Saudi Journal of Kidney Diseases and Transplantation

LETTER TO THE EDITOR
Year
: 2011  |  Volume : 22  |  Issue : 1  |  Page : 146--147

Fractures in patients of chronic kidney disease on maintenance hemodialysis


V Sivakumar, P Sriram Naveen, V.V. Sai Naresh, DG Sivaramakrishna 
 Department of Nephrology, Sri Venkateswara Institute of Medical Sciences, Tirupati 517507, Andhra Pradesh, India

Correspondence Address:
V Sivakumar
Department of Nephrology, Sri Venkateswara Institute of Medical Sciences, Tirupati 517507, Andhra Pradesh
India




How to cite this article:
Sivakumar V, Naveen P S, Naresh VS, Sivaramakrishna D G. Fractures in patients of chronic kidney disease on maintenance hemodialysis.Saudi J Kidney Dis Transpl 2011;22:146-147


How to cite this URL:
Sivakumar V, Naveen P S, Naresh VS, Sivaramakrishna D G. Fractures in patients of chronic kidney disease on maintenance hemodialysis. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2019 Dec 9 ];22:146-147
Available from: http://www.sjkdt.org/text.asp?2011/22/1/146/74384


Full Text

To the Editor,

Fractures in men and women with stage 5 Chronic Kidney Disease (CKD) are common and often associated with excessive morbidity and mortality. The relative risk of mortality is al­most twice as high for dialysis patients with hip fractures. [1] In addition, fractures impose a sig­nificant economic burden in their management. [2] United States Renal Data System (USRDS) shows that compared with fracture rates in general population, the risk of hip fractures is approximately fourfold greater in patients with stage 5 CKD, independent of age and sex. [3],[4] In CKD, while the patients were on hemodialysis, the risk factors for fractures were older age, female gender, low body mass index (BMI), peripheral vascular disease, increasing dialysis vintage, high iPTH levels (exceeding 300 pg/ mL), usage of drugs such as selective serotonin uptake inhibitors, antidepressants, benzodiaze­pines and narcotics and β-2 microglobulin amy­loidosis. [3]

Keeping this in view, we evaluated 44 patients on maintenance hemodialysis in our unit to study the demographic, mineral and bone density parameters between the group of patients with fractures and the group of patients with­out fractures. The details are summarized in [Table 1].{Table 1}

The data analysis showed a statistically signi­ficant relation between the association of frac­ture with the vintage of dialysis duration and serum albumin levels. We did not find any re­lation between the fractures and calcium, phos­phorus, iPTH levels. The distribution of fracture sites in our patients was fracture neck of femur in three, vertebral fractures in three, rib frac­tures in three, and pelvis, ulna and fibula frac­tures in one each. The patients with fracture neck of femur were surgically managed and the rest were managed by conservative methods.

There is a paradigm shift in the understanding of the mineral and bone disease in CKD with the introduction of the concept of bone strength by K/DOQI and KDIGO groups. [5] Bone strength reflects the integration of two main features: bone quality and bone density. The bone quality depends on the physical composition, architec­ture, turnover, damage, accumulation and mine­ralization. Bone histomorphometry helps partly in their understanding. The bone density is de­termined by peak bone mass and amount of bone loss described as osteopenia or osteoporo­sis. This is assessed by dual X-ray absorption (DXA). This suggests that bone strength and fracture risk, which are the key end points of bone disease in CKD, are determined by bone mineral density and bone quality. [5],[6]

In different studies on fractures in CKD, hy­perparathyroidism, low vitamin D levels, hyper­phosphatemia and increasing vintage of dialysis were found to be important risk factors for fractures. [3] In our study, we found low vitamin D levels in our patients.

In conclusion, we stress on taking adequate care in the nutritional management from the very early stages of CKD to prevent deficiency of vitamin D and also to prevent low albumin, so as to improve the bone strength. This is in addition to the planned management of mineral and bone disease as per K/DOQI guidelines in CKD patients.

References

1Mittalhenkle A, Gillen DL, Stehman-Breen CO. Increased risk of mortality associated with hip fracture in the dialysis population. Am J Kidney Dis 2004;44(4):672-9.
2Schumock GT, Sprague SM. Clinical and economic burden of fractures in patients with renal osteodystrophy. Clin Nephrol 2007;67(4): 201-8.
3Jadoul M. Towards the prevention of bone fractures in dialysed patients? Nephrol Dial Transplant 2007;22:3377-80.
4Dooley AC, Weiss NS, Kestenbaum B. Increased risk of hip fracture among men with CKD. Am J Kidney Dis 2008;51(1):38-44.
5Moe S, Drueke T, Cunningham J, et al. Defini­tion, evaluation, and classification of renal osteo­dystrophy: A position statement from kidney disease: Improving global outcomes (KDIGO). Kidney Int 2006;69:1945-53.
6Cunnigham J. Pathogenesis and prevention of bone loss in patients who have kidney disease and receive long-term immuno-suppression. J Am Soc Nephrol 2007;6:195-206.