Abstract
BackgroundFractures are a common morbidity that lead to worse outcomes in dialysis patients. Fetuin A inhibits vascular calcification (VC), potentially promotes bone mineralization and its level positively correlates with bone mineral density in the general population. On the other hand, the presence of VC is associated with low bone volume in dialysis patients. Whether the fetuin A level and VC can predict the occurrence of fractures in dialysis patients remains unknown.MethodsWe performed this prospective, observational cohort study including 685 dialysis patients (629 hemodialysis and 56 peritoneal dialysis) from a single center in Taiwan for a median follow-up period of 3.4 years. The baseline fetuin A level and status of presence of aortic arch calcification (VC) and incidence of major fractures (hip, pelvis, humerus, proximal forearm, lower leg or vertebrae) were assessed using adjusted Cox proportional hazards models, recursive partitioning analysis and competing risk models.ResultsOverall, 177 of the patients had major fractures. The incidence rate of major fractures was 3.29 per 100 person-years. In adjusted analyses, the patients with higher baseline fetuin A levels had a lower incidence of fractures (adjusted hazard ratio (HR), 0.3; 95% CI, 0.18‒0.5, fetuin A tertile 3 vs. tertile 1 and HR, 0.52; 95% CI, 0.34‒0.78, tertile 2 vs. tertile 1). The presence of aortic arch calcification (VC) independently predicted the occurrence of fractures (adjusted HR, 1.95; 95% CI, 1.34‒2.84) as well. When accounting for death as an event in competing risk models, the patients with higher baseline fetuin A levels remained to have a lower incidence of fractures (SHR, 0.31; 95% CI, 0.17‒0.56, fetuin A tertile 3 vs. tertile 1 and 0.51; 95% CI, 0.32‒0.81, tertile 2 vs. tertile 1).InterpretationsLower baseline fetuin A levels and the presence of VC were independently linked to higher risk of incident fractures in prevalent dialysis patients.
Highlights
Patients with chronic kidney disease (CKD), especially those undergoing dialysis, have unique mineral and endocrine disturbances which result in altered bone structure and function
The patients with higher baseline fetuin A levels had a lower incidence of fractures (adjusted hazard ratio (HR), 0.3; 95% confidence interval (CI), 0.18-0.5, fetuin A tertile 3 vs. tertile 1 and HR, 0.52; 95% CI, 0.34-0.78, tertile 2 vs. tertile 1)
The main finding of this study is that the prevalent dialysis patients with a higher baseline fetuin A level had a lower long-term risk of incident major fractures regardless of gender, dialysis modality (HD or peritoneal dialysis (PD)) and nutritional or inflammatory status; besides, patients with vascular calcification (VC) at study entry had a higher risk to have incident fracture
Summary
Patients with chronic kidney disease (CKD), especially those undergoing dialysis, have unique mineral and endocrine disturbances which result in altered bone structure and function. It has been shown that patients undergoing dialysis have higher rates of bone fractures compared to the general population.[1, 2] In addition, patients experiencing a major bone fracture (e.g. hip fracture) have been reported to have a remarkable increase in subsequent disability, death and hospitalization.[3,4,5] Several major risk factors such as abnormal intact parathyroid hormone (iPTH) levels, heavy comorbidity burden, sarcopenia, increased susceptibility to falls, and polypharmacy can increase the likelihood of fractures in dialysis patients.[2, 6, 7] the link between fractures and vascular calcification (VC), another major component of mineral bone disorders in CKD patients, is as yet uncertain. VC has a strong correlation with low bone volume in CKD patients, little is known about the interrelationship between VC and fractures in dialysis patients
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