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The Challenge of Fractures in Patients With Chronic Kidney Disease
Andrea G Kattah1, Silvia M Titan1, Robert A Wermers2
1Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota.
Insights
Patients with chronic kidney disease (CKD) face higher fracture risks due to complex bone disease. Current diagnostic and treatment guidelines for CKD bone disease and fracture prevention are insufficient.
Area of Science:
- Nephrology
- Bone Metabolism
- Geriatrics
Background:
- Individuals with chronic kidney disease (CKD) exhibit a significantly elevated risk of fractures compared to the general population.
- Fractures in CKD patients are linked to increased mortality and diminished quality of life.
- Standard approaches for evaluating bone disease and fracture risk in the general population are not directly applicable to CKD patients.
Purpose of the Study:
- To review the pathophysiology of CKD-mineral bone disorder (CKD-MBD).
- To assess current fracture risk assessment strategies in CKD.
- To examine therapeutic options for bone disease in CKD patients.
Main Methods:
- A comprehensive literature review was conducted using PubMed.
- Studies included focused on CKD-MBD pathophysiology, fracture risk assessment, and treatment options.
Main Results:
- Elevated fracture risk in CKD stems from a complex interplay of bone turnover, mineralization, and volume (TMV), compounded by declining glomerular filtration rate.
- Diagnosing renal osteodystrophy requires more than bone density and traditional osteoporosis risk factors.
- Existing fracture risk tools have limitations in the CKD population.
- Treatment decisions must consider TMV components, CKD stage, and comorbidities, though TMV assessment is not well-established.
Conclusions:
- Limited data exist on the efficacy and safety of fracture prevention treatments specifically for CKD patients.
- There is an urgent need for clearer guidelines on diagnosing, stratifying fracture risk, and treating bone disease in CKD.
- Emerging osteoporosis medications necessitate updated clinical guidelines for CKD bone management.
Objective:
People with chronic kidney disease (CKD) are at increased risk of fractures in comparison to the non-CKD population, and fractures are associated with high mortality and worsening quality of life. However, the approach for evaluation of bone disease and fracture risk in CKD is different from the approach in the general population.
Methods:
The authors conducted a literature review of PubMed to include studies on pathophysiology of CKD mineral bone disorder, fracture risk assessment, and therapeutic options in the setting of CKD.
Results:
The higher risk observed in the CKD population is related to the complex interplay of changes in bone turnover (T), mineralization (M), and volume (V), along with other risk factors accumulated as glomerular filtration rate declines. The diagnosis of the type of renal osteodystrophy is not based only on assessment of bone density and traditional risk factors for osteoporosis. There are limitations of currently available fracture risk tools in the CKD population. Treatment choice should take into consideration the 3 components of the TMV classification along with the stage of kidney disease and comorbidities, but the assessment of these components has not been well established.
Conclusions:
Current data are limited on efficacy and safety of treatments for fracture prevention in CKD. As new medications for the treatment of osteoporosis become available, there is an urgency to establish more clear guidelines for the diagnosis, fracture risk stratification, and treatment of bone disease in CKD.
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