.15 to 0) pg/mL (+15.7%, P=0.61)] and the iPTH level [-8.69 (226.73 to 17.79) pg/mL (-22.8%), P=0.36] were less than those of the CKD-II group (P<0.001). β-CTX, P1NP, and OC levels related with iPTH (r=0.413, 0.459, 0.482, respectively, P<0.001), and iPTH level with estimated glomerular filtration rate (eGFR; r=-0.474, P<0.001).

Conclusions

The super-high levels of BTMs and iPTH rapidly descended with recuperating allograft function during the short-term, indicating that improvement of current dialysis equipment to achieve clean up iPTH could more favorably decrease BMTs and improve CKD-MBD. Osteogenesis markers P1NP and OC still decreased and were not affected in CKD-V group, indicating that high-dose glucocorticoids might strongly inhibit osteoblast activity.

Impact of serum cholinesterase on calcified nodules in patients with stable coronary artery disease

BACKGROUND

Calcified nodules (CNs) are an advanced stage of coronary calcification that can have significant clinical implications. We investigated factors associated with CNs, the etiology of which is not fully understood.

METHODS

We retrospectively evaluated 619 patients with stable coronary artery disease who underwent intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI). CNs in the culprit lesion were evaluated via IVUS, and all-cause mortality and major cardiovascular and cerebrovascular events (MACCEs) were compared between the CN and non-CN groups.

RESULTS

The CN group ( n  = 40 patients) had a significantly lower survival rate and a higher incidence of MACCE than the non-CN group ( P  = 0.020 and P  < 0.001, respectively). Multivariate logistic regression analysis models revealed that chronic kidney disease and serum cholinesterase (ChE) level were associated with CN formation [odds ratio (OR): 3.15, 95% confidence interval (CI): 1.30-7.69, P  = 0.001 and OR: 0.94, 95% CI: 0.88-0.99, P  = 0.042]. The optimal cutoff of serum ChE level as per the receiver operating characteristic curve was 309 units/l (Area under the curve = 0.67, sensitivity = 93%, specificity = 40%, P  = 0.001). The low-ChE group divided according to the optimal cutoff value showed significantly higher cumulative incidence of MACCEs after PCI than the high-ChE group as per Kaplan-Meier analysis.

CONCLUSION

The presence of CNs is significantly associated with a poor prognosis and MACCE after PCI among patients with stable coronary artery disease. Serum ChE levels may affect CN formation.

The Quality of Life in Elderly Patients in Comprehensive Conservative Management or Hemodialysis: A Case-Control Study in Analogous Basal Conditions

BACKGROUND/OBJECTIVES

Comprehensive conservative management (CCM) is a viable treatment option for elderly patients with end-stage kidney disease (ESKD). However, it involves a significant change in dietary habits, such as adopting a low-protein diet. Therefore, it is crucial to understand its impact on the patient's quality of life (QoL), particularly when compared to hemodialysis (HD). The study aims to evaluate the differences in the QoL between patients undergoing CCM and HD.

METHODS

The study included 50 patients over 75 with ESKD, with 25 patients in the CCM group and 25 in the HD group. The CCM group followed a personalized low-protein diet, while the HD group did not have protein restrictions. Various parameters were assessed, including demographic data, urine output, blood tests, comorbidity index, Visual Analog Scale (VAS), and hospitalization. The SF-12 questionnaire assessed the QoL, and the Physical Composite Score (PCS) and Mental Composite Score (MCS) were calculated.

RESULTS

The study revealed no age and comorbidity index differences between CCM and HD patients. In contrast, CCM patients reported significantly better physical and mental well-being than HD patients. In univariate analysis, CCM (B 0.24, p = 0.001), protein intake (B -0.004, p = 0.008), hospitalization (B -0.18, p = 0.024), urine output (B 0.25, p = 0.001), and VAS (B -0.26, p < 0.001) influenced the PCS. At the same time, only the type of treatment (B = 0.15, p = 0.048), urine output (B 0.18, p = 0.02), and VAS (B -0.14, p = 0.048) influence the MCS. In contrast, in multivariate analysis, only CCM contributed to an improved PCS (B 0.19, p = 0.003) and MCS (B 0.16, p = 0.03), while a higher VAS worsened the PCS (B -0.24, p < 0.001) and MCS (B -0.157, p = 0.0024).

CONCLUSIONS

In elderly patients with similar basal conditions, health-related QoL perception is better in CCM than in HD patients.

Effect of denosumab on the incidence of fractures and mortality in patients undergoing hemodialysis: A retrospective cohort study

BACKGROUND

Patients undergoing hemodialysis are at an elevated risk of fractures; however, substantial evidence for osteoporosis treatment in this population is lacking. We explored the efficacy of denosumab, an anti-IgG2 antibody that targets the receptor activator of nuclear factor-kappa B ligand, in reducing fracture incidence and all-cause mortality in patients undergoing hemodialysis.

METHODS

This retrospective cohort study-conducted from December 2013 to December 2022-evaluated the effects of denosumab on fracture incidence and all-cause mortality. Patients who initiated denosumab treatment during the study period were defined as the denosumab group, while those without a history of denosumab administration were defined as the non-denosumab group. Kaplan-Meier curves and log-rank tests were used to assess survival and fracture/mortality risks, respectively. Cox proportional hazards models were used to analyze both fractures and all-cause mortality.

RESULTS

Among 214 patients undergoing hemodialysis, 52 (24.3%) received denosumab. The median age was 73.0 ± 11.5 years, with 92 (43.0%) females, and the median dialysis duration was 59 months (interquartile range, 6-126). During the study, thirty-seven non-denosumab-treated patients had fractures compared to eight in the denosumab group. No significant differences were observed in the unadjusted model (HR, 0.53; 95% confidence interval (CI), 0.24-1.14). Adjusting for competing mortality and clinical factors, the HR remained at 0.64 (95% CI, 0.27-1.51). Regarding all-cause mortality, we found a statistically significant difference in the unadjusted model (HR, 0.61 [95% CI, 0.38-0.98]). A significant reduction in mortality was observed in the adjusted model (HR, 0.46 [95% CI, 0.26-0.80]). Notably, the denosumab group showed a significant decrease in mortality, particularly in cardiovascular disease-related cases (HR, 0.33 [95% CI, 0.14-0.78]).

CONCLUSIONS

Denosumab may reduce all-cause mortality in patients undergoing hemodialysis, particularly in those with cardiovascular complications. This finding offers a promising direction for osteoporosis treatment in patients undergoing hemodialysis.

Association between CKD-MBD and hip-bone microstructures in dialysis patients

Background

The longitudinal changes in hip-bone microstructures and estimated bone strength in dialysis patients, and the impact of chronic kidney disease-mineral and bone disorder (CKD-MBD) biomarkers on these changes, remain insufficiently explored.

Methods

This retrospective study examined changes in cortical and trabecular bone compartments and estimated bone-strength indices, obtained by using 3D-SHAPER software, in the hip regions of 276 dialysis patients over up to 2.5 years. We used multivariate mixed models to investigate the associations between time-dependent CKD-MBD biomarkers and bone health metrics.

Results

There was a significant decrease in areal bone mineral density (aBMD), integral volumetric BMD (vBMD), trabecular vBMD, cortical thickness and cortical surface BMD (sBMD). Similar deteriorations were found in estimated bone-strength indices [cross-sectional area (CSA), cross-sectional moment of inertia (CSMI), section modulus (SM) and buckling ratio]. Neither serum calcium nor phosphate levels were significantly associated with changes in three-dimensional parameters or estimated bone-strength indices. In contrast, serum alkaline phosphatase levels showed a significant inverse correlation with aBMD and CSA. The intact-parathyroid hormone (i-PTH) was significantly inversely correlated with aBMD, integral vBMD, trabecular vBMD, cortical thickness, cortical vBMD, CSA, CSMI and SM. When applying the KDIGO criteria as a sensitivity analysis, the higher PTH group had significant negative associations with aBMD, integral vBMD, cortical vBMD, cortical thickness and cortical sBMD. Notably, the lower PTH group showed a positive significant correlation with integral vBMD and trabecular vBMD.

Conclusions

Elevated PTH, not low PTH, was associated with deterioration of hip-bone microstructures. Better management of PTH levels may play a crucial role in the hip-bone microstructure in dialysis patients.

Bilateral Femoral Neck Fractures in a 50-Year-Old Patient with Chronic Kidney Disease

BACKGROUND Renal osteodystrophy is a serious complication of advanced chronic kidney disease (CKD). It predisposes the patient to fragility fracture and an increased risk of mortality. CASE REPORT We present the case of a 50-year-old male patient with stage 4 CKD and consequent renal osteodystrophy, who presented with a history of a recent provoked seizure, a severe electrolyte imbalance, and excruciating pain in the hip region. He had no history of a fall or trauma. A radiographic evaluation confirmed the rare finding of a bilateral femoral neck fracture. Upon stabilizing the patient, he was surgically managed with a bilateral hemiarthroplasty. A postoperative radiograph revealed a well-fixed prosthesis with no post-surgical complications. The patient had a full recovery. At the last follow-up visit, the patient was fully functional and had resumed normal activities. CONCLUSIONS This is a rare report with unusual mechanism of injury, involving a case of bilateral femoral neck fragility fractures, secondary to renal osteodystrophy in a stage 4 CKD patient. It draws the attention of medical care providers to the high risk of femoral fragility fractures that are secondary to renal osteodystrophy. Hemiarthroplasty is a safe and highly efficacious surgical option for managing such cases. This case also reiterates the dire need for greater public awareness and knowledge of CKD. Early diagnosis and treatment can substantially mitigate the associated morbidity and mortality.

Impact of Parathyroidectomy Versus Oral Cinacalcet on Bone Mineral Density in Patients on Peritoneal Dialysis With Advanced Secondary Hyperparathyroidism: The PROCEED Pilot Randomized Trial

RATIONALE & OBJECTIVE

Parathyroidectomy and calcimimetics have been used to reduce fracture risk in patients with kidney failure and advanced secondary hyperparathyroidism (SHPT), but direct comparisons of these treatment approaches have not been implemented. This pilot study compared their effects on bone mineral density (BMD) in this patient population.

STUDY DESIGN

A prospective pilot open-label randomized trial.

SETTING & PARTICIPANTS

65 patients receiving maintenance peritoneal dialysis with advanced SHPT recruited from 2 university-affiliated hospitals in Hong Kong.

INTERVENTIONS

Total parathyroidectomy with forearm autografting versus oral cinacalcet treatment for 12 months.

OUTCOME

Prespecified secondary end points including changes in BMD z and T scores of femoral neck, lumbar spine, and distal radius 12 months after treatment initiation and also categorized as osteopenia or osteoporosis according to the World Health Organization.

RESULTS

Both total parathyroidectomy and cinacalcet significantly improved BMD of the lumbar spine and femoral neck over 12 months, but the total parathyroidectomy group had a greater increase than the cinacalcet-treated group (P<0.001). The proportion of study participants classified as having osteopenia/osteoporosis by femoral neck T-score fell from 78.2% to 51.7% in the total parathyroidectomy group (P<0.001) and from 65.7% to 52.0% in cinacalcet-treated group after 12 months (P=0.7). The proportion of participants with a T-score at the lumbar spine classified as osteopenia/osteoporosis fell from 53.1% to 31.0% in the total parathyroidectomy group (P=0.01) and from 59.4% to 53.8% with cinacalcet (P=0.3). No significant change was observed in BMD T or z score of the distal radius over 12 months with either intervention.

LIMITATIONS

Bone histology was not assessed, and the study duration was 12 months.

CONCLUSIONS

A large proportion of peritoneal dialysis patients with advanced SHPT had low bone densities and osteopenia/osteoporosis. Total parathyroidectomy increased the BMD of the lumbar spine and femoral neck and reduced osteopenia/osteoporosis more than oral cinacalcet.

FUNDING

Grants from academic (The University of Hong Kong Research) and not-for-profit (Hong Kong Society of Nephrology) entities.

REGISTRATION

Registered at Clinicaltrials.gov with study number NCT01447368.

PLAIN-LANGUAGE SUMMARY

It is not known whether oral cinacalcet and surgical parathyroidectomy differ in their effects on bone parameters in patients with advanced secondary hyperparathyroidism (SHPT) receiving peritoneal dialysis. This pilot randomized trial evaluated the effect of medical versus surgical therapy on bone mineral densities (BMD) as prespecified secondary study end points. The findings showed that a large proportion of peritoneal dialysis patients with advanced SHPT had low bone densities and osteopenia/osteoporosis. Parathyroidectomy increased the BMD of the lumbar spine and femoral neck more than cinacalcet over 12 months. Parathyroidectomy reduced the proportion of patients with osteopenia/osteoporosis at the lumbar spine and femoral neck more than cinacalcet after 12 months. Neither intervention led to an increase in the BMD of the distal radius over 12 months.

History of fragility fracture is associated with cardiovascular mortality in hemodialysis patients: the Q-Cohort study

INTRODUCTION

In patients undergoing dialysis, major bone fracture is associated with a high risk of mortality, including death of cardiovascular (CV) origin. In the present study, we aimed to determine whether a history of fragility fracture is a predictor of CV death in patients undergoing hemodialysis with long-term follow-up.

MATERIALS AND METHODS

In total, 3499 patients undergoing hemodialysis were analyzed for 10 years. We evaluated the history of fragility fracture in each patient at enrollment. The primary outcome was CV death. A Cox proportional hazard model and a competing risk approach were applied to determine the association between a history of fragility fracture and CV death.

RESULTS

A total of 346 patients had a history of fragility fracture at enrollment. During a median follow-up of 8.8 years, 1730 (49.4%) patients died. Among them, 621 patients experienced CV death. Multivariable Cox analyses after adjustment for confounding variables showed that a history of fragility fracture was associated with CV death (hazard ratio, 1.47; 95% confidence interval, 1.16-1.85). In the Fine-Gray regression model, a history of fragility fracture was an independent risk factor for CV death (subdistribution hazard ratio, 1.36; 95% confidence interval, 1.07-1.72).

CONCLUSION

In a large cohort of patients undergoing hemodialysis, a history of fragility fracture was an independent predictor of CV death.

Effect of osteosarcopenia on longitudinal mortality risk and chronic kidney disease progression in older adults

INTRODUCTION

Chronic kidney disease (CKD) causes a progressive loss of muscle and bone mass, which frequently overlap with and affect clinical outcomes. However, the impact of sarcopenia, low bone mineral density (BMD; osteopenia or osteoporosis), and osteosarcopenia (sarcopenia and low BMD) on CKD progression is yet to be determined. We aimed to address these issues in patients with CKD without kidney replacement therapy (KRT).

METHODS

This prospective cohort study included 251 outpatients aged ≥65 years with CKD without KRT enrolled in our hospital between June 2016 and March 2017. Sarcopenia was defined according to the 2014 criteria of the Asian Working Group for Sarcopenia (AWGS), and low BMD was defined as a T-score of ≤-1.0. The patients were divided into four groups: normal (no sarcopenia/normal BMD), only low BMD (no sarcopenia/low BMD), only sarcopenia (sarcopenia/normal BMD), and osteosarcopenia (sarcopenia/low BMD). The primary outcome was a composite of all-cause deaths, initiating KRT, and admissions owing to major adverse cardiovascular and cerebrovascular events (MACEs). The secondary outcome was a kidney composite outcome that included a 30 % reduction in creatinine-based estimated glomerular filtration rate (eGFR) and initiating KRT. The outcome risk was determined using the Cox regression models adjusted for potential confounders.

RESULTS

Median age (25th-75th percentile) and eGFR of the outpatients (35 % women) were 76 (69-81) years and 32.1 (20.8-41.7) ml/min/1.73 m2, respectively. During a median follow-up period of 5.2 years, there were 22 deaths, 117 30 % eGFR reductions, 48 KRTs, and 18 admissions owing to MACEs. The osteosarcopenia group rather than the only low BMD or only sarcopenia groups exhibited a higher risk of the primary (hazard ratio [HR]: 3.28, 95 % confidence interval [CI]: 1.52-7.08) and kidney composite (HR: 2.07, 95 % CI: 1.10-3.89) outcomes. Among the osteosarcopenia-related body compositions and physical functions, low handgrip strength (HGS) was strongly associated with a high risk of primary and kidney composite outcomes (HR: 2.44, 95 % CI: 1.46-4.08; HR: 1.48, 95 % CI: 0.97-2.24, respectively). The increase in HGS but not the body mass index, skeletal muscle mass index, or BMD was associated with lower risks of primary and kidney composite outcomes (HR: 0.93, 95 % CI: 0.89-0.98; HR: 0.96, 95 % CI: 0.92-0.99 per 1 kg, respectively).

CONCLUSIONS

Osteosarcopenia was associated with poor survival and kidney outcomes in older patients with CKD. Low HGS, which is common in patients with osteosarcopenia and CKD, was associated with increased mortality risk and kidney function decline. These findings can help the risk prediction and pathogenesis of the kidney-bone-muscle axis and improving muscle strength can help mitigate CKD progression.

Poor prognosis and risk factors of nonoperative treatment hip fracture patients with end-stage renal disease

This study aims to summarize the prognosis and risk factors of nonoperative treatment patients of hip fracture with end-stage renal disease (ESRD). A total of 113 individuals of hip fracture with nonoperative treatment were retrospectively enrolled, 38 patients with ESRD were defined as the observation group, and the other 75 patients without ESRD were served as the control group. The difference in 30-day and 1-year mortality rate between the 2 groups was compared. The effects of risk factors on survival were estimated by the Cox proportional-hazards model. The survival difference was estimated by the method of Kaplan-Meier. In the subsequent subgroup analysis of the observation group, as before, the Cox proportional-hazards model and the Kaplan-Meier method were used. The 1-year mortality rate of the observation group was considerably higher than that of the control group, which was 86.84% and 32.0%, respectively (P < .005). For nonoperative treatment hip fracture subjects, ESRD, age ≥ 82, BMI (BMI) < 20, high Charlson Comorbidity Index (CCI) and low Barthel Index (BI) were associated with a low survival curve (P < .05). In the subsequent multivariable subgroup analyses, for nonoperative treatment hip fracture subjects with ESRD, high CCI and low BI were also the independent risk factors of mortality. For nonoperative treatment hip fracture subjects, ESRD, old age, low BMI, high CCI and low BI were the independent risk factors of mortality. For hip fracture subjects with ESRD, nonoperative treatment was associated with excess high 1-year mortality rate, especially for patients with high CCI and low BI.

Long-Term Effect of Denosumab on Bone Disease in Patients with CKD

BACKGROUND

The effect of long-term denosumab therapy and of denosumab discontinuation on the cortical bone of the hip regions in dialysis patients has not been studied.

METHODS

This retrospective study investigated the cortical and trabecular compartments and estimated strength indices of the hip region, obtained using 3D-SHAPER software, after a maximum of 5 years of denosumab therapy in 124 dialysis patients. A Wilcoxon signed-rank test was used to identify the differences in each parameter before and after denosumab initiation. Similarly, we investigated the changes in these parameters after denosumab discontinuation in 11 dialysis patients.

RESULTS

Integral and trabecular volumetric bone mineral densities (BMD) were significantly lower at the start of denosumab therapy than those in 1 year before denosumab initiation. After starting denosumab, areal BMD (median change +7.7% [interquartile range (IQR), +4.6 to +10.6]), cortical volumetric BMD (median change +3.4% [IQR, +1.0 to +4.7]), cortical surface BMD (median change +7.1% [IQR, +3.4 to +9.4]), and cortical thickness (median change +3.2% [IQR, +1.8 to +4.9]) showed a significantly higher trend for 3.5 years, which then stabilized at a higher value compared with baseline. A similar trend in the trabecular volumetric BMD (median change +9.8% [IQR, +3.8 to +15.7]) was observed over 2.5 years, with a higher value maintained thereafter. The whole area of the hip region improved after denosumab therapy. Similar trajectories were also found in the estimated strength indices. Conversely, at 1 year after denosumab discontinuation, these 3D parameters and estimated strength indices tended to largely worsen. The lateral aspect of the greater trochanter was the most pronounced location showing volumetric BMD loss.

CONCLUSIONS

The BMD of both cortical and trabecular components in the hip region was significantly higher after starting denosumab therapy. However, these measurements exhibited a trend of declining substantially after the discontinuation of denosumab.

Stroke and kidney transplantation

PURPOSE OF REVIEW

This review will focus on the epidemiological data, risk factors, and management of stroke before and after kidney transplant. Stroke is highly prevalent in waitlisted patients as well as kidney transplant recipients and is associated with impaired transplant outcomes. Multiple traditional, nontraditional, and transplanted risk factors increase the risk of stroke.

RECENT FINDINGS

Although the risk of stroke is reduced after kidney transplantation compared with remaining on dialysis, the morbidity and mortality from stroke after transplantation remain significant.

SUMMARY

Early screening for risk factors before and after a kidney transplant and following the Kidney Disease Improving Global Outcomes (KDIGO) management guidelines could minimize the incidence of stroke and transplant outcomes.

How is exercise being prescribed for patients on hemodialysis? A scoping review

BACKGROUND

Exercise is important for patients on hemodialysis, but details and descriptions on how it is prescribed are lacking. We reviewed the existing literature and described how exercise is being prescribed for patients on hemodialysis.

METHODS

A scoping review according to the JBI and PRISMA-ScR guidelines was conducted. MEDLINE, EMBASE and other databases were searched from inception until December 2021. Websites, books, and guidelines were also searched. We included evidence from patients on hemodialysis, describing exercise protocols, in all settings and designs.

RESULTS

Two hundred and eighty-five studies were included, yielding 327 exercise protocols. Aerobic (38.8%) and strength (21.4%) were the most prescribed exercise types. Exercise was mainly prescribed during dialysis (71.0%) and delivered within the first half of the session (94.6%). Although 33.3% of the exercise protocols did not report whether there was supervision or not, those that did were mostly delivered by physiotherapists (20.5%) and exercise physiologists (17.4%). The most followed exercise training principles were type (99.0%) and frequency (93.2%), whereas progression was adopted in 40.7% protocols. The most prescribed frequency and duration were three times/week (79.9%) and 30-60-min (69.2%) sessions, respectively. Exercise intensity was predominantly prescribed in moderate cut-offs (72.3%), mostly assessed by subjective methods (47.5%).

CONCLUSIONS

Aerobic and strength were the most prescribed exercise types, mainly during dialysis. Interventions were mostly supervised by physiotherapists and exercise physiologists. Future exercise protocols for patients on hemodialysis should adopt recommended exercise principles, especially with systematic progression.

Role of nutritional vitamin D in chronic kidney disease-mineral and bone disorder: A narrative review

Chronic kidney disease-mineral and bone disorder has complex and diverse clinical manifestations, including the simplest abnormalities of calcium, phosphorus and parathyroid hormone detected in blood, abnormalities of bone transformation and mineralization in bone, and calcification of blood vessels or other soft tissues detected on imaging. Patients with CKD-MBD combined low bone mineral density and fragility fractures are referred to as CKD-MBD with low bone mineral density. Vascular calcification refers to ectopic deposition of calcium phosphate in the blood vessel walls and heart valves. The degree of vascular calcification was inversely proportional to bone mineral density. The more severe the degree of vascular calcification, the lower the bone mineral density, and the higher the risk of death, indicating that the bone-vascular axis exists. Activation and alteration of the Wnt signaling pathway are central to the treatment of vascular diseases in uremia. Vitamin D supplementation can prevent secondary hyperparathyroidism, activate osteoblasts, relieve muscle weakness and myalgia, and reduce vascular calcification. Nutritional vitamin D may improve vascular calcification in uremia patients by regulating Wnt signaling pathway.

Role of galectin-3 in vascular calcification

Vascular calcification is an abnormal process in which bone specific hydroxyapatite crystals are actively deposited on the vascular wall mediated by phenotypic differentiated smooth muscle cells and other mesenchymal cells under various pathological conditions. It is one of the important characteristics in the occurrence and development of atherosclerosis, prevalent in patients with type 2 diabetes and advanced chronic kidney disease, especially those requiring maintenance hemodialysis, with severely threatening human health. Previous studies have shown that the early diagnosis and control of vascular calcification is of great significance for cardiovascular risk stratification, prevention of acute cardiovascular events, which can greatly improve the prognosis and quality of life of patients. Galectins are a family of lectin superfamily. It is widely distributed in various animals and plays an important role in many physiological and pathological processes, such as cell adhesion, apoptosis, inflammatory response, tumor metastasis and so on. Many biomarker-and association-related studies and Preclinical-mechanistic studies have suggested that galactose-specific lectin-3 (galectin-3) plays an important role in vascular calcification and vascular intimal calcification (VIC) calcification induced by Wnt/βcatenin signaling pathway, NF-κB signaling pathway and ERK1/2 signaling pathway. This paper mainly expounds the role and mechanism of galectin-3 in vascular calcification under different pathological conditions including atherosclerosis, diabetes and chronic kidney disease.

Serum calcification propensity and its association with biochemical parameters and bone mineral density in hemodialysis patients

BACKGROUND

T50 is a novel serum-based marker that assesses the propensity for calcification in serum. A shorter T50 indicates a greater propensity to calcify and has been associated with cardiovascular disease and mortality among patients with chronic kidney disease. The factors associated with T50 and the correlation between T50 and bone mineral density (BMD) are unknown in hemodialysis (HD) patients.

METHODS

This cross-sectional study included 184 patients undergoing HD. Individuals were grouped into tertiles of T50 to compare the demographic and disease indicators of the tertiles. Linear regression was used to evaluate the association between T50 and hip and spinal BMD in a multivariate model.

RESULTS

Mineral and inflammatory parameters, including serum phosphate (r = -0.156, p = 0.04), albumin (r = 0.289, p < 0.001), and high-sensitivity C-reactive protein (r = -0.224, p = 0.003) levels, were associated with T50. We found a weak association between T50 and BMD in the total hip area in the unadjusted model (β = 0.030, p = 0.04) but did not find a statistically significant association with the total hip (β = 0.017, p = 0.12), femoral neck (β = -0.001, p = 0.96), or spinal BMD (β = 0.019, p = 0.33) in multivariable-adjusted models.

CONCLUSION

T50 was moderately associated with mineral and inflammatory parameters but did not conclusively establish an association with BMD in HD patients. Broad-scale future studies should determine whether T50 can provide insights into BMD beyond traditional risk factors in this population.

Prevalence of low bone mineral density (T-score ≤ - 2.5) in the whole spectrum of chronic kidney disease: a systematic review and meta-analysis

The prevalence of low bone mineral density (LBMD) in people with chronic kidney disease (CKD) remains unknown. We identified a high prevalence of LBMD in CKD population. Thus, public health strategies should include efforts to prevent, early detect, and manage LBMD in CKD patients, especially in patients undergoing kidney replacement therapy. Mineral and bone disorders are common among patients with CKD, which affects bone mineral density. We conducted a systematic review and meta-analysis to estimate the prevalence of low bone mineral density (LBMD) in adults with CKD. We searched MEDLINE, EMBASE, Web of Science, CINAHL, and LILACS databases from inception to February 2021. Observational studies that reported the prevalence of LBMD in adults with CKD stages 3a-5D were included. The LBMD was defined according to the World Health Organization criterion (T-score ≤  - 2.5). Random-effect model meta-analyses were used to estimate the pooled prevalence of LBMD. Meta-regressions and subgroup analyses were conducted for stages of CKD, dialysis modality, gender, bone sites and morphology, and geographical region. This study was registered in PROSPERO, number CRD42020211077. One-hundred and fifty-three studies with 78,092 patients were included. The pooled global prevalence of LBMD in CKD was 24.5% (95% CI, 21.3 - 27.8%). Subgroup analyses indicated a higher prevalence of LBMD in dialysis patients (30%, 95% CI 25 - 35%) compared with non-dialysis CKD patients (12%, 95% CI 8 - 16%), cortical bone sites (28%, 95% CI 23 - 35%) relative to trabecular sites (19%, 95% CI 14 - 24%), while similar estimates in the European and the Asiatic continents (26%, 95% CI 21 - 30% vs 25%, 95% CI 21 - 29). The prevalence of LBMD in CKD patients is high, particularly in those undergoing dialysis and in cortical bone sites. Therefore, efforts to early diagnosis and management strategies should be implemented in clinical routine for an epidemiological control of LBMD in CKD patients.

Bone Mineral Density and All-Cause Mortality in Patients with Nondialysis Chronic Kidney Disease: Results from KNOW-CKD Study

Despite the clear association between low BMD and all-cause mortality in the general population, the association has not been validated in patients with nondialysis CKD. To investigate the association of low BMD with all-cause mortality in this population, a total of 2089 patients with nondialysis CKD at stages 1 to predialysis 5 were categorized into normal BMD (T-score ≥ -1.0), osteopenia (-2.5 < T-score < -1.0), and osteoporosis (T-score ≤ - 2.5) by the BMD at femoral neck. The study outcome was all-cause mortality. Kaplan-Meier curve depicted a significantly increased number of all-cause death events in the subjects with osteopenia or osteoporosis during the follow-up period compared with subjects with normal BMD. Cox regression models demonstrated that osteoporosis, but not osteopenia, was significantly associated with an increased risk of all-cause mortality (adjusted hazard ratio 2.963, 95% confidence interval 1.655 to 5.307). Smoothing curve fitting model visualized a clear inverse correlation between BMD T-score and the risk of all-cause mortality. Even after recategorizing the subjects by BMD T-scores at total hip or lumbar spine, the result was similar to the primary analyses. Subgroup analyses revealed that the association was not significantly modified by clinical contexts, such as age, gender, body mass index, estimated glomerular filtration rate, and albuminuria. In conclusion, low BMD is associated with an increased risk of all-cause mortality in patients with nondialysis CKD. This emphasizes that the routine measurement of BMD by DXA may confer an additional benefit beyond the prediction of fracture risk in this population.

Serum Intact Fibroblast Growth Factor 23 Levels Are Negatively Associated with Bone Mineral Density in Chronic Hemodialysis Patients

(1) Background: Fibroblast growth factor 23 (FGF23) is predominantly secreted from bone and plays an important role in mineral balance in chronic kidney disease. However, the relationship between FGF23 and bone mineral density (BMD) in chronic hemodialysis (CHD) patients remains unclear. (2) Methods: This was a cross-sectional observational study that involved 43 stable outpatients on CHD. A linear regression model was used to determine risk factors for BMD. Measurements included serum hemoglobin, intact FGF23 (iFGF23), C-terminal FGF23 (cFGF23), sclerostin, Dickkopf-1, α-klotho, 1,25-hydroxyvitamin D, intact parathyroid hormone levels and dialysis profiles. (3) Results: Study participants had a mean age of 59.4 ± 12.3 years, and 65% were male. In the multivariable analysis, cFGF23 levels showed no significant associations with the BMD of the lumbar spine (p = 0.387) nor that of the femoral head (p = 0.430). However, iFGF23 levels showed a significant negative association with the BMD of the lumbar spine (p = 0.015) and that of the femoral neck (p = 0.037). (4) Conclusions: Among patients on CHD, higher serum iFGF23 levels, but not serum cFGF23 levels, were associated with lower BMD values of the lumbar spine and femoral neck. However, further research is required to validate our findings.

Evaluation of the Association between Low-Density Lipoprotein (LDL) and All-Cause Mortality in Geriatric Patients with Hip Fractures: A Prospective Cohort Study of 339 Patients

BACKGROUND

Many factors affect the prognosis of hip fractures in the elderly. Some studies have suggested a direct or indirect association among serum lipid levels, osteoporosis, and hip fracture risk. LDL levels were found to have a statistically significant nonlinear U-shaped relationship with hip fracture risk. However, the relationship between serum LDL levels and the prognosis of patients with hip fractures remains unclear. Therefore, in this study, we assessed the influence of serum LDL levels on patient mortality over a long-term follow-up period.

METHODS

Elderly patients with hip fractures were screened between January 2015 and September 2019, and their demographic and clinical characteristics were collected. Linear and nonlinear multivariate Cox regression models were used to identify the association between LDL levels and mortality. Analyses were performed using Empower Stats and R software.

RESULTS

Overall, 339 patients with a mean follow-up period of 34.17 months were included in this study. Ninety-nine patients (29.20%) died due to all-cause mortality. Linear multivariate Cox regression models showed that LDL levels were associated with mortality (HR = 0.69, 95%CI: 0.53, 0.91, p = 0.0085) after adjusting for confounding factors. However, the linear association was unstable, and nonlinearity was identified. An LDL concentration of 2.31 mmol/L was defined as the inflection point for prediction. A LDL level < 2.31 mmol/L was associated with mortality (HR = 0.42, 95%CI: 0.25, 0.69, p = 0.0006), whereas LDL > 2.31 mmol/L was not a risk factor for mortality (HR = 1.06, 95%CI: 0.70, 1.63, p = 0.7722).

CONCLUSIONS

The preoperative LDL level was nonlinearly associated with mortality in elderly patients with hip fractures, and the LDL level was a risk indicator of mortality. Furthermore, 2.31 mmol/L could be considered a predictor cut-off for risk.

The Association of Beta-Blocker Use and Bone Mineral Density Level in Hemodialysis Patients: A Cross-Sectional Study

Background and Objectives: Osteoporosis results in increasing morbidity and mortality in hemodialysis patients. The medication for treatment has been limited. There is evidence that beta-blockers could increase bone mineral density (BMD) and reduce the risk of fracture in non-dialysis patients, however, a study in hemodialysis patients has not been conducted. This study aims to determine the association between beta-blocker use and bone mineral density level in hemodialysis patients. Materials and Methods: We conducted a cross-sectional study in hemodialysis patients at Thammasat University Hospital from January 2018 to December 2020. A patient receiving a beta-blocker ≥ 20 weeks was defined as a beta-blocker user. The association between beta-blocker use and BMD levels was determined by univariate and multivariate linear regression analysis. Results: Of the 128 patients receiving hemodialysis, 71 were beta-blocker users and 57 were non-beta-blocker users (control group). The incidence of osteoporosis in hemodialysis patients was 50%. There was no significant difference in the median BMD between the control and the beta-blocker groups of the lumbar spine (0.93 vs. 0.91, p = 0.88), femoral neck (0.59 vs. 0.57, p = 0.21), total hip (0.73 vs. 0.70, p = 0.38), and 1/3 radius (0.68 vs. 0.64, p = 0.40). The univariate and multivariate linear regression analyses showed that the beta-blocker used was not associated with BMD. In the subgroup analysis, the beta-1 selective blocker used was associated with lower BMD of the femoral neck but not within the total spine, total hip, and 1/3 radius. The multivariate logistic regression showed that the factors of age ≥ 65 years (aOR 3.31 (1.25−8.80), p = 0.02), female sex (aOR 4.13 (1.68−10.14), p = 0.002), lower BMI (aOR 0.89 (0.81−0.98), p = 0.02), and ALP > 120 U/L (aOR 3.88 (1.33−11.32), p = 0.01) were independently associated with osteoporosis in hemodialysis patients. Conclusions: In hemodialysis patients, beta-blocker use was not associated with BMD levels, however a beta-1 selective blocker used was associated with lower BMD in the femoral neck.

Crosstalk between bone and muscle in chronic kidney disease

With increasing life expectancy, the related disorders of bone loss, metabolic dysregulation and sarcopenia have become major health threats to the elderly. Each of these conditions is prevalent in patients with chronic kidney disease (CKD), particularly in more advanced stages. Our current understanding of the bone-muscle interaction is beyond mechanical coupling, where bone and muscle have been identified as interrelated secretory organs, and regulation of both bone and muscle metabolism occurs through osteokines and myokines via autocrine, paracrine and endocrine systems. This review appraises the current knowledge regarding biochemical crosstalk between bone and muscle, and considers recent progress related to the role of osteokines and myokines in CKD, including modulatory effects of physical exercise and potential therapeutic targets to improve musculoskeletal health in CKD patients.

Radiofrequency echographic multi-spectrometry and DXA for the evaluation of bone mineral density in a peritoneal dialysis setting

BACKGROUND

The aim of this real-life cross-sectional explorative study was to compare radiofrequency echographic multi-spectrometry (REMS) with dual-energy X-rays absorptiometry (DXA) in the BMD assessment of patients receiving peritoneal dialysis (PD). Furthermore, we investigated the relationship between lumbar aortic calcifications (AOCs) and the DXA lumbar measurements.

METHODS

Consecutive patients referring to the PD clinic of our hospital were included. Lumbar spine and femur scans were acquired with both techniques (including lumbar laterolateral DXA scans). The risk assessment of two fracture risk algorithms (FRAX^® and DeFRA^®) were compared. Cohen's k coefficients were used to assess the inter-technique agreement in the classification of patients as osteoporotic. Lumbar AOCs were estimated semi-quantitatively on laterolateral DXA scans.

RESULTS

41 patients were enrolled. No significant differences were documented between the BMD T-scores measured through DXA or REMS at the femur. At the lumbar spine, the DXA anteroposterior mean T-score (- 0.49 ± 1.98) was significantly higher than both the laterolateral DXA (- 1.66 ± 0.99) and the REMS (- 2.00 ± 1.94) measurements (p < 0.01 vs both). No significant differences were found between the DXA and REMS fracture risk estimates with both algorithms. The inter-technique Cohen's k coefficient (for the worst T-score, any site) was 0.421, p < 0.001. The discrepancy between the DXA laterolateral and anteroposterior lumbar T-score was positively associated with the AOCs extent and severity (r = 0.402, p < 0.01).

CONCLUSIONS

Our data showed a promising agreement, in a real-life PD setting, between DXA and REMS BMD assessment and in the consequent fracture risk estimation and confirm the AOCs interference on the diagnostic accuracy of lumbar DXA.

Association of Chronic Kidney Disease and Complications Following Acute Torsional Ankle Fracture

BACKGROUND

Although chronic kidney disease (CKD) has been associated with poor outcomes following traumatic fractures, there is a scarcity of literature describing the effect on outcomes of ankle fractures. We will examine the impact of CKD on clinical outcomes following torsional ankle fracture, including complications and unplanned surgical procedures.

METHODS

A retrospective review of 1981 adult patients with torsional ankle fractures treated at a level 1 trauma center was performed to identify patients with CKD based on glomerular filtration rate. Demographic, injury, and treatment-related characteristics were collected. Outcomes included any unplanned procedure: implant removal, debridement, revision, arthrodesis, and amputation; in addition to complications of superficial infection, deep infection, and implant irritation. Patients with CKD were matched with patients without CKD by propensity score matching. Univariate comparisons between groups were conducted using chi-square and Mann-Whitney U tests.

RESULTS

136 patients (68 with CKD and 68 without CKD) were analyzed. Of the 68 patients with CKD, the mean stage of disease was 3.7 with 24% on dialysis for a mean length of 4.1 years. Patients without CKD were more likely to undergo primary ORIF (100% vs 54%, P < .001). Thirty-five percent of patients with CKD had surgical complications vs 19% in the cohort without (P = .07). Patients with open fractures, dislocation, and chronic kidney disease were, respectively, 5.19, 3.77, and 3.91 times more likely to have any complication (P = .02, P = .05, P = .05). Patients with CKD were more likely to undergo unplanned arthrodesis (P = .01). Only dislocation was an independent predictor for unplanned procedure (odds ratio = 5.08, P = .026).

CONCLUSION

Following torsional ankle fracture, CKD is associated with increased likelihood of having a complication or an unplanned arthrodesis. Open fractures and dislocation at time of injury are also associated with complications. Our findings encourage caution about surgical treatment of ankle fractures in patients with CKD.

LEVEL OF EVIDENCE

Level III, retrospective, comparative, prognostic.

Irisin and Bone in Sickness and in Health: A Narrative Review of the Literature

Irisin is a hormone-like myokine produced by the skeletal muscle in response to exercise. Upon its release into the circulation, it is involved in the browning process and thermogenesis, but recent evidence indicates that this myokine could also regulate the functions of osteoblasts, osteoclasts, and osteocytes. Most human studies have reported that serum irisin levels decrease with age and in conditions involving bone diseases, including both primary and secondary osteoporosis. However, it should be emphasized that recent findings have called into question the importance of circulating irisin, as well as the validity and reproducibility of current methods of irisin measurement. In this review, we summarize data pertaining to the role of irisin in the bone homeostasis of healthy children and adults, as well as in the context of primary and secondary osteoporosis. Additional research is required to address methodological issues, and functional studies are required to clarify whether muscle and bone damage per se affect circulating levels of irisin or whether the modulation of this myokine is caused by the inherent mechanisms of underlying diseases, such as genetic or inflammatory causes. These investigations would shed further light on the effects of irisin on bone homeostasis and bone disease.

Significant associations between bone mineral density and vascular calcification in patients with different stages of chronic kidney disease

Introduction

Chronic kidney disease—mineral and bone disorders (CKD-MBD) is characterised by generalised vascular calcification (VC) and impaired bone health. We aimed to investigate the relationship between VC and bone mineral density (BMD) in CKD patients.

Methods

We performed a cross-sectional study of patients with different stages of CKD. For assessment of VC of abdominal aorta lateral lumbar X-rays (Kauppila score), the ankle-brachial index (ABI) and echocardiography were used. Total body densitometry provided BMD.

Results

Ninety patients (41% male, median age 64 years (range 29–87)) were included, of whom 41.1% had a Kauppila score > 1. Evidence of peripheral VC as measured by ABI was detected in 23.3% of cases. Lesions of the heart valves were found in 46.7% of patients. There was a significant association between high ABI and lesions of the heart valves. In the multivariate regression model to analyse the independent determinants of abdominal aorta calcification (AAC) and ABI, the BMD of the femoral neck was identified as significant for both (p = 0.001, p = 0.001). The total spine BMD was found to be significant for AAC (p = 0.001), and the BMD of spine L1-L4 and the ribs were found to be significant for ABI (p = 0.01, p = 0.002 respectively). In factorial regression analysis, where BMD was independent determinant, valvular calcification was significant for BMD of femur, femoral neck and total BMD. Age and tALP were inversely correlated with the BMD of femur and femoral neck.

Conclusions

Our work highlighted clinically important relationships between VC and bone mineral density (BMD) in CKD patients. We detected inverse relationships between AAC, high ABI and BMD. Secondly, BMD at certain bone sites (femur, femoral neck) and total BMD were associated with important lesions of heart valves. Thirdly, a significant association between a high ABI and lesions of the heart valves. We believe that the results of our study will help in the planning of future research and in current clinical practice for the early diagnosis, further monitoring and management of CKD-MBD. Additionally, these results may have treatment implications on use of different CKD-MBD medications.

Influence of type 2 diabetes microangiopathy on bone mineral density and bone metabolism: A meta-analysis

BACKGROUND

Diabetic microangiopathy is a type of vascular dysfunction. The effect of type 2 diabetes microangiopathy (DMA) on bone mineral density (BMD) and bone metabolism is still unclear.

OBJECTIVE

A meta-analysis was performed to investigate the effects of microangiopathy on BMD and bone metabolism in type 2 diabetic patients.

METHODS

We searched the PubMed, Embase, Cochrane Library and CNKI databases to identify observational studies investigating the effects of type 2 diabetes microangiopathy on BMD or bone metabolism. The time limit for the literature retrieval was from the establishment of the database to September 25, 2021. The Newcastle-Ottawa scale (NOS) and the Agency for Healthcare Research and Quality (AHRQ) scale were used to evaluate the quality of the studies. RevMan 5.3 software was used for the data analysis. Stata 14.0 was used to quantitatively evaluate the publication bias of the outcome indicators.

RESULTS

In total, 12 observational studies were included, including 7 cohort studies, 4 case-control studies and 1 cross-sectional study. In total, 2,500 patients with type 2 diabetes were included. Among them, 1,249 patients had microangiopathy (DMA group), and 1,251 patients did not have microangiopathy (control group). The results of the meta-analysis showed that the BMDs of the femoral neck (SMD = -1.34, 95% CI = -2.22 to -0.45, P = 0.003), lumbar spine (SMD = -0.69, 95% CI = -1.31 to -0.08, P = 0.03) and Ward's triangle (SMD = -2.84, 95% CI = -4.84 to -0.83, P = 0.006) in the DMA group were lower than those in the control group. In the comparison of the bone metabolism indexes, the contents of N-terminal propeptide of type I procollagen (P1NP) (SMD = 0.18, 95% CI = 0.03 to 0.32, P = 0.02), osteocalcin (SMD = 6.97, 95% CI = 3.46 to 10.48, P < 0. 0001), parathyroid hormone (PTH) (SMD = 0.38, 95% CI = 0.03 to 0.73, P = 0.03) and C-telopeptide of type 1 collagen (CTX) (SMD = 0.39, 95% CI = 0.03 to 0.75, P = 0.03) in serum from the DMA group were higher than those in serum from the control group. The serum content of 25-hydroxyvitamin D3 (25(OH)D3) (SMD = -0.63, 95% CI = -1.19 to -0.07, P = 0.03) in the DMA group was lower than that in the control group. There was no significant difference in serum alkaline phosphatase (ALP), calcium or phosphorus between the two groups (P > 0.05).

CONCLUSIONS

Type 2 diabetes microangiopathy can reduce the lumbar spine, femoral neck and Ward's triangle BMD and has a higher risk of osteoporosis or osteoporosis fractures. The levels of P1NP, PTH, CTX and OC in the serum of patients with type 2 diabetes microangiopathy are higher, and the lower 25(OH)D3 content may be a mechanism by which DMA destroys bone metabolism balance.

Inactivation of Osteoblast PKC Signaling Reduces Cortical Bone Mass and Density and Aggravates Renal Osteodystrophy in Mice with Chronic Kidney Disease on High Phosphate Diet

Chronic kidney disease (CKD) frequently leads to hyperphosphatemia and hyperparathyroidism, mineral bone disorder (CKD-MBD), ectopic calcifications and cardiovascular mortality. PTH activates the osteoanabolic Gα_s/PKA and the Gα_q/11/PKC pathways in osteoblasts, the specific impact of the latter in CKD-MBD is unknown. We generated osteoblast specific Gα_q/11 knockout (KO) mice and established CKD-MBD by subtotal nephrectomy and dietary phosphate load. Bone morphology was assessed by micro-CT, osteoblast function by bone planar scintigraphy at week 10 and 22 and by histomorphometry. Osteoblasts isolated from Gα_q/11 KO mice increased cAMP but not IP3 in response to PTH 1-34, demonstrating the specific KO of the PKC signaling pathway. Osteoblast specific Gα_q/11 KO mice exhibited increased serum calcium and reduced bone cortical thickness and mineral density at 24 weeks. CKD Gα_q/11 KO mice had similar bone morphology compared to WT, while CKD Gα_q/11-KO on high phosphate diet developed decreased metaphyseal and diaphyseal cortical thickness and area, as well as a reduction in trabecular number. Gα_q/11-KO increased bone scintigraphic tracer uptake at week 10 and mitigated tracer uptake in CKD mice at week 22. Histological bone parameters indicated similar trends. Gα_q/11-KO in osteoblast modulates calcium homeostasis, bone formation rate, bone morphometry, and bone mineral density. In CKD and high dietary phosphate intake, osteoblast Gα_q/11/PKC KO further aggravates mineral bone disease.

Global longitudinal strain is superior to ejection fraction for detecting myocardial dysfunction in end-stage renal disease with hyperparathyroidism

BACKGROUND

The estimation of left ventricular ejection fraction (LVEF) by 2D echocardiography (2D-ECHO) is the most used tool to assess LV systolic function (LVSF). Global longitudinal strain (GLS) has recently been suggested as a superior method for several evaluations. This study explored the association and prevalence of LV systolic dysfunction (LVSD) by using these methods in patients with end-stage renal disease (ESRD) and severe hyperparathyroidism (SHPTH); both associated with cardiovascular events (CEs).

AIM

To evaluate the myocardial function in patients with ESRD and SHPTH by using the GLS and LVEF measured through conventional 2D-ECHO.

METHODS

In 62 patients with ESRD and SHPTH, asymptomatic, and without a history of CEs, LVSF was evaluated by 2D-ECHO, obtaining the EF, by the Simpson biplane method, and GLS by speckle tracking.

RESULTS

The total patients with ESRD had a preserved LVEF (> 50%) but abnormal GLS (< 13.55%). Additionally, multivariate analysis showed an independent association of GLS and serum parathyroid hormone (PTH), LV mass index, and hemoglobin. Also, PTH was independently associated with lateral e' wave and tricuspid regurgitation velocity.

CONCLUSION

In patients with SHPTH linked to ESRD, the use of GLS by 2D-ECHO is a more sensitive tool than LVEF for detecting LVSD.

Prevalence and risk factors of osteoporosis in saudi end-stage renal disease patients on hemodialysis

Background:

Objective:

Methods:

Results:

Conclusion:

Quantitative assessment of lumbar spine bone marrow in patients with different severity of CKD by IDEAL-IQ magnetic resonance sequence

BACKGROUND

Chronic kidney disease (CKD) has a significant negative impact on bone health. Bone marrow is an essential component of bone, mainly composed of trabecular bone and fat. The IDEAL-IQ sequence of MRI allows indirect quantification of trabecular bone mass by R2* and direct quantification of bone marrow fat content by FF map, respectively.

OBJECTIVE

Our objective was to explore the association of CKD severity with bone marrow using IDEAL-IQ and whether mineral and bone metabolism markers alter this association.

METHOD

We recruited 68 CKD patients in this cross-sectional research (15 with CKD stages 3-4, 26 with stage 5, and 27 with stage 5d). All patients underwent lumbar spine IDEAL-IQ, BMD, and several bone metabolism markers (iPTH, 25-(OH)-VitD, calcium and phosphorus). Multiple linear regression analysis was used to examine the association of CKD severity with MRI measurements (R2* and FF).

RESULTS

More severe CKD was associated with a higher R2* value [CKD 5d versus 3-4: 30.077 s^-1 (95% CI: 12.937, 47.217), P for trend < 0.001], and this association was attenuated when iPTH was introduced [CKD 5d versus 3-4: 19.660 s^-1 (95% CI: 0.205, 39.114), P for trend = 0.042]. Furthermore, iPTH had an association with R2* value [iPTH (pg/mL): 0.033 s^-1 (95% CI: 0.001, 0.064), P = 0.041]. Besides, FF was mainly affected by age and BMI, but not CKD.

CONCLUSIONS

The bone marrow R2* value measured by IDEAL-IQ sequence is associated with CKD severity and iPTH. The R2* of IDEAL-IQ has the potential to reflect lumbar bone changes in patients with CKD.

Association between the appendicular lean mass index or handgrip strength and bone mineral density in patients undergoing peritoneal dialysis

Background: Few studies have investigated the association between muscle mass and bone mineral density (BMD) in patients undergoing peritoneal dialysis (PD). We aimed to investigate the association between muscle mass or strength and BMD in patients undergoing PD. Methods: The data of all prevalent PD cases at a tertiary medical center between September 2017 and November 2020 were collected. Among all patients, 199 patients undergoing PD were finally analyzed. Baseline measurements including handgrip strength (HGS), appendicular lean mass (ALM) index, and BMD were obtained during a peritoneal membrane equilibration test. Patients with a T-score of ≤ -2.5 were categorized into the low BMD group. Results: The number of male patients was 113 (56.8%). Significant differences were observed in various indices, such as BMD, body composition parameters, and laboratory findings, between male and female patients. There was a stronger association between BMD and ALM index than between BMD and HGS in male patients (r = 0.432 and P < 0.001). The association between BMD and HGS was more definitive in female patients than in male patients (r = 0.357 and P = 0.001). Univariate and mutivariate linear regression and AUROC analyses showed similar trends those obtained in correlation analyses. Conclusion: The present study demonstrated that BMD is associated with the ALM index in male patients and with HGS in female patients undergoing PD.

Replacing sedentary time for physical activity on bone density in patients with chronic kidney disease

INTRODUCTION

This study aimed to examine the cross-sectional associations of sedentary time and physical activity time with bone density in patients with chronic kidney disease (CKD). The isotemporal substitution (IS) modeling was used to estimate the beneficial effects of behavioral changes (e.g., replacing sedentary time with physical activity time) on bone density in these patients.

MATERIALS AND METHODS

A total of 92 patients with CKD (age: 65 ± 9 years; estimated glomerular filtration rate: 57 ± 22 mL/min/1.73 m²) were included in this cross-sectional study. The times spent in sedentary behavior (SB), light-intensity physical activity (LPA), and moderate- to vigorous-intensity physical activity (MVPA) were assessed using a triaxial accelerometer. Through quantitative ultrasound measurements, the stiffness index, as a measure of bone density, was calculated using the speed of sound and broadband ultrasound attenuation.

RESULTS

In multivariate analyses, the stiffness index was beneficially associated with the MVPA time (β = 0.748), but was not significantly associated with the SB and LPA times. The IS models showed that replacing 10 min/day of SB with the equivalent LPA time was not significantly associated with the stiffness index; however, replacing 10 min/day of SB with the equivalent MVPA time was beneficially associated with the stiffness index (β = 0.804).

CONCLUSION

These results suggest that a small increase in MVPA time (e.g., 10 min/day) may attenuate the decline in bone density in patients with CKD. Our findings may provide insight for the development of novel strategies for improving bone health in patients with CKD.

Osteoporosis, an Inevitable Circumstance of Chronic Kidney Disease: A Systematic Review

Nowadays, chronic kidney disease (CKD) and osteoporosis have become crucial health-related issues globally. CKD-induced osteoporosis is a systemic disease characterized by the disruption of mineral, hormone, and vitamin homeostasis that elevates the likelihood of fracture. Here, we review recent studies on the association of CKD and osteoporosis. In particular, we focus on the pathogenesis of CKD-associated osteoporosis, including the homeostasis and pathways of several components such as parathyroid hormone, calcium, phosphate, vitamin D, fibroblast growth factor, and klotho, as well as abnormal bone mineralization, remodeling, and turnover. In addition, we explore the diagnostic tools and possible therapeutic approaches for the management and prevention of CKD-associated osteoporosis. Patients with CKD show higher osteoporosis prevalence, greater fracture rate, increased morbidity and mortality, and an elevated occurrence of hip fracture. We also rule out that increased severity of CKD is related to a more severe condition of osteoporosis. Furthermore, supplements such as calcium and vitamin D as well as lifestyle modifications such as exercise and cessation of smoking and alcohol help in fracture prevention. However, new approaches and advancements in treatment are needed to reduce the fracture risk in patients with CKD. Therefore, further collaborative multidisciplinary research is needed in this regard.

Estimated Glomerular Filtration Rate (eGFR) based on cystatin C was associated with increased risk of hip and proximal humerus fractures in women and decreased risk of hip fracture in men, whereas eGFR based on creatinine was not associated with fracture risk in both sexes: The Tromsø Study

PURPOSE

Patients with end-stage kidney disease have an increased fracture risk. Whether mild to moderate reductions in kidney function is associated with increased fracture risk is uncertain. Results from previous studies may be confounded by muscle mass because of the use of creatinine-based estimates of the glomerular filtration rate (eGFRcre). We tested the hypothesis that lower eGFR within the normal range of kidney function based on serum cystatin C (eGFRcys) or both cystatin C and creatinine (eGFRcrecys) predict fractures better than eGFR based on creatinine (eGFRcre).

METHODS

In the Tromsø Study 1994-95, a cohort of 3016 women and 2836 men aged 50-84 years had eGFRcre, eGFRcys and eGFRcrecys estimated using the Chronic Kidney Disease Epidemiology Collaboration equations. Hazard ratios (HRs) (95% confidence intervals) for fracture were calculated in Cox's proportional hazards models and adjusted for age, height, body mass index, bone mineral density, diastolic blood pressure, smoking, physical activity, previous fracture, diabetes and cardiovascular disease.

RESULTS

During a median of 14.6 years follow-up, 232, 135 and 394 women and 118, 35 and 65 men suffered incident hip, proximal humerus and wrist fractures. In women, lower eGFRcre did not predict fracture, but the risk for hip and proximal humerus fracture increased per standard deviation (SD) lower eGFRcys (HRs 1.36 (1.16-1.60) and 1.33 (1.08-1.63)) and per SD lower eGFRcrecys (HRs 1.25 (1.08-1.45) and 1.30 (1.07-1.57)). In men, none of the eGFR estimates were related to increased fracture risk. In contrast, eGFRcys and eGFRcrecys were inversely associated with hip fracture risk (HRs 0.85 (0.73-0.99) and 0.82 (0.68-0.98)).

CONCLUSIONS

In women, each SD lower eGFRcys and eGFRcrecys increased the risk of hip and proximal humerus fracture by 25-36%, whereas eGFRcre did not. In men, none of the estimates of eGFR were related to increased fracture risk, and each SD lower eGFRcys and eGFRcrecys decreased the risk of hip fracture by 15-18%. The findings particularly apply to a cohort of generally healthy individuals with a normal kidney function. In future studies, the association of measured GFR using the gold standard method of iohexol clearance with fractures risk should be examined for causal inference. More clinical research is needed before robust clinical inferences can be made.

Phosphate, Microbiota and CKD

Phosphate is a key uremic toxin associated with adverse outcomes. As chronic kidney disease (CKD) progresses, the kidney capacity to excrete excess dietary phosphate decreases, triggering compensatory endocrine responses that drive CKD-mineral and bone disorder (CKD-MBD). Eventually, hyperphosphatemia develops, and low phosphate diet and phosphate binders are prescribed. Recent data have identified a potential role of the gut microbiota in mineral bone disorders. Thus, parathyroid hormone (PTH) only caused bone loss in mice whose microbiota was enriched in the Th17 cell-inducing taxa segmented filamentous bacteria. Furthermore, the microbiota was required for PTH to stimulate bone formation and increase bone mass, and this was dependent on bacterial production of the short-chain fatty acid butyrate. We review current knowledge on the relationship between phosphate, microbiota and CKD-MBD. Topics include microbial bioactive compounds of special interest in CKD, the impact of dietary phosphate and phosphate binders on the gut microbiota, the modulation of CKD-MBD by the microbiota and the potential therapeutic use of microbiota to treat CKD-MBD through the clinical translation of concepts from other fields of science such as the optimization of phosphorus utilization and the use of phosphate-accumulating organisms.

Sparing effect of peritoneal dialysis vs hemodialysis on BMD changes and its impact on mortality

INTRODUCTION

Bone loss in end stage renal disease (ESRD) patients associates with fractures, vascular calcification, cardiovascular disease (CVD) and increased mortality. We investigated factors associated with changes of bone mineral density (ΔBMD) during the initial year on dialysis therapy and associations of ΔBMD with subsequent mortality in ESRD patients initiating dialysis.

MATERIALS AND METHODS

In 242 ESRD patients (median age 55 years, 61% men) starting dialysis with peritoneal dialysis (PD; n = 138) or hemodialysis (HD; n = 104), whole-body dual-energy X-ray absorptiometry (DXA), body composition, nutritional status and circulating biomarkers were assessed at baseline and 1 year after dialysis start. We used multivariate linear regression analysis to determine factors associated with ΔBMD, and fine and gray competing risk analysis to determine associations of ΔBMD with subsequent mortality risk.

RESULTS

BMD decreased significantly in HD patients (significant reductions of BMD_total and BMD_{leg, trunk, rib, pelvis and spine}) but not in PD patients. HD compared to PD therapy associated with negative changes in BMD_{total (β=- 0.15)}, BMD_{head (β=- 0.14)}, BMD_{leg (β=- 0.18)} and BMD_{trunk (β=- 0.16)}. Better preservation of BMD associated with significantly lower all-cause mortality for ΔBMD_total (sub-hazard ratio, sHR, 0.91), ΔBMD_head (sHR 0.91) and ΔBMD_leg (sHR 0.92), while only ΔBMD_head (sHR 0.92) had a beneficial effect on CVD-mortality.

CONCLUSIONS

PD had beneficial effect compared with HD on BMD changes during first year of dialysis therapy. Better preservation of BMD, especially in bone sites rich in cortical bone, associated with lower subsequent mortality. BMD in cortical bone may have stronger association with clinical outcome than BMD in trabecular bone.

Role of Uremic Toxins in Early Vascular Ageing and Calcification

In patients with advanced chronic kidney disease (CKD), the accumulation of uremic toxins, caused by a combination of decreased excretion secondary to reduced kidney function and increased generation secondary to aberrant expression of metabolite genes, interferes with different biological functions of cells and organs, contributing to a state of chronic inflammation and other adverse biologic effects that may cause tissue damage. Several uremic toxins have been implicated in severe vascular smooth muscle cells (VSMCs) changes and other alterations leading to vascular calcification (VC) and early vascular ageing (EVA). The above mentioned are predominant clinical features of patients with CKD, contributing to their exceptionally high cardiovascular mortality. Herein, we present an update on pathophysiological processes and mediators underlying VC and EVA induced by uremic toxins. Moreover, we discuss their clinical impact, and possible therapeutic targets aiming at preventing or ameliorating the harmful effects of uremic toxins on the vasculature.