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Low bone mineral density and fractures in stages 3–5 CKD: an updated systematic review and meta-analysis

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Abstract

Summary

The utility of bone mineral density (BMD) testing in chronic kidney disease (CKD) is not known. We performed a meta-analysis of studies reporting on BMD and fracture in CKD. All but one study was cross-sectional. BMD was lower in those with CKD and fractures compared to those without fractures.

Introduction

CKD is associated with an increased risk of fracture. The utility of dual energy X-ray absorptiometry (DXA) to assess fracture risk in CKD is unknown.

Methods

We performed an updated meta-analysis and systematic review of published studies that reported on the association between DXA and fracture (morphometric spine or clinical nonspine) in predialysis and dialysis CKD. We identified 2,894 potential publications, retrieved 292 for detailed review, and included 13. All but one study was cross-sectional and three reported on the ability of DXA to discriminate fracture status in predialysis CKD. Results were pooled using a random effects model and statistical heterogeneity was assessed using the I 2 statistic.

Results

BMD was statistically significantly lower at the femoral neck, lumbar spine, the 1/3 and ultradistal radius in subjects with fractures compared to those without regardless of dialysis status. For example, femoral neck BMD was 0.06 g/cm2 lower in dialysis subjects and 0.102 g/cm2 lower in predialysis subjects with fractures compared to those without. Lumbar spine BMD was 0.05 g/cm2 lower in dialysis subjects and 0.108 g/cm2 lower in predialysis subjects with fractures compared to those without. Our meta-analysis was limited to studies with small numbers of subjects and even smaller numbers of fractures. All of the studies were observational and only one was prospective. There was statistical heterogeneity at the lumbar spine, 1/3 and ultradistal radius.

Conclusions

Our findings suggest that BMD can discriminate fracture status in predialysis and dialysis CKD. Larger, prospective studies are needed.

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References

  1. Ensrud KE, Lui LY, Taylor BC, Ishani A, Shlipak MG, Stone KL, Cauley JA, Jamal SA, Antoniucci DM, Cummings SR (2007) Renal function and risk of hip and vertebral fractures in older women. Arch Intern Med 167:133–139

    Article  PubMed  Google Scholar 

  2. Alem AM, Sherrard DJ, Gillen DL, Weiss NS, Beresford SA, Heckbert SR, Wong C, Stehman-Breen C (2000) Increased risk of hip fracture among patients with end-stage renal disease. Kidney Int 58:396–399

    Article  CAS  PubMed  Google Scholar 

  3. Cummings SR, Black D (1995) Bone mass measurements and risk of fracture in Caucasian women: a review of findings from prospective studies. Am J Med 98:24S–28S

    Article  CAS  PubMed  Google Scholar 

  4. WHO (2008) FRAX WHO fracture risk asssessment tool. World Health Organization, Geneva.

  5. Parfitt AM (1998) A structural approach to renal bone disease. J Bone Miner Res 13:1213–1220

    Article  CAS  PubMed  Google Scholar 

  6. Kidney Disease: Improving Global Outcomes (KDIGO) CKD-MBD Work Group (2009) KDIGO clinical practice guideline for the diagnosis, evaluation, prevention, and treatment of chronic kidney disease-mineral and bone disorder (CKD-MBD). Kidney Int Suppl S1–S130

  7. Jamal SA, Hayden JA, Beyene J (2007) Low bone mineral density and fractures in long-term hemodialysis patients: a meta-analysis. Am J Kidney Dis 49:674–681

    Article  PubMed  Google Scholar 

  8. Moher D, Liberati A, Tetzlaff J, Altman DG (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 339:b2535

    Article  PubMed Central  PubMed  Google Scholar 

  9. World Health Organization (1994) Assessment of osteoporotic fracture risk and its role in screening for postmenopausal osteoporosis. WHO Technical Series Geneva

  10. Furlan AD, Pennick V, Bombardier C, van Tulder M (2009) 2009 updated method guidelines for systematic reviews in the Cochrane Back Review Group. Spine (Phila Pa 1976) 34:1929–1941

    Article  Google Scholar 

  11. Berlin JA (1997) Does blinding of readers affect the results of meta-analyses? University of Pennsylvania Meta-analysis Blinding Study Group. Lancet 350:185–186

    Article  CAS  PubMed  Google Scholar 

  12. Wells GA, Shea B, O’Connell D, Peterson J, Welch V, Losos M, Tugwell P The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. Accessed 18 Nov 2013

  13. Herzog R, Alvarez-Pasquin MJ, Diaz C, Del Barrio JL, Estrada JM, Gil A (2013) Are healthcare workers’ intentions to vaccinate related to their knowledge, beliefs and attitudes? A systematic review. BMC Public Health 13:154. doi:10.1186/1471-2458-13-154

    Article  PubMed Central  PubMed  Google Scholar 

  14. DerSimonian R, Laird N (1986) Meta-analysis in clinical trials. Control Clin Trials 7:177–188

    Article  CAS  PubMed  Google Scholar 

  15. Higgins J (2009) Cochrane handbook for systematic reviews of interventions. Version 5.0.2: The Cochrane Collaboration. GS eds

  16. Cummings SR, Nevitt MC, Browner WS, Stone K, Fox KM, Ensrud KE, Cauley J, Black D, Vogt TM (1995) Risk factors for hip fracture in white women. Study of Osteoporotic Fractures Research Group. N Engl J Med 332:767–773

    Article  CAS  PubMed  Google Scholar 

  17. Jamal SA, Gilbert J, Gordon C, Bauer DC (2006) Cortical PQCT measures are associated with fractures in dialysis patients. J Bone Miner Res 21:543–548

    Article  PubMed  Google Scholar 

  18. Nickolas TL, Cremers S, Zhang A, Thomas V, Stein E, Cohen A, Chauncey R, Nikkel L, Yin MT, Liu XS, Boutroy S, Staron RB, Leonard MB, McMahon DJ, Dworakowski E, Shane E (2011) Discriminants of prevalent fractures in chronic kidney disease. J Am Soc Nephrol 22:1560–1572

    Article  PubMed Central  PubMed  Google Scholar 

  19. Nickolas TL, Stein E, Cohen A, Thomas V, Staron RB, McMahon DJ, Leonard MB, Shane E (2010) Bone mass and microarchitecture in CKD patients with fracture. J Am Soc Nephrol 21:1371–1380

    Article  PubMed Central  PubMed  Google Scholar 

  20. Ambrus C, Almasi C, Berta K, Deak G, Marton A, Molnar MZ, Nemeth Z, Horvath C, Lakatos P, Szathmari M, Mucsi I (2011) Vitamin D insufficiency and bone fractures in patients on maintenance hemodialysis. Int Urol Nephrol 43:475–482

    Article  CAS  PubMed  Google Scholar 

  21. Cejka D, Patsch JM, Weber M, Diarra D, Riegersperger M, Kikic Z, Krestan C, Schueller-Weidekamm C, Kainberger F, Haas M (2011) Bone microarchitecture in hemodialysis patients assessed by HR-pQCT. Clin J Am Soc Nephrol 6:2264–2271

    Article  PubMed Central  PubMed  Google Scholar 

  22. Iimori S, Mori Y, Akita W, Kuyama T, Takada S, Asai T, Kuwahara M, Sasaki S, Tsukamoto Y (2011) Diagnostic usefulness of bone mineral density and biochemical markers of bone turnover in predicting fracture in CKD stage 5D patients—a single-center cohort study. Nephrol Dial Transplant 27:345–351

    Article  PubMed  Google Scholar 

  23. Jamal SA, Cheung AM, West SL, Lok CE (2012) Bone mineral density by DXA and HR pQCT can discriminate fracture status in men and women with stages 3 to 5 chronic kidney disease. Osteoporos Int 23:2805–2813

    Article  CAS  PubMed  Google Scholar 

  24. Yamaguchi T, Kanno E, Tsubota J, Shiomi T, Nakai M, Hattori S (1996) Retrospective study on the usefulness of radius and lumbar bone density in the separation of hemodialysis patients with fractures from those without fractures. Bone 19:549–555

    Article  CAS  PubMed  Google Scholar 

  25. Fontaine MA, Albert A, Dubois B, Saint-Remy A, Rorive G (2000) Fracture and bone mineral density in hemodialysis patients. Clin Nephrol 54:218–226

    CAS  PubMed  Google Scholar 

  26. Jamal SA, Chase C, Goh YI, Richardson R, Hawker GA (2002) Bone density and heel ultrasound testing do not identify patients with dialysis-dependent renal failure who have had fractures. Am J Kidney Dis 39:843–849

    Article  PubMed  Google Scholar 

  27. Kaji H, Suzuki M, Yano S, Sugimoto T, Chihara K, Hattori S, Sekita K (2002) Risk factors for hip fracture in hemodialysis patients. Am J Nephrol 22:325–331

    Article  PubMed  Google Scholar 

  28. Urena P, Bernard-Poenaru O, Ostertag A, Baudoin C, Cohen-Solal M, Cantor T, de Vernejoul MC (2003) Bone mineral density, biochemical markers and skeletal fractures in haemodialysis patients. Nephrol Dial Transplant 18:2325–2331

    Article  CAS  PubMed  Google Scholar 

  29. Inaba M, Okuno S, Kumeda Y, Yamakawa T, Ishimura E, Nishizawa Y (2005) Increased incidence of vertebral fracture in older female hemodialyzed patients with type 2 diabetes mellitus. Calcif Tissue Int 76:256–260

    Article  CAS  PubMed  Google Scholar 

  30. (1993) Consensus development conference: diagnosis, prophylaxis, and treatment of osteoporosis. Am J Med 94:646–650

  31. Brown JP, Josse RG (2002) 2002 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. CMAJ 167:S1–S34

    PubMed Central  PubMed  Google Scholar 

  32. Cummings SR, Kelsey JL, Nevitt MC, O’Dowd KJ (1985) Epidemiology of osteoporosis and osteoporotic fracture. Epidemiol Rev 7:178–208

    CAS  PubMed  Google Scholar 

  33. Duan Y, De Luca V, Seeman E (1999) Parathyroid hormone deficiency and excess: similar effects on trabecular bone but differing effects on cortical bone. J Clin Endocrinol Metab 84:718–722

    Article  CAS  PubMed  Google Scholar 

  34. Jamal SA, Bauer DC, Ensrud KE, Cauley JA, Hochberg M, Ishani A, Cummings SR (2007) Alendronate treatment in women with normal to severely impaired renal function: an analysis of the fracture intervention trial. J Bone Miner Res 22:503–508

    Article  CAS  PubMed  Google Scholar 

  35. Miller PD, Roux C, Boonen S, Barton IP, Dunlap LE, Burgio DE (2005) Safety and efficacy of risedronate in patients with age-related reduced renal function as estimated by the Cockcroft and Gault method: a pooled analysis of nine clinical trials. J Bone Miner Res 20:2105–2115

    Article  CAS  PubMed  Google Scholar 

  36. Ishani A, Blackwell T, Jamal SA, Cummings SR, Ensrud KE (2008) The effect of raloxifene treatment in postmenopausal women with CKD. J Am Soc Nephrol 19:1430–1438

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  37. Miller PD, Schwartz EN, Chen P, Misurski DA, Krege JH (2007) Teriparatide in postmenopausal women with osteoporosis and mild or moderate renal impairment. Osteoporos Int 18:59–68

    Article  CAS  PubMed  Google Scholar 

  38. Jamal SA, Ljunggren O, Stehman-Breen C, Cummings SR, McClung MR, Goemaere S, Ebeling PR, Franek E, Yang YC, Egbuna OI, Boonen S, Miller PD (2011) Effects of denosumab on fracture and bone mineral density by level of kidney function. J Bone Miner Res 26:1829–1835

    Article  CAS  PubMed  Google Scholar 

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Acknowledgments

The authors would like to thank Dr. Pablo Urena for provision of his raw data. Dr. Jamal’s research is funded in part by the Canadian Institute of Health Research (CIHR).

Conflicts of interest

Roxana C. Bucur, Dilshaan D. Panjwani, Lucy Turner, Tamara Rader, Sarah L. West, and Sophie A. Jamal declare that they have no conflict of interest.

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Authors and Affiliations

  1. Women’s College Research Institute, 790 Bay Street, 7th Floor, Toronto, ON, M6G 1N8, Canada

    R. C. Bucur, D. D. Panjwani, S. L. West & S. A. Jamal

  2. Ottawa Hospital Research Institute, 725 Parkdale Avenue, Ottawa, ON, K1Y 4E9, Canada

    L. Turner

  3. Cochrane Musculoskeletal Group, Centre for Global Health, University of Ottawa, 1 Stewart St., Ottawa, ON, K1N 6N5, Canada

    T. Rader

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  1. R. C. Bucur
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  3. L. Turner
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Correspondence to S. A. Jamal.

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Bucur, R.C., Panjwani, D.D., Turner, L. et al. Low bone mineral density and fractures in stages 3–5 CKD: an updated systematic review and meta-analysis. Osteoporos Int 26, 449–458 (2015). https://doi.org/10.1007/s00198-014-2813-3

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  • DOI: https://doi.org/10.1007/s00198-014-2813-3

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