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[Fragility fracture in the Chronic Kidney Disease (CKD)]
Maria Fusaro1,2, Andrea Aghi3, Maria Cristina Mereu4
1Consiglio Nazionale delle Ricerche (CNR) - Istituto di Fisiologia Clinica (IFC), Pisa e Dipartimento di Medicina, Università di Padova.
Insights
Fragility fractures are a significant concern in chronic kidney disease (CKD) patients. Advanced diagnostic tools and bone biomarkers can help identify high-risk individuals for better fracture prevention.
Area of Science:
- Nephrology
- Orthopedics
- Bone Metabolism
Background:
- Fragility fractures (FF) are prevalent in chronic kidney disease (CKD) patients, occurring more frequently and at younger ages than in the general population.
- These fractures contribute to substantial morbidity, mortality, and healthcare expenses.
- The exact mechanisms linking CKD and FF, beyond CKD-Mineral Bone Disorder (CKD-MBD), remain unclear, though uremic toxicity affecting bone quality (uremic osteoporosis) is implicated.
Purpose of the Study:
- To review current understanding and diagnostic approaches for fragility fractures in CKD patients.
- To highlight limitations of existing fracture risk prediction algorithms (FRAX, DeFRA) in CKD populations.
- To discuss the utility of various imaging and biochemical markers for assessing fracture risk in CKD.
Main Methods:
- Review of existing literature and guidelines (e.g., KDIGO) on CKD-MBD and fracture risk.
- Discussion of diagnostic techniques including Quantitative Vertebral Morphometry (QVM), Dual-energy X-ray Absorptiometry (DXA) for Bone Mineral Density (BMD), Trabecular Bone Score (TBS), and Quantitative Computerized Tomography (QCT).
- Evaluation of specific bone biomarkers such as parathyroid hormone (PTH) and bone alkaline phosphatase (BAP).
Main Results:
- DXA measurement of BMD is recognized by KDIGO for fracture risk assessment in stages G3a-G5D CKD.
- TBS provides valuable assessment of bone quality and fracture risk prediction.
- QCT, particularly HR-pQCT, and bone biomarkers (PTH, BAP) are useful adjuncts for risk stratification in CKD-MBD patients.
Conclusions:
- Multiple tools, including advanced imaging and biomarkers, are available for identifying CKD patients at high risk of fragility fractures.
- Accurate interpretation by experienced clinicians is crucial for effective implementation of these diagnostic approaches.
- Further research into pathogenic mechanisms and prospective studies are needed to refine risk prediction in this population.
Abstract:
Fragility fractures (FF) are common in patients with chronic kidney disease (CKD), and they occur at a younger age and with a higher frequency than in the general population, producing significant morbidity, mortality and healthcare costs. The pathogenic mechanisms underlying FF in CKD patients have not been completely understood. Behind CKD-MBD, the uremic toxicity should play a role in their pathogenesis, by affecting bone quality (uremic osteoporosis). There are very few prospective studies investigating risk factors for fragility fractures in CKD patients, and available algorithms for fracture risk prediction (FRAX and DeFRA) have never considered CKD. The diagnosis of vertebral fractures (FV), under-diagnosed in CKD patients as well as in general population, should be performed by Quantitative Vertebral Morphometry (QVM) both with DXA or Spine (D4-L5) x-Ray. A recent KDIGO review has qualified the measurement of the Bone Mineral Density by DXA as a predictive tool for fracture risk assessment in patients with stage G3a-G5D. Furthermore, the Trabecular Bone Score (TBS, software applied to DXA) allows the bone quality evaluation as well as the fracture risk prediction. Other techniques, such as Quantitative Computerized Tomography (QCT), especially High Resolution-peripheral QCT (HR-pQCT), have been shown to be useful, although expensive. Finally, some bone biomarkers (PTH and BAP) demonstrated to be informative for the definition of fracture risk in patients with CKD-MBD. In conclusion, there are several different tools and approaches that demonstrated to be useful for the identification of CKD patients at high risk of fracture, when these are appropriately performed and interpreted by expertise clinicians.
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