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      Fracture Risk in Dialysis and Kidney Transplanted Patients: A Systematic Review

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          ABSTRACT

          Chronic kidney disease is associated with an increased risk of fracture and cardiovascular mortality. The risk of fracture in hemodialysis (HD), peritoneal dialysis (PD) and kidney transplant (KT) patients is higher when compared with the general population. However, there exists a knowledge gap concerning which group has the highest risk of fracture. We aimed to compare the risk of fracture in HD, PD, and KT populations. We conducted a systematic review of observational studies evaluating the risk of fracture in HD, PD, or KT patients. Eligible studies were searched using MEDLINE, Embase, Web of Science, and Cochrane Library from their inception to January 2016, and in grey literature. Incidences (cumulative and rate) of fracture were described together using the median, according to fracture sites, the data source (administrative database or cohort and clinical registry), and fracture diagnosis method. Prevalence estimates were described separately. We included 47 studies evaluating the risk of fracture in HD, PD, and KT populations. In administrative database studies, incidence of hip fracture in HD (median 11.45 per 1000 person‐years [p‐y]), range: 9.3 to 13.6 was higher than in KT (median 2.6 per 1000 p‐y; range 1.5 to 3.8) or in PD (median 5.2 per 1000 p‐y; range 4.1 to 6.3). In dialysis (HD+PD), three studies reported a higher incidence of hip fracture than in KT. Prevalent vertebral fracture (assessed by X‐rays or questionnaire) reported in HD was in a similar range as that reported in KT. Incidence of overall fracture was similar in HD and KT, from administrative databases studies, but lower in HD compared with KT, from cohorts or clinical registry studies. This systematic review suggests an important difference in fracture risk between HD, PD, and KT population, which vary according to the diagnosis method for fracture identification. © 2018 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

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          Most cited references69

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          Increased incidence of hip fractures in dialysis patients with low serum parathyroid hormone.

          To study the complications of renal osteodystrophy in patients with end-stage renal disease, we reviewed the incidence of hip fractures in our outpatient dialysis population from 1988 to 1998. One thousand two hundred seventy-two patients were treated for a total of 4,039 patient-years; 56 hip fractures were documented during this period. The incidence of hip fractures was many times greater in the dialysis patients than in the general population in each of the age-, race-, and sex-matched subgroups. The 1-year mortality rate from the hip fracture event was nearly two and a half times greater in the dialysis patients compared with the general population. The incidence of hip fractures in the first half of the decade was similar to that observed in the second half. When parathyroid hormone (PTH) levels were evaluated, we determined that patients with lower serum PTH levels were more likely to sustain a hip fracture than patients with higher PTH levels (P: < 0.006). In addition, we determined that patients with lower PTH levels had an earlier mortality than patients with higher PTH levels (P: < 0.03). We conclude that despite more aggressive therapy directed toward bone health in our dialysis patients in recent years, the incidence of hip fractures and their devastating morbidity and mortality remained unchanged over the past decade. Lower PTH levels may predispose to earlier mortality.
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            PTH and the risks for hip, vertebral, and pelvic fractures among patients on dialysis.

            Few investigations have described fracture risk and its relation to disorders in calcium (Ca), phosphorus (P), and parathyroid hormone (PTH) metabolism in the end-stage renal disease population. Laboratory values for Ca, P, and PTH were obtained from Dialysis Morbidity and Mortality Study (DMMS) Waves 1 to 4. Additional data available from the US Renal Data System were used to determine the incidence and associated costs of hip, vertebral, and pelvic fractures in 9,007 patients with nonmissing laboratory values and Medicare as primary payor. Cox proportional hazards and Poisson models were used to analyze time to first fracture and numbers of fractures, respectively. There was no association between Ca or P values and risk for fracture; risks for vertebral and hip fractures and PTH concentrations were U shaped and weakly significant using Poisson regression (P = 0.03). The age- and sex-adjusted mortality rate after fracture was 2.7 times greater (580/1,000 person-years) than for general dialysis patients from the DMMS (217/1,000 person-years). Mean total episodic costs of hip, vertebral, and pelvic fractures were 20,810 dollars +/- 16,743 dollars (SD), 17,063 dollars +/- 26,201 dollars, and 14,475 dollars +/- 19,209 dollars, respectively. Using data from the DMMS, there were no associations between Ca and P concentrations and risk for fracture. Risks for hip and vertebral fracture were associated weakly with PTH concentration, with the lowest risk observed around a PTH concentration of 300 pg/mL (ng/L). Fractures were associated with high subsequent mortality and costs. Prospective studies are needed to determine whether therapies that maintain PTH concentrations within or near the National Kidney Foundation-Kidney Disease Outcomes Quality Initiative range will result in fewer complications of disordered mineral metabolism.
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              Increased risk of mortality associated with hip fracture in the dialysis population.

              Patients with end-stage renal disease (ESRD) are at increased risk of bone loss and hip fracture. Although it is well known that hip fracture in the general population is associated with increased mortality, this relationship is not well elucidated in the ESRD population. The authors studied the association between hip fracture and mortality in dialysis patients. The authors used data from the United States Renal Data System to identify patients initiating dialysis between May 1, 1995, and December 31, 2000. Patients with hip fractures were identified using Medicare claims data. Each patient who experienced a hip fracture was matched to 3 nonfracture controls by age, history of cardiovascular disease (CVD), and dialysis duration. Proportional hazards models were used to estimate the risk of all-cause and cardiovascular mortality associated with hip fracture stratified by CVD history. A total of 7,636 patients with a hip fracture and 22,896 matched controls were identified. Median survival time for patients with hip fracture was 289 days (95% confidence interval [CI]: 275, 302) compared with 714 days (95% CI: 697, 732) for those without a hip fracture. The average relative risk of mortality associated with hip fracture was 1.99 (95% CI: 1.91, 2.07; P < 0.001). Hip fracture is associated with an increased risk of all-cause mortality in the dialysis population.
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                Author and article information

                Contributors
                fabrice.mac-way@mail.chuq.qc.ca
                Journal
                JBMR Plus
                JBMR Plus
                10.1002/(ISSN)2473-4039
                JBM4
                JBMR Plus
                John Wiley and Sons Inc. (Hoboken )
                2473-4039
                05 July 2018
                January 2019
                : 3
                : 1 ( doiID: 10.1002/jbm4.v3.1 )
                : 45-55
                Affiliations
                [ 1 ] Centre de Recherche du CHU de Québec Hôpital Hôtel‐Dieu de Québec Division of Nephrology, Endocrinology, and Nephrology Axis Faculty of Medicine Department of Social and Preventive Medicine Laval University Quebec Canada
                [ 2 ] Centre de Recherche du CHU de Québec Hôpital Saint‐Sacrement Faculty of Medicine Department of Social and Preventive Medicine Laval University Quebec Canada
                [ 3 ] Centre de Recherche du CHU de Québec Hôpital Hôtel‐Dieu de Québec Division of Nephrology, Endocrinology, and Nephrology Axis Faculty and Department of Medicine Laval University Quebec Canada
                [ 4 ] Institut National de Santé Publique du Québec Medicine Faculty Department of Social and Preventive Medicine Laval University Quebec Canada
                [ 5 ] Centre de Recherche du CHU de Québec Hôpital de l'Enfant‐Jésus Traumatology Axis Medicine Faculty Department of Social and Preventive Medicine Laval University Quebec Canada
                Author notes
                [*] [* ] Address correspondence to: Fabrice Mac‐Way, MD, FRCPC, Centre de Recherche du CHU de Québec, Hôpital Hôtel‐Dieu de Québec, 10 McMahon, Québec City (Québec), Université Laval, G1R 2J6 Canada. E‐mail: fabrice.mac-way@ 123456mail.chuq.qc.ca

                Article
                JBM410067
                10.1002/jbm4.10067
                6339558
                30680363
                150858ed-3031-4788-9040-30d9b0bef366
                © 2018 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

                This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

                History
                : 22 January 2018
                : 07 June 2018
                : 14 June 2018
                Page count
                Figures: 3, Tables: 3, Pages: 11, Words: 6595
                Funding
                Funded by: CIHR
                Categories
                Original Article
                Original Articles
                Custom metadata
                2.0
                jbm410067
                January 2019
                Converter:WILEY_ML3GV2_TO_NLMPMC version:5.5.6 mode:remove_FC converted:19.01.2019

                ckd‐mbd,fractures,hemodialysis,peritoneal dialysis,kidney transplantation

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