Hip fracture in patients with non-dialysis chronic kidney disease stage 5

AbstractHip fracture is a significant health problem and is associated with increased mortality. Patients with chronic kidney disease (CKD) are more at risk of hip fracture than the general population, but the hip fracture risk is not evident among non-dialysis CKD stage 5 patients. This study aims to assess the risk of hip fracture in patients with non-dialysis CKD stage 5 comparing to those with CKD stages 1–4. Patients with non-dialysis CKD stage 5 and CKD stages 1–4 were retrieved from Taiwan longitudinal health insurance database 2011–2014. All patients were followed to the end of 2018 for the development of hip fractures. We analyze the risk of hip fracture of propensity score-matched patients with CKD stage 5 compared to patients with CKD stages 1–4 using stepwise Cox regression and competing risks regression. We analyzed 5649 propensity score-matched non-dialysis CKD 1–4 patients and non-dialysis CKD 5 patients between 2011 and 2014. All patients were followed to the end of 2018, 229 (4.1%) of CKD 1–4 patients in 21,899 patient-year, and 290 (5.1%) of CKD 5 patients had hip fractures in 18,137 patient-year. CKD 5 patients had a higher risk of hip fracture than patients with CKD stages 1–4. The adjusted HR was 1.53 (95% CI 1.08–1.54) in the Cox regression with adjustments for age, gender, comorbidity, and history of fracture. In the competing risks regression, the subdistribution hazard ratio was 1.29 (95% CI 1.08–1.54). Female gender, age, history of fractures, and Charlson–Deyo comorbidity index were independently associated with increased hip fracture risks. Non-dialysis CKD 5 patients had a higher risk of hip fracture than patients with CKD stages 1–4. This association is independent of patients’ age, female gender, history of fractures, and comorbidities.

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Fractures and their sequelae in non-dialysis-dependent chronic kidney disease: the Stockholm CREAtinine Measurement project

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfz142 ◽

2019 ◽

Vol 35 (11) ◽

pp. 1908-1915 ◽

Cited By ~ 3

Author(s):

Björn Runesson ◽

Marco Trevisan ◽

Ken Iseri ◽

Abdul Rashid Qureshi ◽

Bengt Lindholm ◽

...

Keyword(s):

Chronic Kidney Disease ◽

Kidney Disease ◽

Hip Fractures ◽

Cox Regression ◽

Adverse Outcomes ◽

Care Utilization ◽

Cardiac Events ◽

Increased Risk ◽

Ckd Stage ◽

Creatinine Measurement

Abstract Introduction People undergoing maintenance dialysis are at high risk for fractures, but less is known about fracture incidence and associated outcomes in earlier stages of chronic kidney disease (CKD). Methods We conducted an observational analysis from the Stockholm Creatinine Measurement project, a Swedish health care utilization cohort during 2006–11. We identified all adults with confirmed CKD Stages 3–5 and no documented history of fractures and extracted information on comorbid history, ongoing medication, cardiovascular events and death. We studied incidence rates of fractures (overall and by location), with the estimated glomerular filtration rate (eGFR) as time-dependent exposure. We then studied hazard ratios [HRs and 95% confidence intervals (CIs)] for the events of death and major adverse cardiac events (MACE) using Cox regression with fracture as time-varying exposure. Results We identified 68 764 individuals with confirmed CKD (mean age 79 years, 56% women). During a median follow-up of 2.7 years, 9219 fractures occurred, of which 3105 were hip fractures. A more severe CKD stage was associated with a higher risk of fractures, particularly hip fractures: compared with CKD Stage 3a, the adjusted HR was 1.10 (95% CI 1.02–1.19), 1.32 (1.17–1.49) and 2.47 (1.94–3.15) for CKD Stage 3b, 4 and 5, respectively. Spline curves suggested a linear association with fracture risk with an eGFR <30 mL/min/1.73 m2. Compared with non-fracture periods, incident fracture was associated with a 4-fold increased mortality within 90 days [HR 4.21 (95% CI 3.95–4.49)]. The risk remained elevated beyond 90 days [HR 1.47 (95% CI 1.40–1.54)] and was stronger after hip fractures. Post-fracture MACE risk was also highest in the first 90 days [HR 4.02 (95% CI 3.73–4.33)], particularly after hip fractures, and persisted beyond 90 days [HR 1.20 (95% CI 1.10–1.30)]. Conclusion Our findings highlight the commonness of fractures and the increased risk for subsequent adverse outcomes in CKD patients. These results may inform clinical decisions regarding post-fracture clinical surveillance and fracture prevention strategies.

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The urinary proteomics classifier chronic kidney disease 273 predicts cardiovascular outcome in patients with chronic kidney disease

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfz242 ◽

2019 ◽

Cited By ~ 4

Author(s):

Francis Verbeke ◽

Justyna Siwy ◽

Wim Van Biesen ◽

Harald Mischak ◽

Anneleen Pletinck ◽

...

Keyword(s):

Chronic Kidney Disease ◽

Kidney Disease ◽

Cox Regression ◽

Total Mortality ◽

Independent Information ◽

Increased Risk ◽

Ckd Stage ◽

History Of ◽

Cv Disease ◽

Stratified Analysis

Abstract Background The urinary proteomic classifier chronic kidney disease 273 (CKD273) is predictive for the development and progression of chronic kidney disease (CKD) and/or albuminuria in type 2 diabetes. This study evaluates its role in the prediction of cardiovascular (CV) events in patients with CKD Stages G1–G5. Methods We applied the CKD273 classifier in a cohort of 451 patients with CKD Stages G1–G5 followed prospectively for a median of 5.5 years. Primary endpoints were all-cause mortality, CV mortality and the composite of non-fatal and fatal CV events (CVEs). Results In multivariate Cox regression models adjusting for age, sex, prevalent diabetes and CV history, the CKD273 classifier at baseline was significantly associated with total mortality and time to fatal or non-fatal CVE, but not CV mortality. Because of a significant interaction between CKD273 and CV history (P = 0.018) and CKD stages (P = 0.002), a stratified analysis was performed. In the fully adjusted models, CKD273 classifier was a strong and independent predictor of fatal or non-fatal CVE only in the subgroup of patients with CKD Stages G1–G3b and without a history of CV disease. In those patients, the highest tertile of CKD273 was associated with a >10-fold increased risk as compared with the lowest tertile. Conclusions The urinary CKD273 classifier provides additional independent information regarding the CV risk in patients with early CKD stage and a blank CV history. Determination of CKD273 scores on a random urine sample may improve the efficacy of intensified surveillance and preventive strategies by selecting patients who potentially will benefit most from early risk management.

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Pre-eclampsia and risk of later kidney disease: nationwide cohort study

BMJ ◽

10.1136/bmj.l1516 ◽

2019 ◽

pp. l1516 ◽

Cited By ~ 22

Author(s):

Jonas H Kristensen ◽

Saima Basit ◽

Jan Wohlfahrt ◽

Mette Brimnes Damholt ◽

Heather A Boyd

Keyword(s):

Chronic Kidney Disease ◽

Cohort Study ◽

Kidney Disease ◽

Outcome Measure ◽

Cox Regression ◽

Hazard Ratio ◽

Hazard Ratios ◽

Gestational Age At Delivery ◽

History Of

ABSTRACTObjectiveTo investigate associations between pre-eclampsia and later risk of kidney disease.DesignNationwide register based cohort study.SettingDenmark.PopulationAll women with at least one pregnancy lasting at least 20 weeks between 1978 and 2015.Main outcome measureHazard ratios comparing rates of kidney disease between women with and without a history of pre-eclampsia, stratified by gestational age at delivery and estimated using Cox regression.ResultsThe cohort consisted of 1 072 330 women followed for 19 994 470 person years (average 18.6 years/woman). Compared with women with no previous pre-eclampsia, those with a history of pre-eclampsia were more likely to develop chronic renal conditions: hazard ratio 3.93 (95% confidence interval 2.90 to 5.33, for early preterm pre-eclampsia (delivery <34 weeks); 2.81 (2.13 to 3.71) for late preterm pre-eclampsia (delivery 34-36 weeks); 2.27 (2.02 to 2.55) for term pre-eclampsia (delivery ≥37 weeks). In particular, strong associations were observed for chronic kidney disease, hypertensive kidney disease, and glomerular/proteinuric disease. Adjustment for cardiovascular disease and hypertension only partially attenuated the observed associations. Stratifying the analyses on time since pregnancy showed that associations between pre-eclampsia and chronic kidney disease and glomerular/proteinuric disease were much stronger within five years of the latest pregnancy (hazard ratio 6.11 (3.84 to 9.72) and 4.77 (3.88 to 5.86), respectively) than five years or longer after the latest pregnancy (2.06 (1.69 to 2.50) and 1.50 (1.19 to 1.88). By contrast, associations between pre-eclampsia and acute renal conditions were modest.Conclusions Pre-eclampsia, particularly early preterm pre-eclampsia, was strongly associated with several chronic renal disorders later in life. More research is needed to determine which women are most likely to develop kidney disease after pre-eclampsia, what mechanisms underlie the association, and what clinical follow-up and interventions (and in what timeframe post-pregnancy) would be most appropriate and effective.

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Hypertension, Chronic Kidney Disease, and Renal Pathology in a Child with Hermansky-Pudlak Syndrome

International Journal of Nephrology ◽

10.4061/2011/324916 ◽

2011 ◽

Vol 2011 ◽

pp. 1-5 ◽

Cited By ~ 4

Author(s):

Roberto Gordillo ◽

Marcela Del Rio ◽

David B. Thomas ◽

Joseph T. Flynn ◽

Robert P. Woroniecki

Keyword(s):

Chronic Kidney Disease ◽

Kidney Disease ◽

Chronic Kidney Disease Stage ◽

Stage Ii ◽

Renal Pathology ◽

Disease Stage ◽

Not Otherwise Specified ◽

Ckd Stage ◽

History Of ◽

Hermansky Pudlak Syndrome

We report a child with Hermansky-Pudlak Syndrome (HPS) and chronic kidney disease (stage II) with histological diagnosis of focal segmental glomerulosclerosis (FSGS). A 15-year-old male of Puerto Rico ancestry with history of HPS, hypertension (HTN), asthma, obesity, and chronic kidney disease (CKD) stage II presented with new-onset proteinuria without edema. His blood pressure had been controlled, serum creatinine had been 0.9–1.4 mg/dL, and first morning urine protein/creatinine ratio (UPC) ranged from 0.2 to 0.38. Due to persistent nonorthostatic proteinuria with CKD, renal biopsy was performed and FSGS (not otherwise specified) with chronic diffuse tubulopathy (tubular cytoplasmic droplets) and acute tubular injury was reported. Ceroid-like material is known to infiltrate tissues (i.e., lungs, colon, and kidney) in HPS, but the reason for the renal insufficiency is unknown. Nonspecific kidney disease and in one adult case IgA nephropathy with ANCA-positive glomerulonephritis have previously been reported in patients with Hermansky-Pudlak syndrome. To our knowledge, we report the first pediatric renal pathology case of HPS associated with CKD. This paper discusses presentation and management of renal disease in HPS.

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Increased hip fracture and mortality in chronic kidney disease individuals: The importance of competing risks

Bone ◽

10.1016/j.bone.2014.12.020 ◽

2015 ◽

Vol 73 ◽

pp. 154-159 ◽

Cited By ~ 24

Author(s):

María José Pérez-Sáez ◽

Daniel Prieto-Alhambra ◽

Clara Barrios ◽

Marta Crespo ◽

Dolores Redondo ◽

...

Keyword(s):

Chronic Kidney Disease ◽

Hip Fracture ◽

Kidney Disease ◽

Competing Risks

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Fistula and Survival Outcomes after Fistula Creation among Predialysis Chronic Kidney Disease Stage 5 Patients

American Journal of Nephrology ◽

10.1159/000466707 ◽

2017 ◽

Vol 45 (4) ◽

pp. 356-364

Author(s):

Masahito Miyamoto ◽

Noriaki Kurita ◽

Kotaro Suemitsu ◽

Masaaki Murakami

Keyword(s):

Chronic Kidney Disease ◽

Kidney Disease ◽

Chronic Kidney Disease Stage ◽

Female Gender ◽

Japanese Patients ◽

Disease Stage ◽

Secondary Outcome ◽

Multicenter Cohort Study ◽

Ckd Stage ◽

Japanese Guideline

Background: Most guidelines recommend the creation of arteriovenous fistula (AVF) in patients with chronic kidney disease (CKD) stage 4. However, an increasing number of studies suggest that early AVF creation leads to high rates of AVF failure and death before dialysis commencement. Only the Japanese guideline recommends AVF creation at CKD stage 5; however, no data are available regarding access-related outcomes at this stage. Method: This was a multicenter cohort study involving Japanese CKD stage 5 patients who underwent preemptive AVF creation from 2009 to 2013. The primary outcome was unnecessary AVF creation, defined as death before requiring dialysis or AVF failure before dialysis commencement. The secondary outcome was dialysis commencement. The associations with candidate predictors and the outcomes were examined. Results: A total of 303 patients were registered. Four cases of death before dialysis and 13 cases of AVF failure before dialysis commencement were observed. A total of 283 patients who advanced to dialysis were found to have functional AVFs. The cumulative incidences of unnecessary AVF creation and dialysis commencement at 1 year were 4.8 and 89.3%, respectively. Competing risk regression analyses showed that age ≥75 years (subhazard ratio [SHR] 3.12, 95% CI 1.20-8.09) and female gender (SHR 3.31, 95% CI 1.20-9.09) were associated with unnecessary AVF creation. Conclusions: A low incidence of unnecessary AVF creation was revealed among Japanese patients who received AVF at CKD stage 5. These results may help clarify the natural history of unnecessary AVF creation for other countries reformatting their guidelines regarding late vascular access creation.

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Tryptophan levels associate with incident cardiovascular disease in chronic kidney disease

Clinical Kidney Journal ◽

10.1093/ckj/sfaa031 ◽

2020 ◽

Cited By ~ 4

Author(s):

Vetalise C Konje ◽

Thekkelnaycke M Rajendiran ◽

Keith Bellovich ◽

Crystal A Gadegbeku ◽

Debbie S Gipson ◽

...

Keyword(s):

Risk Factors ◽

Cardiovascular Disease ◽

Chronic Kidney Disease ◽

Kidney Disease ◽

Receiver Operating Curve ◽

Cvd Risk ◽

Diabetes Status ◽

Ckd Stage ◽

History Of

Abstract Background Non-traditional risk factors like inflammation and oxidative stress play an essential role in the increased cardiovascular disease (CVD) risk prevalent in chronic kidney disease (CKD). Tryptophan catabolism by the kynurenine pathway (KP) is linked to systemic inflammation and CVD in the general and dialysis population. However, the relationship of KP to incident CVD in the CKD population is unknown. Methods We measured tryptophan metabolites using targeted mass spectrometry in 92 patients with a history of CVD (old CVD); 46 patients with no history of CVD and new CVD during follow-up (no CVD); and 46 patients with no CVD history who developed CVD in the median follow-up period of 2 years (incident CVD). Results The three groups are well-matched in age, gender, race, diabetes status and CKD stage, and only differed in total cholesterol and proteinuria. Tryptophan and kynurenine levels significantly decreased in patients with ‘Incident CVD’ compared with the no CVD or old CVD groups (P = 5.2E–7; P = 0.003 respectively). Kynurenic acid, 3-hydroxykynurenine and kynurenine are all increased with worsening CKD stage (P < 0.05). An increase in tryptophan levels at baseline was associated with 0.32-fold lower odds of incident CVD (P = 0.000014) compared with the no CVD group even after adjustment for classic CVD risk factors. Addition of tryptophan and kynurenine levels to the receiver operating curve constructed from discriminant analysis predicting incident CVD using baseline clinical variables increased the area under the curve from 0.76 to 0.82 (P = 0.04). Conclusions In summary, our study demonstrates that low tryptophan levels are associated with incident CVD in CKD.

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Loss of the Normal Gradient in Arterial Compliance and Outcomes of Chronic Kidney Disease Patients

Cardiorenal Medicine ◽

10.1159/000500479 ◽

2019 ◽

Vol 9 (5) ◽

pp. 297-307

Author(s):

Qiong Bai ◽

Chun-Yan Su ◽

Ai-Hua Zhang ◽

Tao Wang ◽

Wen Tang

Keyword(s):

Patient Outcome ◽

Chronic Kidney Disease ◽

Regression Analysis ◽

Kidney Disease ◽

Cox Regression ◽

Arterial Compliance ◽

Prognostic Significance ◽

Significant Interaction Effect ◽

Cox Regression Analysis ◽

Ckd Stage

Background: In dialysis patients, loss of the normal gradient in arterial compliance, assessed by the pulse wave velocity (PWV) ratio, predicts all-cause mortality better than does carotid-femoral PWV (CF-PWV) alone. However, the prognostic significance of the PWV ratio for outcome in chronic kidney disease (CKD) patients remains unclear. Methods: In this longitudinal cohort study, CKD patients who visited our CKD management clinic between April 27, 2006, and March 27, 2008, were included and followed up. To assess the gradient in arterial compliance, the PWV ratio was calculated using CF-PWV divided by carotid-radial PWV. Results: A total of 209 patients in CKD stages 1–4 with a median follow-up of 3.74 years were included. Patients with higher PWV ratio were relatively older (p < 0.001) and had worse renal function (p < 0.001), more hypertension (p < 0.001), diabetes mellitus (p < 0.001), and cardiovascular or cerebrovascular disease (p < 0.001). The median time to patient outcome (death, renal replacement therapy, or double increase in serum creatinine from baseline) in the group with a PWV ratio above the median (89.8 months, 95% CI 84.2–95.5) was shorter than that in the group with a PWV ratio below the median (105.3 months, 95% CI 101.3–109.3, p = 0.001). Univariate Cox regression analysis showed that both PWV ratio and CF-PWV were significantly associated with patient outcome. In multivariate Cox regression analysis, both PWV ratio and CF-PWV were associated with patient outcome. However, the HR for CF-PWV (2.177, 95% CI 1.064–4.453, p = 0.033) was slightly higher than that for PWV ratio (2.091, 95% CI 1.049–4.167, p = 0.036). There was a significant interaction effect between PWV ratio and CKD stage. It was shown that patients with advanced CKD stages and higher PWV ratios had a significantly higher risk of adverse CKD outcome (p = 0.006). Conclusions: The PWV ratio, as a measure of loss of the normal gradient in arterial compliance, was associated with CKD patient outcome. Patients with advanced CKD and a higher PWV ratio had a significantly higher risk of adverse CKD outcome.

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Predictors of long-term renal function after kidney surgery for patients with preoperative chronic kidney disease

Canadian Urological Association Journal ◽

10.5489/cuaj.6485 ◽

2020 ◽

Vol 15 (2) ◽

Author(s):

Andrew Silagy ◽

Emily Zabor ◽

Roy Mano ◽

Renzo DiNatale ◽

Julian Marcon ◽

...

Keyword(s):

Chronic Kidney Disease ◽

Renal Function ◽

Kidney Disease ◽

Kidney Cancer ◽

Cumulative Incidence ◽

Radical Nephrectomy ◽

Cox Regression ◽

Cancer Specific Survival ◽

Kidney Surgery ◽

Ckd Stage

Introduction: We evaluated the trajectory of estimated glomerular filtration rate (eGFR) after kidney surgery in patients with kidney cancer and chronic kidney disease (CKD). Methods: We identified 1204 consecutive patients in our institutional database with preoperative CKD undergoing partial or radical nephrectomy from 1998–2016. Postoperative eGFR was tracked, with patients censored when receiving dialysis or kidney transplantation. A multivariable mixed-effects models assessed associations between preoperative baseline patient and tumor characteristics, and longitudinal eGFR. The Kaplan-Meier method and multivariable Cox regression were used to estimate overall survival, cancer-specific survival, and cumulative incidence of dialysis. Results: Preoperatively, 892 (74.1%), 271 (22.5%), and 41 (3.4%) patients had CKD stage 3a, 3b, and 4/5, respectively. There were 55 patients dialyzed and 355 deaths (99 from kidney cancer). Median followup was 8.1 years, with 25 781 postoperative eGFR measurements. Factors associated with decreasing eGFR postoperatively included radical nephrectomy, male gender, older age, increased body mass index (BMI), and cardiovascular risk factors. We observed a significant interaction effect between time from surgery and preoperative CKD stage: the eGFR of stage 3a patients improved, while stage ≥3b declined (p<0.001). The two- year and five-year cumulative incidence of dialysis was 1.8% (1.1–2.6%) and 3.1% (2.2–4.2%), respectively. The cumulative incidence of dialysis, with death as a competing event, significantly differed by preoperative CKD stage. Conclusions: Preoperative CKD stage ≥3b is independently associated with a higher risk of declining renal function, dialysis, and mortality. With careful selection, patients with preoperative CKD withstand kidney surgery with low rates of dialysis.

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Prolonged Hypocalcemia After a Single Dose of Denosumab in Chronic Kidney Disease

Journal of the Endocrine Society ◽

10.1210/jendso/bvab048.439 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

pp. A216-A217

Author(s):

Akshan Puar ◽

Zeb Ijaz Saeed

Keyword(s):

Chronic Kidney Disease ◽

Vitamin D ◽

Alkaline Phosphatase ◽

Single Dose ◽

Calcium Carbonate ◽

Kidney Disease ◽

Serum Calcium ◽

Ckd Stage ◽

25 Hydroxy Vitamin D ◽

History Of

Abstract Introduction: Denosumab, a monoclonal antibody that inhibits RANK L (receptor activator nuclear factor-kappa beta ligand), is one of the few medications that can be used to treat osteoporosis in patients with chronic kidney disease (CKD). However, its use is associated with a much higher incidence of hypocalcemia in this patient population. What remains unclear is the duration of hypocalcemia after denosumab use. We describe a case of prolonged hypocalcemia of 9 months in a patient with CKD after a single dose of denosumab. Case: A 64-year-old Caucasian man with a history of bilateral lung transplant for interstitial pulmonary fibrosis and CKD Stage IV was referred to the Endocrinology clinic for evaluation of steroid-induced osteoporosis. Bone density scan was consistent with osteoporosis with the lowest T-score of -2.8 at the left femoral neck, which showed a 25.3% decline from a previous one two years prior. His labs upon initial visit: 25 hydroxy Vitamin D: 36.5 ng/mL (30–100), 1, 25 hydroxy vitamin D 32 pg/ml (19.9–79.3), corrected Serum Calcium 8.9 mg/dL (8.5–10.5), Serum Cr 4.38 mg/dL (0.6–1.4), PTH 157 pg/mL (10–65), Serum Alkaline Phosphatase 61 Units/L (25–125), Urine NTX 39 nM BCE/mM creatinine (21–83). After discussing risks and benefits, he was given a dose of subcutaneous denosumab 60 mg. He had been started on Calcium/Vitamin D (600 mg/400 IU BID) prior to receiving his dose. Keeping in mind the increased risk of hypocalcemia given his history of CKD, his corrected serum calcium was checked one week later, and it was 6.5 mg/dL. The patient was asymptomatic. However, given the severity of his hypocalcemia, he was started on calcitriol 0.25 mcg oral BID and calcium carbonate 1200 mg daily. He did show mild improvement in three days to a corrected calcium of 7.0 mg/dL. His calcitriol was briefly increased to 0.5 mcg BID and calcium carbonate was increased to 1800 mg daily. The regimen was weaned to calcitriol 0.25 mcg daily and previous calcium/Vitamin D dosing later that month. Thereafter, his labs were monitored regularly and there were several unsuccessful attempts made to decrease the calcitriol/calcium carbonate. Given persistent hypocalcemia, other bloodwork including a bone specific alkaline phosphatase and celiac screen were checked which were unremarkable. Finally, nine months after his denosumab dose, calcitriol was discontinued safely. Serum calcium levels have remained stable thereafter. Given prolonged hypocalcemia, it was decided not to administer another dose of denosumab. Conclusion: Patients with CKD who receive denosumab are not only at risk for developing severe, but also prolonged hypocalcemia. Therefore, it is imperative to monitor serum calcium levels, not only immediately after receiving a dose, but serially.

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