Major fractures after initiation of dialysis:​ incidence, predictors and association with mortality

Iseri, Ken; Carrero, Juan Jesús; Evans, Marie; Felländer-Tsai, Li; Berg, Hans; Runesson, Björn; Stenvinkel, Peter; Lindholm, Bengt; Qureshi, Abdul Rashid

Affiliations

¹Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden

²Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan

³Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden

⁴Division of Orthopaedics and Biotechnology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden

Abstract and keywords

Background: Major fractures (MF) are common in dialysis patients. We investigated incidence, predictors and clinical outcomes associated with first MF occurring after initiation of dialysis (MF_first).

Methods: In Swedish Renal Registry of 9714 incident (2005–2016) dialysis patients (age 68 years, 67% men), we identified all MF_first in hip, spine, humerus and forearm. Using flexible parametric hazard models and Fine-Gray analysis, we estimated incidence, mortality rates and predictors of MF_first, and, in time-dependent analysis, risk of all-cause and cardiovascular disease (CVD) mortality following MF_first.

Results: During median follow-up of 2.2 years, the crude incidence rate of MF_first (n = 835) was 23.7/1000 patient-years and that of hip fractures (n = 470) 13.3/1000 patient-years. The multivariate-adjusted fracture incidence rates increased gradually after dialysis initiation and were 47% higher among women. Female sex, higher age, comorbidity, and previous history of MF (MF_previous) were associated with increased risk for MF_first, whereas peritoneal dialysis as compared to hemodialysis was associated with decreased risk. The adjusted fracture incidence rate of MF_first during the first 90 days following dialysis initiation was higher in patients with MF_previous than in those without MF_previous. MF_first independently predicted increased all-cause (sub-distribution hazard ratio, SHR, 1.67(95%CI 1.47–1.91)) and CVD (SHR 1.49 (95%CI 1.22–1.84)) mortality. Adjusted mortality rate following hip fractures was higher than for other types of MF. Spline curves showed that mortality following MF_first was highest during the first 6 months of follow-up.

Conclusions: MF are common and associated with increased mortality in incident dialysis patients.

Keywords: Osteoporosis; Fracture; End-stage renal disease; Dialysis; Mortality; Renal osteodystrophy

Links

DOI: 10.1016/j.bone.2020.115242

PubMed: 31958531

WoS: 000517355400014

History

Received: 2019-12-20

Revised: 2020-01-15

Accepted: 2020-01-15

Online: 2020-01-17

Cited Works (4)

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Cited By (4)

Year	Entry
2020	Iseri K, Carrero JJ, Evans M, Felländer-Tsai L, Berg HE, Runesson B, Stenvinkel P, Lindholm B, Qureshi AR. Fractures after kidney transplantation: incidence, predictors, and association with mortality. Bone. November 2020;140:115554.
2021	Iseri K, Carrero JJ, Evans M, Runesson B, Stenvinkel P, Lindholm B, Berg HE, Felländer-Tsai L, Qureshi AR. Secular trends in hip fracture incidence and subsequent mortality in dialysis patients and the general population in Sweden. Bone. June 2021;147:115909.
2020	Iseri K, Carrero JJ, Evans M, Felländer‐Tsai L, Berg HE, Runesson B, Stenvinkel P, Lindholm B, Qureshi AR. Incidence of fractures before and after dialysis initiation. J Bone Miner Res. December 2020;35(12):2372-2380.
2020	Sharma AK. Evaluation of Renal Bone Disease: Advancing Our Understanding of Associations and Diagnostic Challenges [PhD thesis]. University of Melbourne; April 2020.