Fractures after kidney transplantation:​ incidence, predictors, and association with mortality

Iseri, Ken; Carrero, Juan Jesús; Evans, Marie; Felländer-Tsai, Li; Berg, Hans E.; 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 Institute, Stockholm, Sweden

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

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

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

Abstract and keywords

Background: Major fractures (MF) are associated with increased mortality in the general population and represent an even higher risk in patients with chronic kidney disease. We investigated incidence, predictors and clinical outcomes associated with first MF (MF_first) following kidney transplantation (KT).

Methods: We used the Swedish National Renal Registry of 3992 first KT recipients (2005–2016) (median age 53 years, 65% men) and identified all MF_first in hip, spine, humerus and forearm following KT. We estimated incidence rates and predictors of MF_first using flexible parametric hazard models and Fine-Gray analysis accounting for competing risk of death, and risk of all-cause mortality following MF_first using Cox proportional hazards models with fracture as time-varying exposure.

Results: During median follow-up of 4.8 years (IQR 2.2–7.9 years), there were 279 fractures of which 139 were forearm fractures. The crude incidence rate of MF_first (n = 279) was 13.5/1000 patient-years and that of hip fractures (n = 69) 3.4/1000 patient-years. The multivariate-adjusted fracture incidence rates were highest during the first 6 months following KT, and 86% higher in women than in men. High age, female sex, previous history of MF, diabetes nephropathy, pretransplant dialysis therapy and acute rejection were associated with increased risk for MF_first, whereas pre-emptive KT was associated with lower risk of MF_first. Spline curves showed markedly higher impact of higher age on risk of MF_first in women than in men. MF_first (n = 279) independently predicted increased all-cause mortality risk (hazard ratio, HR, 1.78(95%CI 1.35–2.36)). Among MF_first, with humerus fracture as reference, hip fracture (HR, 4.68(95%CI 1.56–14.06)) and spine fracture (HR, 4.02(95%CI 1.19–13.54)), but not forearm fracture (HR, 1.17 (95%CI 0.38–3.53)), were associated with increased all-cause mortality risk.

Conclusions: The initial 6 months following kidney transplantation is a high-risk period for MF. Among MF, hip fracture and spine fracture associate with substantially increased all-cause mortality risk.

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

Links

DOI: 10.1016/j.bone.2020.115554

PubMed: 32730931

WoS: 000572849900004

History

Received: 2020-04-1

Revised: 2020-07-21

Accepted: 2020-07-21

Online: 2020-07-28

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Cited By (1)

Year	Entry
2022	Tsujita M, Doi Y, Obi Y, Hamano T, Tomosugi T, Futamura K, Okada M, Hiramitsu T, Goto N, Isaka Y, Takeda A, Narumi S, Watarai Y. Cholecalciferol supplementation attenuates bone loss in incident kidney transplant recipients: a prespecified secondary endpoint analysis of a randomized controlled trial. J Bone Miner Res. February 2022;37(2):303-311.