Abstract
Maintenance dialysis is associated with almost universal changes in bone metabolism collectively known as chronic kidney disease—mineral and bone disorder (CKD-MBD). These are accompanied in various proportions by bone loss and altered bone quality that led to an increased risk of fracture. Osteoporosis, age-related or postmenopausal, a condition that often coexists with CKD, is also a leading cause of fracture. Dual-energy X-ray densitometry (DXA) is the main tool for assessing the bone quantity and bone loss and the associated fracture risk. It has been validated in both CKD-MBD and osteoporosis. Trabecular bone score (TBS) is a DXA-derived algorithm for the evaluation of bone microarchitecture, and its clinical value has been repeatedly demonstrated in large cohorts of osteoporotic patients. However, its utility in patients on maintenance dialysis has not been conclusively shown. Published studies showed a lower TBS score and implicitly an altered bone microarchitecture in patients on maintenance dialysis, even after adjusting for various variables. Moreover, FRAX-based fracture risk is higher after adjusting for TBS, showing promise on an algorithm better estimating the clinical fracture risk in dialysis patients. However, TBS has not been demonstrated to independently predict clinical fractures in prospective studies on dialysis patients. Also, aortic calcifications and altered fluid balance could significantly affect TBS score and could hamper the widespread clinical use in patients on maintenance dialysis. In this mini-review, we focus on the benefits and pitfalls of TBS in the management of CKD-MBD and fracture risk assessment in patients on maintenance dialysis.
Highlights
Maintenance dialysis has been repeatedly associated with an increased risk of hip (1, 2) nonvertebral (2) and vertebral (3) fractures
Most cases were hemodialysis patients (n = 236) while only 18 patients were on peritoneal dialysis and 2 were transplant recipients The largest and smallest Trabecular bone score (TBS) differences between dialysis patients and controls were encountered in the study of Yavropoulou et al (25) (1.11 ± 0.16 vs. 1.3 ± 0.13) and Dusceac et al (22) (0.07 [0.03– 0.1] lower in HD) respectively
Maintenance dialysis is associated with profound derangements of the mineral and bone metabolism that lead to an increased risk of fracture (34)
Summary
Maintenance dialysis has been repeatedly associated with an increased risk of hip (1, 2) nonvertebral (2) and vertebral (3) fractures. Its predictive value is significantly lower in dialysis than in the non-CKD population, probably because fracture risk is more dependent on low bone quality in these patients, a feature that is not captured by DXA (6). Based on the gray-scale variogram of DXA examination, the TBS correlates with the trabecular organization of the cancellous bone independent of the total amount of osseous tissue (11) This correlates with bone resistance and fracture risk (12) in the general population. Trabecular bone score (TBS) might be a promising tool for assessing fracture risk in patients on maintenance dialysis In theory, it might fill the gap between the fracture risk calculated based on hip BMD and the much higher observed risk of hip and non-vertebral fracture. The current study aims to review the available evidence on TBS in patients on maintenance dialysis and to provide a basis for future developments in this field
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