Fragility Fractures in Chronic Kidney Disease: Assessment and Pharmacologic Management

Abstract

Fractures are common in all stages of chronic kidney disease (CKD), and are associated with increased morbidity and mortality. Both CKD and osteoporosis often coexist as they both are strongly age associated. However, the management of fragility fractures in CKD poses many dilemmas. These include diagnosing the aetiology of fractures and choosing appropriate treatment. This paper reviews the current evidence for the assessment and pharmacologic management of fragility fractures in CKD.

The frequency of bone fractures among patients with chronic kidney disease not on dialysis: two-year follow-up

“…BMD by dual-energy X-ray absorptiometry (DEXA) is unlikely to be sensitive or specific to either diagnose or differentiate osteoporosis from other disorders of ROD [3]. In patients with CKD stages 1-3, WHO DEXA criteria can be used for diagnosing osteoporosis if there is normal serum bone biochemistry [1].…”

“…In patients with CKD stages 1-3, WHO DEXA criteria can be used for diagnosing osteoporosis if there is normal serum bone biochemistry [1]. But in patients with CKD stages 4 and 5, it is the best to exclude ROD with quantitative bone histomorphometry [3]. Therefore, KDIGO recommended that BMD testing should not be performed routinely in patients with CKD stages 3-5, because BMD does not predict fracture risk in CKD patients as well as in the general population, and, also, BMD does not predict the type of renal osteodystrophy [1].…”

“…Also, antiresorptives can cause a risk for low turnover bone disease [29]. Even though there are not enough data about safety of the use of antiresorptives in patients with CKD stage 5, bisphosphonates may be considered in those patients with fractures after exclusion of adynamic bone disease and osteomalacia by undertaking a bone biopsy [3]. In the group of patients that did not develop fractures, one patient had bisphosphonate therapy, but due to this small number, the correlation could not be performed.…”

“…Renal osteodystrophy is a severe complication of chronic kidney disease that increases morbidity and mortality in these patients. Renal osteodystrophy (ROD) consists of the following group of disorders: a high bone turnover disease (usually associated with secondary hyperparathyroidism), a low bone turnover disease (includes adynamic bone disease, osteomalacia, and aluminum bone disease) and mixed uraemic osteodystrophy [3]. Mineral and bone disorder (CKD-MBD), that includes ROD, vascular calcifications and mineral disturbances, starts early in CKD and affects the incidence of bone fractures.…”

Pathological fracture of subtrochanter femur, soft tissue infection along the fracture site, shaft femur bone cortex thickening and blastic lession on contralateral shaft femur due to renal osteodystrophy on the end stage renal disease patient: a case report

“…In ROD, bone remodelling is a dynamic process that occurs throughout the life of the individual in all segments of the skeleton. [10][11][12][13] Remodelling involves the action of resorption and formation cells (osteoclasts and osteoblasts, respectively), and its essential objective is to replace old tissue with new tissue. This process is regulated carefully by local and hormonal factors, and an imbalance between resorption and formation in certain cases can result in bone loss with disastrous consequences such as fractures.…”