Temporal Trends in the Incidence, Treatment, and Outcomes of Hip Fracture in Older Patients Initiating Dialysis in the United States

Nair, S.; Mitani, Aya A.; Goldstein, Benjamin A.; Chertow, Glenn M.; Lowenberg, David W.; Winkelmayer, Wolfgang C.

doi:10.2215/cjn.10901012

Cited by 72 publications

(95 citation statements)

References 19 publications

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“…With the exception of PAD, our group has previously established algorithms to identify these cardiovascular events from Medicare claims 20, 21. PAD was defined using previously established diagnosis codes and diagnosis‐related groups (Table 1).…”

Section: Methodsmentioning

confidence: 99%

Associations of Glycemic Control With Cardiovascular Outcomes Among US Hemodialysis Patients With Diabetes Mellitus

Rhee

Zheng

Montez‐Rath

et al. 2017

JAHA

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BackgroundThere is a lack of data on the relationship between glycemic control and cardiovascular end points in hemodialysis patients with diabetes mellitus.Methods and ResultsWe included adult Medicare‐insured patients with diabetes mellitus who initiated in‐center hemodialysis treatment from 2006 to 2008 and survived for >90 days. Quarterly mean time‐averaged glycated hemoglobin (HbA1c) values were categorized into <48 mmol/mol (<6.5%) (reference), 48 to <58 mmol/mol (6.5% to <7.5%), 58 to <69 mmol/mol (7.5% to <8.5%), and ≥69 mmol/mol (≥8.5%). Medicare claims were used to identify outcomes of cardiovascular mortality, nonfatal myocardial infarction (MI), fatal or nonfatal MI, stroke, and peripheral arterial disease. We used Cox models as a function of time‐varying exposure to estimate multivariable adjusted hazard ratios and 95%CI for the associations between HbA1c and time to study outcomes in a cohort of 16 387 eligible patients. Patients with HbA1c 58 to <69 mmol/mol (7.5% to <8.5%) and ≥69 mmol/mol (≥8.5%) had 16% (CI, 2%, 32%) and 18% (CI, 1%, 37%) higher rates of cardiovascular mortality (P‐trend=0.01) and 16% (CI, 1%, 33%) and 15% (CI, 1%, 32%) higher rates of nonfatal MI (P‐trend=0.05), respectively, compared with those in the reference group. Patients with HbA1c ≥69 mmol/mol (≥8.5%) had a 20% (CI, 2%, 41%) higher rate of fatal or nonfatal MI (P‐trend=0.02), compared with those in the reference group. HbA1c was not associated with stroke, peripheral arterial disease, or all‐cause mortality.ConclusionsHigher HbA1c levels were significantly associated with higher rates of cardiovascular mortality and MI but not with stroke, peripheral arterial disease, or all‐cause mortality in this large cohort of hemodialysis patients with diabetes mellitus.

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Section: Methodsmentioning

confidence: 99%

Associations of Glycemic Control With Cardiovascular Outcomes Among US Hemodialysis Patients With Diabetes Mellitus

Rhee

Zheng

Montez‐Rath

et al. 2017

JAHA

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“…Alem et al (1) found the rate of hip fractures to be 4.4 times higher among patients on dialysis. Nair et al (2) reported the incidence of hip fractures in patients on dialysis to be 29.3/1000 person-years. Outcomes postfracture are poor, with 17.4% of patients dying within 30 days (2), a mean of 55.9 skilled nursing facility days per year (3), and a posthospital discharge death rate of 0.82 per patient-year (3).…”

Section: Introductionmentioning

confidence: 99%

“…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%

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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“…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

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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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Temporal Trends in the Incidence, Treatment, and Outcomes of Hip Fracture in Older Patients Initiating Dialysis in the United States

Cited by 72 publications

References 19 publications

Associations of Glycemic Control With Cardiovascular Outcomes Among US Hemodialysis Patients With Diabetes Mellitus

Associations of Glycemic Control With Cardiovascular Outcomes Among US Hemodialysis Patients With Diabetes Mellitus

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

Effects of Cinacalcet on Fracture Events in Patients Receiving Hemodialysis

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