Incidence of Fractures Before and After Dialysis Initiation

Abstract

Fractures are common in dialysis patients, but little is known about the trajectory of incidence rates of different types of fractures before and after dialysis initiation. To address this, we investigated the incidence of major fractures before and after dialysis initiation. We performed a retrospective statistical analysis using the Swedish Renal Registry of 9041 incident dialysis patients (median age 67 years, 67% men) starting dialysis 2005 through 2015 to identify major fractures (hip, spine, humerus, and forearm) occurring during the dialysis transition period from 1 year before until 1 year after dialysis initiation. Using flexible parametric hazard models and the Fine-Gray model, we estimated adjusted fracture incidence rates and predictors of major fractures. We identified 361 cases with primary diagnosis of major fracture, of which 196 (54%) were hip fractures. The crude incidence rate of major fractures before dialysis initiation was 17 per 1000 patient-years (n = 157) and after dialysis initiation it was 24 per 1000 patient-years (n = 204). The adjusted incidence rate of major fractures began to increase 6 months before dialysis initiation, and then stabilized at a higher rate after 1 year. The adjusted incidence rate of hip fractures started to increase sharply 3 months before dialysis initiation, peaked at initiation, and declined thereafter. In contrast, the adjusted incidence rate of non-hip fractures was stable during the transition period and gradually increased over time. Higher age, female sex, and history of previous major fractures were associated with increased fracture incidence both before and after dialysis initiation. We conclude that the incidence of major fractures, especially hip fractures, start to rise 6 months before initiation of dialysis therapy, indicating that heightened surveillance with implementation of preventive measures to avoid fractures is warranted during the transition period to dialysis.

Long-Term Effect of Denosumab on Bone Disease in Patients with CKD

“…7,8 Epidemiologic studies have shown that dialysis patients have a higher hip fracture risk than nondialyzed CKD patients and the general population. [9][10][11][12] Hip fracture is the most prevalent type of fracture in dialysis patients, and subsequent high mortality is well described. 11 Therefore, preventing hip fractures is crucial for achieving better clinical outcomes.…”

Fracture Management in Chronic Kidney Disease: Challenges and Considerations for Orthopedic Surgeons

“…A study using the Swedish Renal Registry 17) found that the incidence rate of hip fractures began to sharply increase 3 months before dialysis initiation, peaked at initiation, and then declined thereafter. In contrast, the incidence rate of non-hip fractures remained stable during the transition period and gradually increased over time.…”

“…Risk factors of fractures after KT include older age, female sex, diabetes, dialysis vintage before transplantation, previous history of fracture, and receipt of a kidney from a deceased donor rather than a living one. 18) While hip fractures are more common among dialysis patients, 16 17) studies 22 23) have shown that peripheral fractures, such as forearm or foot fractures, may be more common than hip fractures after KT. Although the overall incidence of hip fractures in HD patients is higher than that in PD or KT patients during the first 1 to 3 years after KT, the incidence of hip fractures among KT patients exceeds that among dialysis patients.…”

The Role of Alterations in Alpha-Klotho and FGF-23 in Kidney Transplantation and Kidney Donation

“…The spectrum includes disorders in bone turnover, impaired mineralization, and changes in bone volume (82,83). These abnormalities cause decreased mechanical strength with increased risk of fractures (84,85), and altered mineral metabolism with increased risk of ectopic calcification (86). Malluche et al reported a series of 630 bone biopsies from patients with CKD on dialysis.…”