scholarly journals Bone fragility in patients with chronic kidney disease

2020 ◽  
Vol 9 (4) ◽  
pp. R93-R101
Author(s):  
Martine Cohen-Solal ◽  
Thomas Funck-Brentano ◽  
Pablo Ureña Torres
Keyword(s):  
Chronic Kidney Disease ◽  
Kidney Disease ◽  
Fracture Risk ◽  
Bone Mineralization ◽  
Imaging Techniques ◽  
Bone Diseases ◽  
Special Focus ◽  
Type I ◽  
Mineral Density ◽  
Bone Specific Alkaline Phosphatase

Mineral and bone diseases (MBD) are predominant in patients with chronic kidney disease (CKD) and lead to several bone manifestations, from pain to skeletal fractures. Cumulative traditional clinical risk factors, such as age and gender, in addition to those related to CKD, enhance the risk of comorbidity and mortality related to fractures. Despite great advances in understanding MBD in CKD, clinical and biological targets are lacking, which leads to under-management of fractures. Optimal PTH control results in a net improvement in defining the levels of bone remodeling. In addition, circulating biomarkers such as bone-specific alkaline phosphatase and cross-linked collagen type I peptide will also provide additional information about remodeling rate, bone mineralization and the evaluation of fracture risk. Imaging techniques identify patients at risk by measurement of bone mineral density by DEXA or by high peripheral QCT, which allow the discrimination of trabecular and cortical bone. Here, we have reviewed the literature related to epidemiology and the pathophysiological role of mineral and biochemical factors involved in CKD-MBD with a special focus on fracture risk. We also provide an algorithm that could be used for the management of bone diseases and to guide treatment decisions. Finally, the combined expertise of clinicians from various disciplines is crucial for the best prevention of fractures.

scholarly journals Association of Bone Mineral Density With Fractures Across the Spectrum of Chronic Kidney Disease: The Regina CKD-MBD Study

2019 ◽  
Vol 6 ◽  
pp. 205435811987053 ◽  
Author(s):  
Bhanu Prasad ◽  
Thomas Ferguson ◽  
Navdeep Tangri ◽  
Chee Yong Ng ◽  
Thomas L. Nickolas
Keyword(s):  
Risk Factors ◽  
Bone Mineral Density ◽  
Chronic Kidney Disease ◽  
Kidney Disease ◽  
Fracture Risk ◽  
Bone Mineral ◽  
Biochemical Markers ◽  
Clinical Risk Factors ◽  
Mineral Density ◽  
Clinical Risk

Background: Recent studies have demonstrated that measurement of areal bone mineral density by dual-energy x-ray absorptiometry (DXA) predicts fractures in patients with chronic kidney disease (CKD). However, whether fracture risk prediction through bone mineral density (BMD) is enhanced due to the assessment of biochemical markers of chronic kidney disease and mineral and bone disease (CKD-MBD) or clinical risk factors is not clear. We hypothesized that in a select cohort of patients managed in a CKD clinic, that combining T-Scores with biochemical markers would optimize fracture discrimination than using DXA alone. Objective: To examine the relationships among BMD, biochemical markers of CKD-MBD, and fracture risk across Kidney Disease Improving Global Outcomes (KDIGO) glomerular filtration rate (GFR) categories G3a to G5. Design: Retrospective study. Setting: Patients were recruited from the multidisciplinary CKD clinic, Regina General Hospital, Canada. Patients: A total of 374 patients who received a DXA scan upon initial referral to Regina Multidisciplinary CKD Program from January 31, 2001 to January 31, 2010, were included in this study. The patients were followed for a total of 5 years. Methods: We conducted a retrospective review of 374 consecutive patients who underwent DXA imaging at the point of entry into our multidisciplinary CKD program. Areal BMD, T- and Z-Scores were obtained at the lumbar spine, total hip, mean of left and right femoral neck, and the one-third radius. We collected data on demographic, cross-sectional biochemical markers of mineral metabolism and fractures (identified through self-reported questionnaires, hospital electronic medical records, and physician billing records). We were able to gather data on 8/11 variables of Fracture Risk Assessment (FRAX) tool. Results: In our cohort, 14.3% of GFR categories G3a and G3b, 15.7% of GFR category G4, and 19.7% of GFR category G5 experienced a clinical fracture during the study period. On multivariate analysis, each decline of 1.0 SD in total hip BMD T-Score was associated with a significant increase in the risk of fracture (OR = 1.46, 95% confidence interval [CI], 1.12-1.89). Adding CKD-MBD markers and clinical risk factors did not further contribute to the model. Low BMD was the only independent risk factor for fracture in patients with CKD. Limitations: Self-reporting by patients and administrative records were used to identify fractures. We did not perform spine imaging to ascertain morphometric vertebral fractures. We were unable to gather all 11 variables of FRAX score and information on ethnicity. We were unable to capture site of fracture (hips, spine, etc) from billing records. Albumin excretion rates were not collected at baseline. Treatment of the underlying bone disease with pharmacotherapeutic agents may have attenuated patients’ fracture risk and thus underestimated the association between BMD and future fracture. Conclusions: Our findings confirm that BMD predicts fracture. The addition of cross-sectional CKD-MBD parameters and clinical risk factors to BMD did not add to fracture prediction. Prospective studies should investigate the utility of longitudinal biochemical markers on improving fracture risk assessment.

scholarly journals Osteoclast-Released Wnt-10b Underlies Cinacalcet Related Bone Improvement in Chronic Kidney Disease

2019 ◽  
Vol 20 (11) ◽  
pp. 2800 ◽  
Author(s):  
Cai-Mei Zheng ◽  
Yung-Ho Hsu ◽  
Chia-Chao Wu ◽  
Chien-Lin Lu ◽  
Wen-Chih Liu ◽  
...  
Keyword(s):  
Chronic Kidney Disease ◽  
Kidney Disease ◽  
Bone Loss ◽  
Bone Fractures ◽  
Bone Mineralization ◽  
Critical Role ◽  
Beta Catenin ◽  
Mineral Density ◽  
High Turnover

Secondary hyperparathyroidism (SHPT) relates to high turnover bone loss and is responsible for most bone fractures among chronic kidney disease (CKD) patients. Changes in the Wingless/beta-catenin signaling (Wnt/β-catenin) pathway and Wnt inhibitors have been found to play a critical role in CKD related bone loss. A calcimimetic agent, cinacalcet, is widely used for SHPT and found to be similarly effective for parathyroidectomy clinically. A significant decrease in hip fracture rates is noted among US hemodialysis Medicare patients since 2004, which is probably related to the cinacalcet era. In our previous clinical study, it was proven that cinacalcet improved the bone mineral density (BMD) even among severe SHPT patients. In this study, the influence of cinacalcet use on bone mass among CKD mice was determined. Cinacalcet significantly reduced the cortical porosity in femoral bones of treated CKD mice. It also improved the whole-bone structural properties through increased stiffness and maximum load. Cinacalcet increased femoral bone wingless 10b (Wnt10b) expression in CKD mice. In vitro studies revealed that cinacalcet decreased osteoclast bone resorption and increased Wnt 10b release from osteoclasts. Cinacalcet increased bone mineralization when culturing the osteoblasts with cinacalcet treated osteoclast supernatant. In conclusion, cinacalcet increased bone quantity and quality in CKD mice, probably through increased bone mineralization related with osteoclast Wnt 10b secretion.

scholarly journals A study on WHO Frax score to predict fracture risk in predialysis patients of chronic kidney disease

2020 ◽  
Vol 8 (8) ◽  
pp. 2978
Author(s):  
Ramawtar Manda ◽  
Shashikant Bhargava
Keyword(s):  
Chronic Kidney Disease ◽  
Kidney Disease ◽  
Fracture Risk ◽  
Osteoporotic Fractures ◽  
World Health ◽  
Mineral Density ◽  
Mineral And Bone Disorder ◽  
Cross Sectional ◽  
Stage 4 ◽  
Frax Score

Background: Disturbances in mineral and bone metabolism are prevalent in chronic kidney disease (CKD) and are an important cause of morbidity and decreased quality of life. These disturbances include renal osteodystrophy and CKD-Mineral and Bone Disorder (CKD-MBD). The Frax tool developed by WHO is an attempt to better estimate the fracture risk. It calculates a 10 year probability of osteoporotic fractures of spine, forearm, hip or shoulder based on clinical risk factors with or without BMD measurements.Methods: It is a Cross sectional observational study which was done from 01 November 2013 to 31 March 2015. The study group included 60 cases of pre dialysis Chronic Kidney Disease attending OPD, Emergency or admitted in medicine wards of Dr. RML Hospital, New Delhi. Bone mineral density measured by dual-energy X-ray absorptiometry and all patients were classified according to World Health Organization criteria. DEXA SCAN (manufacturer-Hologic INC.) was done of the lumbar spine, radius bone and neck of the femur. Frax score was calculated as per WHO guidelines.Results: On using the Indian Frax calculator the average 10 year probability for major osteoporotic fractures in stage 4 (9.47±2.62%) was found to be significantly higher (p<0.0001) than that in stage 3 (1.92±0.8%).Similarly, the average 10 year probability for hip fracture in stage 4 (4.61±1.45%) was also found to be significantly higher (p< 0.0001) than that in the stage 3 (0.75±0.49%).Conclusions: The study confirmed the high incidence of low BMD in patients of CKD. The 10 year fracture risk in these patients as predicted by Frax score was significantly higher in CKD patients irrespective of whether the Chinese or the Indian calculator was used.

scholarly journals A review and perspective on the assessment, management and prevention of fragility fractures in patients with osteoporosis and chronic kidney disease

Endocrine ◽  
2021 ◽  
Author(s):  
Geeta Hampson ◽  
Grahame J. Elder ◽  
Martine Cohen-Solal ◽  
Bo Abrahamsen
Keyword(s):  
Chronic Kidney Disease ◽  
Kidney Disease ◽  
Fracture Risk ◽  
Severe Renal Impairment ◽  
Fracture Prevention ◽  
Close Monitoring ◽  
Mineral Density ◽  
Age Related ◽  
Selective Approach ◽  
Biochemical Abnormalities

AbstractThis article aims to review the methods used for the assessment of fracture risk and the use of osteoporosis medications for fracture prevention in the population with CKD, and highlights the difficulties faced by clinicians in the management of these patients and the latest recommendations and guidelines. Chronic kidney disease (CKD) and osteoporosis often co-exist in older adults, and they present a major healthcare challenge. CKD mineral and bone disorder (CKD-MBD) occurs as renal function declines and this syndrome affects most patients in CKD stages 4 and 5. The biochemical abnormalities of CKD-MBD, renal bone disease and risk factors associated with age-related bone loss and osteoporosis lead to a cumulative effect on fracture risk and mortality. There is a need for routine evaluation of fracture risk and fracture prevention in this population. Measurement of bone mineral density (BMD) and the use of the FRAX tool have predictive value for incident fractures in the general population and in CKD. This enables physicians to identify CKD patients most at risk of sustaining a fragility fracture and allows a more targeted approach to fracture prevention. Data analysis from the pivotal trials of therapeutic agents used in osteoporosis show that these drugs can be considered in mild and moderate CKD (stages 1–3 CKD). Off-label drug use in patients with CKD-MBD and more severe renal impairment (CKD stages 4 and 5) could offer significant benefits to sub-groups of patients when carefully tailored to each individual’s bone turnover and calcium and phosphate balance. However, this requires a selective approach and treatment decisions based on inference from pathophysiology while we await further trials. Guidelines advocate the correction and/or reduction of the biochemical abnormalities of CKD-MBD before initiation of treatment with osteoporosis drugs and close monitoring during treatment.

Densitometria ossea: una breve guida per il nefrologo

2019 ◽  
Vol 31 (2) ◽  
pp. 89-93
Author(s):  
Francesco Iannuzzella ◽  
Giulio Pioli ◽  
Mariarosa Maiorana ◽  
Mariacristina Gregorini
Keyword(s):  
Chronic Kidney Disease ◽  
Clinical Practice ◽  
Kidney Disease ◽  
Fracture Risk ◽  
Dual Energy ◽  
Clinical Applications ◽  
Response To Treatment ◽  
Special Focus ◽  
X Ray

Studies in patients with chronic kidney disease have definitively shown that “dual-energy X-ray absorptiometry” (DXA) may be helpful in assessing fracture risk. Moreover, it is essential to diagnose osteoporosis and evaluate response to treatment. In order to obtain the best utility from DXA, nephrologists need to know the fundamentals of this technique, its indications in clinical practice, and the potential pitfalls in the interpretation of its results. This review will provide an overview of the fundamentals, methodology, and current clinical applications of DXA with special focus on the nephrologist’s perspective.

THYROID DYSFUNCTION IN PATIENTS WITH CHRONIC KIDNEY DISEASE: THE STATE OF THE PROBLEM AND THE WAYS OF SOLVING

2018 ◽  
Vol 22 (4) ◽  
pp. 40-49 ◽  
Author(s):  
A. R. Volkova ◽  
O. D. Dygun ◽  
B. G. Lukichev ◽  
S. V. Dora ◽  
O. V. Galkina
Keyword(s):  
Chronic Kidney Disease ◽  
Thyroid Gland ◽  
Kidney Disease ◽  
Thyroid Hormones ◽  
Thyroid Function ◽  
Thyroid Dysfunction ◽  
The Body ◽  
Type I ◽  
Low T3 ◽  
Iodine Excretion

Disturbance of the thyroid function is often detected in patients with different profiles. A special feature of patients with chronic kidney  disease is the higher incidence of various thyroid function  disturbances, especially hypothyroidism. It is known that in patients  with chronic kidney disease (CKD) iodine excretion from the body is  violated, since normally 90% of iodine is excreted in urine.  Accumulation of high concentrations of inorganic iodine leads to the  formation of the Wolf-Chaikoff effect: suppression of iodine  organization in the thyroid gland and disruption of the thyroid  hormones synthesis. Peripheral metabolism of thyroid hormones is  also disturbed, namely, deiodinase type I activity is suppressed and  peripheral conversion of T4 into T3 is inhibited (so-called low T3  syndrome). Therefore, patients with CKD are often diagnosed with  hypothyroidism, and the origin of hypothyroidism is not always  associated with the outcome of autoimmune thyroiditis. The article  presents an overview of a large number of population studies of  thyroid gland dysfunction in patients with CKD, as well as  experimental data specifying the pathogenetic mechanisms of  thyroid dysfunction in patients with CKD. Therapeutic tactics are still  not regulated. However, in a number of studies, replacement therapy with thyroid hormones in patients with CKD had some advantages.

Hyperuricemia and Cardiovascular Disease

2019 ◽  
Vol 25 (6) ◽  
pp. 700-709 ◽  
Author(s):  
Shuangshuang Zhang ◽  
Yong Wang ◽  
Jinsong Cheng ◽  
Ning Huangfu ◽  
Ruochi Zhao ◽  
...  
Keyword(s):  
Cardiovascular Disease ◽  
Metabolic Syndrome ◽  
Chronic Kidney Disease ◽  
Uric Acid ◽  
Kidney Disease ◽  
Kidney Stones ◽  
Treatment Plan ◽  
Circulatory System ◽  
Special Focus ◽  
Positive Effects

Purine metabolism in the circulatory system yields uric acid as its final oxidation product, which is believed to be linked to the development of gout and kidney stones. Hyperuricemia is closely correlated with cardiovascular disease, metabolic syndrome, and chronic kidney disease, as attested by the epidemiological and empirical research. In this review, we summarize the recent knowledge about hyperuricemia, with a special focus on its physiology, epidemiology, and correlation with cardiovascular disease. This review also discusses the possible positive effects of treatment to reduce urate levels in patients with cardiovascular disease and hyperuricemia, which may lead to an improved clinical treatment plan.

scholarly journals The Use of Imaging Techniques in Chronic Kidney Disease-Mineral and Bone Disorders (CKD-MBD)—A Systematic Review

Diagnostics ◽  
2021 ◽  
Vol 11 (5) ◽  
pp. 772
Author(s):  
Ana Pimentel ◽  
Jordi Bover ◽  
Grahame Elder ◽  
Martine Cohen-Solal ◽  
Pablo Antonio Ureña-Torres
Keyword(s):  
Computed Tomography ◽  
Chronic Kidney Disease ◽  
Magnetic Resonance ◽  
Kidney Disease ◽  
Imaging Techniques ◽  
Quantitative Computed Tomography ◽  
Vertebral Fracture Assessment ◽  
Vascular Calcifications ◽  
Ckd Stage

Although frequently silent, mineral and bone disease (MBD) is one of the most precocious complication of chronic kidney disease (CKD) and is omnipresent in patients with CKD stage 5. Its pathophysiology is complex, but basically, disturbances in vitamin D, phosphate, and calcium metabolism lead to a diverse range of clinical manifestations with secondary hyperparathyroidism usually being the most frequent. With the decline in renal function, CKD-MBD may induce microstructural changes in bone, vascular system and soft tissues, which results in macrostructural lesions, such as low bone mineral density (BMD) resulting in skeletal fractures, vascular and soft tissue calcifications. Moreover, low BMD, fractures, and vascular calcifications are linked with increased risk of cardiovascular mortality and all-cause mortality. Therefore, a better characterization of CKD-MBD patterns, beyond biochemical markers, is helpful to adapt therapies and monitor strategies as used in the general population. An in-depth characterization of bone health is required, which includes an evaluation of cortical and trabecular bone structure and density and the degree of bone remodeling through bone biomarkers. Standard radiological imaging is generally used for the diagnosis of fracture or pseudo-fractures, vascular calcifications and other features of CKD-MBD. However, bone fractures can also be diagnosed using computed tomography (CT) scan, magnetic resonance (MR) imaging and vertebral fracture assessment (VFA). Fracture risk can be predicted by bone densitometry using dual-energy X-ray absorptiometry (DXA), quantitative computed tomography (QTC) and peripheral quantitative computed tomography (pQTC), quantitative ultrasound (QUS) and most recently magnetic resonance micro-imaging. Quantitative methods to assess bone consistency and strength complete the study and adjust the clinical management when integrated with clinical factors. The aim of this review is to provide a brief and comprehensive update of imaging techniques available for the diagnosis, prevention, treatment and monitoring of CKD-MBD.

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