Fracture Risk in Dialysis and Kidney Transplanted Patients: A Systematic Review.

Aboubacar Sidibé,Catherine Fortier,Sonia Jean,Lynne Moore,Louis‐Charles Desbiens,David Auguste,Fabrice Mac‐Way,Yue Pei Wang

doi:10.1002/jbm4.10067

Abstract

ABSTRACTChronic kidney disease is associated with an increased risk of fracture and cardiovascular mortality. The risk of fracture in hemodialysis (HD), peritoneal dialysis (PD) and kidney transplant (KT) patients is higher when compared with the general population. However, there exists a knowledge gap concerning which group has the highest risk of fracture. We aimed to compare the risk of fracture in HD, PD, and KT populations. We conducted a systematic review of observational studies evaluating the risk of fracture in HD, PD, or KT patients. Eligible studies were searched using MEDLINE, Embase, Web of Science, and Cochrane Library from their inception to January 2016, and in grey literature. Incidences (cumulative and rate) of fracture were described together using the median, according to fracture sites, the data source (administrative database or cohort and clinical registry), and fracture diagnosis method. Prevalence estimates were described separately. We included 47 studies evaluating the risk of fracture in HD, PD, and KT populations. In administrative database studies, incidence of hip fracture in HD (median 11.45 per 1000 person‐years [p‐y]), range: 9.3 to 13.6 was higher than in KT (median 2.6 per 1000 p‐y; range 1.5 to 3.8) or in PD (median 5.2 per 1000 p‐y; range 4.1 to 6.3). In dialysis (HD+PD), three studies reported a higher incidence of hip fracture than in KT. Prevalent vertebral fracture (assessed by X‐rays or questionnaire) reported in HD was in a similar range as that reported in KT. Incidence of overall fracture was similar in HD and KT, from administrative databases studies, but lower in HD compared with KT, from cohorts or clinical registry studies. This systematic review suggests an important difference in fracture risk between HD, PD, and KT population, which vary according to the diagnosis method for fracture identification. © 2018 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

Highlights

Chronic kidney disease (CKD) is a major public health issue worldwide
Patients with end-stage renal disease (ESRD) will eventually require a renal replacement therapy (RRT) and will be treated by hemodialysis (HD), peritoneal dialysis (PD), or kidney transplantation (KT).(13) The increased risk of fracture in HD, PD, and KT patients compared with the general population has been recognized.[8,14,15] hip fracture has been shown to be the most common type of fracture in ESRD with a fracture rate 17.2 times greater than that observed in the general population.[8,15] This association was Whereas Beaubrun and colleagues[17] reported in the United States that the incidence rate of hip fracture in HD patients was 20.6 per 1000 persons-years in 2009, Nair and colleagues[18] reported a much lower incidence rate of 3.8 per 1000 personyears in KT patients
After the first 3 years post-KT, the risk of fracture declined and tended to be equal that of HD patients.[19]. When comparing patients in dialysis, a recent study[2] showed that the risk of hip fracture in HD was 1.74-fold that in PD, whereas another study did not find any difference between HD, PD, and KT patients.[9]. Given these disparities, we conducted a systematic review to identify the risk of fracture and cardiovascular mortality post-fracture in HD compared with PD or KT and in PD compared with KT populations

Summary

Introduction

Chronic kidney disease (CKD) is a major public health issue worldwide. In 2011, more than 615,000 people suffered from end-stage renal disease (ESRD) in United States.[1,2] In 2012, the unadjusted prevalence of ESRD was 716.7 per million person (pmp) in Europe,(3) whereas 35,281 Canadians (excluding the province of Quebec) were suffering from ESRD in 2014.(4) Loss of kidney function leads to metabolic disorders that affect bone and vascular health known as CKD-mineral and bone disorder (CKD-MBD).(5–7) Clinically, CKD-MBD is associated with an increased risk of fracture and cardiovascular mortality.[8,9,10,11,12]Patients with ESRD will eventually require a renal replacement therapy (RRT) and will be treated by hemodialysis (HD), peritoneal dialysis (PD), or kidney transplantation (KT).(13) The increased risk of fracture in HD, PD, and KT patients compared with the general population has been recognized.[8,14,15] hip fracture has been shown to be the most common type of fracture in ESRD with a fracture rate 17.2 times greater than that observed in the general population.[8,15] This association was Whereas Beaubrun and colleagues[17] reported in the United States that the incidence rate of hip fracture in HD patients was 20.6 per 1000 persons-years in 2009, Nair and colleagues[18] reported a much lower incidence rate of 3.8 per 1000 personyears in KT patients. In 2011, more than 615,000 people suffered from end-stage renal disease (ESRD) in United States.[1,2] In 2012, the unadjusted prevalence of ESRD was 716.7 per million person (pmp) in Europe,(3) whereas 35,281 Canadians (excluding the province of Quebec) were suffering from ESRD in 2014.(4) Loss of kidney function leads to metabolic disorders that affect bone and vascular health known as CKD-mineral and bone disorder (CKD-MBD).(5–7) Clinically, CKD-MBD is associated with an increased risk of fracture and cardiovascular mortality.[8,9,10,11,12]. We conducted a systematic review to identify the risk of fracture and cardiovascular mortality post-fracture in HD compared with PD or KT and in PD compared with KT populations

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