Increased bone fractures among elderly United States hemodialysis patients

Wagner, John E.; Jhaveri, Kenar D.; Rosen, Lisa; Sunday, Suzanne R.; Mathew, Anna; Fishbane, Steven

doi:10.1093/ndt/gft352

Cited by 61 publications

(61 citation statements)

References 12 publications

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“…In previous studies, we and others found a secular trend toward increased hip fractures in patients on dialysis from 1992 to approximately 2005, which with additional analyses, occurred in patients of white race or those .65 years of age (6). Furthermore, there seemed to be less correlation between histomorphic bone turnover and iPTH in black patients (24).…”

Section: Discussionmentioning

confidence: 59%

“…Furthermore, there seemed to be less correlation between histomorphic bone turnover and iPTH in black patients (24). Taken together, this knowledge led to a hypothesis that, in this subgroup of patients, who often are of a phenotype representative of osteoporosis or bone fragility, oversuppression of iPTH could be particularly harmful (6). However, we found no consistent significant relationship between lower iPTH and higher hip fracture risk in this subgroup.…”

Section: Discussionmentioning

confidence: 59%

“…In contrast, among patients on dialysis, recent studies have documented an increase in fractures beginning in 1992 and continuing until at least [2000][2001][2002][2003][2004][2005], with a leveling off by the mid-2000s (2,6,7). The reasons for these changes in fracture rates are not clear but suggest the possibility that certain treatment practices could have had unanticipated effects.…”

Section: Introductionmentioning

confidence: 99%

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Bone Parameters and Risk of Hip and Femur Fractures in Patients on Hemodialysis

Fishbane¹,

Hazzan²,

Jhaveri³

et al. 2016

CJASN

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Background and objectives Patients on hemodialysis have a high rate of hip fractures. In this study, we performed a contemporary analysis of mineral and bone parameters and their relationship to hip and femur fracture risk. Results The incidence of hip and femur fractures remained generally unchanged (P=0.40), except among patients who were white and .65 years of age, in whom the rate decreased significantly over the 14-year period (P,0.01).Results from combined multivariable models indicated that the lowest quartiles of time-averaged intact parathyroid hormone were independently associated with higher hip fracture risk (intact parathyroid hormone =181-272 pg/ml: hazard ratio, 1.20; 95% confidence interval [95% CI], 1.03 to 1.41 and intact parathyroid hormone ,181 pg/ml: hazard ratio, 1.20; 95% CI, 1.01 to 1.44; referent third quartile, 273 to ,433 pg/ml). The lowest quartile of time-averaged serum calcium was also associated with higher risk (calcium ,8.7 mg/dl; hazard ratio, 1.17; 95% CI, 1.00 to 1.37) compared with the referent third quartile of 9.1 to ,9.5 mg/dl. ConclusionsWe found an association between lower levels of intact parathyroid hormone and serum calcium and greater risk for hip and femur fractures among patients on hemodialysis. These findings support additional research toward elucidating long-term safety of treatment approaches for hyperparathyroidism in patients with ESRD.

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Section: Discussionmentioning

confidence: 59%

Section: Discussionmentioning

confidence: 59%

Section: Introductionmentioning

confidence: 99%

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Bone Parameters and Risk of Hip and Femur Fractures in Patients on Hemodialysis

Fishbane¹,

Hazzan²,

Jhaveri³

et al. 2016

CJASN

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“…However, it is unclear whether the incidence of fractures in patients receiving dialysis has decreased in recent years despite active treatment of secondary hyperparathyroidism. [15][16][17][18] Most previous studies of fracture in CKD and ESRD were cross-sectional or had limited follow-up, and/or fracture assessment was made from claims data rather than prospectively collected or adjudicated. Importantly, despite the availability and widespread use of phosphate binders and vitamin D sterols, no randomized controlled trials evaluated whether any drug or other therapeutic strategies (e.g., parathyroidectomy) lowered the risk of fracture in CKD and/or ESRD.…”

mentioning

confidence: 99%

Effects of Cinacalcet on Fracture Events in Patients Receiving Hemodialysis

Moe

Abdalla

Chertow

et al. 2015

Journal of the American Society of Nephrology

178

116

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Fractures are frequent in patients receiving hemodialysis. We tested the hypothesis that cinacalcet would reduce the rate of clinical fractures in patients receiving hemodialysis using data from the Evaluation of Cinacalcet HCl Therapy to Lower Cardiovascular Events trial, a placebo-controlled trial that randomized 3883 hemodialysis patients with secondary hyperparathyroidism to receive cinacalcet or placebo for #64 months. This study was a prespecified secondary analysis of the trial whose primary end point was all-cause mortality and non-fatal cardiovascular events, and one of the secondary end points was first clinical fracture event. Clinical fractures were observed in 255 of 1935 (13.2%) patients randomized to placebo and 238 of 1948 (12.2%) patients randomized to cinacalcet. In an unadjusted intention-to-treat analysis, the relative hazard for fracture (cinacalcet versus placebo) was 0.89 (95% confidence interval [95% CI], 0.75 to 1.07). After adjustment for baseline characteristics and multiple fractures, the relative hazard was 0.83 (95% CI, 0.72 to 0.98). Using a prespecified lag-censoring analysis (a measure of actual drug exposure), the relative hazard for fracture was 0.72 (95% CI, 0.58 to 0.90). When participants were censored at the time of cointerventions (parathyroidectomy, transplant, or provision of commercial cinacalcet), the relative hazard was 0.71 (95% CI, 0.58 to 0.87). Fracture rates were higher in older compared with younger patients and the effect of cinacalcet appeared more pronounced in older patients. In conclusion, using an unadjusted intention-to-treat analysis, cinacalcet did not reduce the rate of clinical fracture. However, when accounting for differences in baseline characteristics, multiple fractures, and/or events prompting discontinuation of study drug, cinacalcet reduced the rate of clinical fracture by 16%-29%. 26: 146626: -147526: , 201526: . doi: 10.1681 Patients with end stage renal disease (ESRD) on dialysis have increased risk of fractures compared with the general population. 1 Fracture incidence rates vary by geographic region, although rates are consistently higher in patients with CKD than matched controls from the same country. [2][3][4][5][6] Depending on the study, 10%-52% of patients receiving dialysis J Am Soc Nephrol

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“…Bone fractures are a major source of morbidity and mortality in patients receiving maintenance dialysis (1)(2)(3)(4)(5)(6). Fractures are substantially more common in patients on dialysis than in the general population (4,(7)(8)(9)(10)(11), and they contribute to significant morbidity and health resource utilization (3).…”

Section: Introductionmentioning

confidence: 99%

Geovariation in Fracture Risk among Patients Receiving Hemodialysis

Wetmore

Liu

Wirtz³

et al. 2016

CJASN

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Background and objectives Fractures are a major source of morbidity and mortality in patients receiving dialysis. We sought to determine whether rates of fractures and tendon ruptures vary geographically.Design, setting, participants, & measurements Data from the US Renal Data System were used to create four yearly cohorts, 2007-2010, including all eligible prevalent patients on hemodialysis in the United States on January 1 of each year. A secondary analysis comprising patients in a large dialysis organization conducted over the same period permitted inclusion of patient-level markers of mineral metabolism. Patients were grouped into 10 regions designated by the Centers for Medicare and Medicaid Services and divided by latitude into one of three bands: south, ,35°; middle, 35°to ,40°; and north, $40°. Poisson regression was used to calculate unadjusted and adjusted region-level rate ratios for events.Results Overall, 327,615 patients on hemodialysis were included. Mean (SD) age was 61.8 (15.0) years old, 52.7% were white, and 55.0% were men. During 716,962 person-years of follow-up, 44,014 fractures and tendon ruptures occurred, the latter being only 0.3% of overall events. Event rates ranged from 5.36 to 7.83 per 100 person-years, a 1.5-fold rate difference across regions. Unadjusted region-level rate ratios varied from 0.83 (95% confidence interval, 0.81 to 0.85) to 1.20 (95% confidence interval, 1.18 to 1.23), a 1.45-fold rate difference. After adjustment for a wide range of case mix variables, a 1.33-fold variation in rates remained. Rates were higher in north and middle bands than the south (north rate ratio, 1.18; 95% confidence interval, 1.13 to 1.23; middle rate ratio, 1.13; 95% confidence interval, 1.10 to 1.17). Latitude explained 11% of variation, independent of region. A complementary analysis of 87,013 patients from a large dialysis organization further adjusted for circulating mineral metabolic parameters and protein energy wasting yielded similar results.Conclusions Rates of fractures vary geographically in the United States dialysis population, even after adjustment for known patient characteristics. Latitude seems to contribute to this phenomenon, but additional analyses exploring whether other factors might influence variation are warranted.

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Increased bone fractures among elderly United States hemodialysis patients

Abstract: Fracture rates increased significantly in hemodialysis patients from 1992 to 2004, with most of the increase occurring in elderly white patients. Assessment of fracture risk and management in dialysis patients at greatest risk requires greater emphasis and further study.

Cited by 61 publications

References 12 publications

Bone Parameters and Risk of Hip and Femur Fractures in Patients on Hemodialysis

Bone Parameters and Risk of Hip and Femur Fractures in Patients on Hemodialysis

Effects of Cinacalcet on Fracture Events in Patients Receiving Hemodialysis

Geovariation in Fracture Risk among Patients Receiving Hemodialysis

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