Chronic kidney disease and its relation to osteoporosis and fracture

With the increase in the number of ageing population, a number of comorbidities have been seen to be on a rise. Increasing prevalence of chronic kidney disease (CKD) with underlying lifestyle related disorders like hypertension and diabetes mellitus has become a major challenge. CKD– mineral bone disorder (MBD) develops in association with secondary hyperparathyroidism due to phosphorus (P) accumulation in the circulating plasma, which in turn leads to increase in risk of cardiovascular disease and bone fracture (Nitta K, 2017). The other reasons for which can be any one amongst adynamic bone, hemodialysis-associated amyloidosis, vitamin D deficiency, hypocalcemia, changes in the bone architecture, nutritional disturbance, and increase in oxidative stress in patients with CKD. 

The frequency of coexisting CKD and osteoporosis increases with advancing age, and the morbidity rates of both of these disorders increase with age. Grade 5 CKD patients are at a 4.4 times increased risk of fracture as compared to the general population (Alem AM, 2000 ).  A study showed that CKD patients had a marked increase in the risk of hip fracture, with a reported incidence of up to 5.2% (Nickolas TL, 2006 Nov). A recent meta-analysis of studies in hemodialysis patients revealed a significant relationship between a low BMD at the lumbar spine and femoral neck and the risk of bone fracture (Jamal SA, 2007 ).  This is further supported by another well-known meta-analysis regarding the association between the BMD and fracture risk among CKD (Bucur RC, 2015 Feb).

The current treatment paradigm is based on suppressing high turnover with active vitamin D and/or calcimimetics, while simultaneously avoiding the development of adynamic bone disease through excessive use of these same agents. Experts opine that there are few guidelines on advised calcium intake in patients with renal failure or CKD; however, based on existing data, it may be safer to have the upper limit of calcium intake (including that of supplementation) up to 1 g (Taksande SR, 2014 ).

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References

Alem AM, S. D.-B. ( 2000 ). Increased risk of hip fracture among patients with end-stage renal disease. Kidney Int., 58(1):396-9.

Bucur RC, P. D. (2015 Feb). Low bone mineral density and fractures in stages 3-5 CKD: an updated systematic review and meta-analysis. Osteoporos Int. , 26(2):449-58.

Jamal SA, H. J. (2007 ). Low bone mineral density and fractures in long-term hemodialysis patients: a meta-analysis. Am J Kidney Dis. , 49(5):674-81.

Nickolas TL, M. D. (2006 Nov). Relationship between moderate to severe kidney disease and hip fracture in the United States. J Am Soc Nephrol, 17(11):3223-32.

Nitta K, Y. A. (2017). Management of osteoporosis in chronic kidney disease. Internal Medicine , 3271–3276.

Taksande SR, W. E. (2014 ). Calcium supplementation in chronic kidney disease. Expert Opin Drug Saf., 13(9):1175-85.