骨折风险评估工具在评估维持性血液透析患者骨折风险中的效能

doi:10.16150/j.1671-2870.2023.01.008

摘要/Abstract

摘要：

目的: 比较亚洲人骨质疏松自我筛查工具（osteoporosis self-screening tool for Asians, OSTA）、世界卫生组织骨折风险评估工具1（fracture risk assessment tool 1, FRAX1）（不包含BMD）和FRAX2（包含BMD）这3种骨折风险评估工具评估维持性血液透析（maintenance hemodialysis, MHD）患者发生骨折风险的效能。方法: 选取2014年12月至2016年12月在上海交通大学医院院附属瑞金医院进行MHD的患者136例，随访36个月，其间收集患者的影像学资料。根据随访中是否发生骨折，将患者分为骨折组与非骨折组，采用双能X射线吸收法（dual-energy X-ray，DXA）测定所有患者腰椎、股骨颈及髋部的骨密度值（bone mineral density, BMD）。根据BMD的测定值以及3种骨折风险评估工具，即OSTA、FRAX1和FRAX2的评估骨折概率计算结果，绘制受试者操作特征曲线（receiver operator characteristic curve,ROC曲线），比较其评估MHD患者发生骨折风险的效能。结果: 136例患者中，男性80例，女性56例，年龄59 (47~67)岁，透析龄55 (26~87)个月，共有16例发生骨折，占11.76%。ROC曲线分析显示，三部位BMD[腰椎（1~4）、股骨颈、全髋]、OSTA、FRAX1及FRAX2评估MHD患者骨折风险的曲线下面积分别为0.669 (95%CI为0.583~0.747)、0.708 (95%CI为0.624~0.783)、0.736 (95%CI为0.654~0.808)、0.686 (95%CI为0.601~0.763)、0.715 (95%CI为0.631~0.789)、0.697 (95%CI为0.613~0.773)；三部位BMD最佳临界值分别为0.973 g/cm²、0.719 g/cm²、0.859 g/cm²，而OSTA、FRAXI和FRAX2的最佳临界值为0.2%、3.3%、2.8%。OSTA、FRAX1及FRAX2在评估MHD患者骨折风险的效能间差异无统计学意义，但高于BMD（P<0.05）。结论: 在MHD患者中，OSTA、FRAX1及FRAX2这3种骨折风险评估工具均可用于评估骨折风险。包含了BMD的FRAX2诊断效能并未见优势，故临床在没有条件行BMD检查的情况下，OSTA和FRAX1也适用于MHD患者骨折风险评估。

关键词: 慢性肾脏病矿物质和骨代谢异常, 维持性血液透析, 骨密度, 骨折风险评估工具

Abstract:

Objective: To compare the diagnostic efficiency and application value of three widely-used fracture risk assessment tools [osteoporosis self-assessment tool for Asians (OSTA), WHO fracture risk assessment tool FRAX1[non-bone mineral density(BMD) model] and FRAX2 (BMD model) to identify fracture status in maintenance hemodialysis (MHD) patients. Methods: A total of 136 patients accepting MHD during December 2014 to December 2016 were enrolled in this study. All patients were divided into fracture group and non-fracture group according to BMD results at lumbar spine and hip region tested with dual-energy X-ray(DXA). OSTA was calculated on weight and age,and FRAX score was obtained through the website. Capacity of BMD, OSTA, FRAX1 and FRAX2 for predicting fracture status were assessed with receiver operator characteristic(ROC) curve analysis. Results: Among 136 MHD patients, the average age was 59(47-67) years and duration of dialysis was 55(26-87) months. There were 16 fractures (11.76%) in those MHD patients. Areas under the curves of BMD (lumbar spine L1-L4, femoral neck, total hip), OSTA, FRAX1 and FRAX2 for predicting fracture were 0.669 (95% CI:0.583-0.747, P=0.0234), 0.708 (95% CI: 0.624-0.783, P=0.0014), 0.736 (95%CI: 0.654-0.808, P=0.0003), 0.686 (95%CI: 0.601-0.763, P=0.0078), 0.715 (95%CI:0.631-0.789, P=0.0004), and 0.697 (95%CI:0.613-0.773, P>0.05), respectively. And cutoff value of BMD of lumbar spine L1-L4, femoral neck, total hip) for predicting fracture were 0.973 g/cm²，0.719 g/cm²，0.859 g/cm²，and while cutoff value of OSTA, FRAX1 and FRAX2 were 0.2,3.3%，2.8%, respectively. Conclusions: BMD, OSTA and FRAX have the same ability to predict fracture status in MHD patients. FRAX2 (BMD model) has no advantage over FRAX1 (non-BMD model) in predicting fracture. OSTA and FRAX1 are able to assess fracture status in MHD patient without BMD detection.

Key words: Chronic kidney disease-mineral bone disorder, Maintenance hemodialysis, Bone mineral density, Fracture risk assessment tool

中图分类号:

R459.5
R683

钱莹, 马晓波, 高琛妮, 陈孜瑾, 马骏, 俞海瑾, 张文, 陈晓农. 骨折风险评估工具在评估维持性血液透析患者骨折风险中的效能[J]. 诊断学理论与实践, 2023, 22(01): 50-57.

QIAN Ying, MA Xiaobo, GAO Chenni, CHEN Zijin, MA Jun, YU Haijin, ZHANG Wen, CHEN Xiaonong. The diagnostic efficiency and application value of fracture risk assessment tools in maintenance hemodialysis patients[J]. Journal of Diagnostics Concepts & Practice, 2023, 22(01): 50-57.

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参考文献 22

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Index	Total （n=136）	Non-fracture (n=120)	Fracture （n=16）	P
Age (years)	59 (47-66.75)	57 (44.25-64.0)	69 (60.75-75.75)	0.001
Gender (%, female)	56 (41.2%)	50 (41.7%)	6 (37.5%)	0.794
Duration of HD(months)	55 (26-86.75)	52.5 (26.0-81.75)	78.5 (27.5-122.25)	0.223
Body mass index (kg/cm²)	21.75 (18.84-23.84)	21.63 (19.12-23.42)	22.76 (18.00-24.52)	0.861
Laboratory parameters
Ca (mmol/L)	2.33 ± 0.25	2.33 ± 0.25	2.33 ± 0.29	0.979
P (mmol/L)	1.81 ± 0.70	1.86 ± 0.70	1.50 ± 0.54	0.051
Alkaline phosphatase (IU/L)	66.50 (54.00-88.50)	66.00 (53.00-84.00)	76.50 (58.00-106.75)	0.114
Parathyroid hormone (ng/L)	265.90 (145.10-535.42)	252.7 (141.72-538.58)	338.8 (146.02-523.18)	0.762
25(OH)D₃ (nmol/L)	41.49 (25.55-65.93)	41.78 (25.62-65.93)	36.80 (23.00-80.33)	0.761
Diabetes (%)	30 (22.1%)	26 (21.7%)	4 (25.0%)	0.763
Oral glucocorticoid (%)	30 (22.1%)	25 (20.8%)	5 (31.3%)	0.346
Oral calcitriol (%)	122(90.4%)	108(90%)	14(93.3%)	0.666
BMD
Lumbar spine (L1-L4) (g/cm²)	1.16 (1.01-1.27)	1.16 (1.03-1.28)	1.02 (0.87-1.20)	0.028
Lumbar spine (L1-L4)(T-score)	-0.10(-0.90-0.88)	-0.05(-0.85-1.00)	-0.80(-2.15-0.80)	0.084
Femoral neck (g/cm²)	0.81 (0.73-0.93)	0.83 (0.74-0.95)	0.73 (0.65-0.85)	0.006
Femoral neck (T-score)	-0.90(-1.60-0.00)	-0.80(-1.50-0.05)	-1.55(-2.2--0.90)	0.004
Total hip (g/cm²)	0.86 (0.77-0.98)	0.88 (0.78-0.98)	0.78 (0.660.85)	0.002
Total hip (T-score)	-0.65(-1.40-0.30)	-0.50(-1.30-0.30)	-1.25(-2.15--0.75)	0.003
OSTA	0.48 (-2.10-3.00)	0.80 (-1.95-3.2)	-1.68 (-4.1-0.95)	0.015
FRAX2（%）	3.55 (2.30-5.28)	3.2 (2.3-4.9)	5.3 (3.7-6.28)	0.005
FRAX1（%）	2.90 (1.80-4.38)	2.7 (1.6-4.2)	3.8 (2.95-5.75)	0.010

Indice	AUC (95%CI)	Cutoff value	Sensitivity (%)	Specificity (%)
L1-L4 BMD (g/cm²)	0.669 (0.583-0.747)	0.973	50.0 (24.7-75.3)	85.0 (77.3-90.9)
Femoral neck BMD (g/cm²)	0.708 (0.624-0.783)	0.719	50.0 (24.7-75.3)	82.5 (74.5-88.8)
Total hip BMD (g/cm²)	0.736 (0.654-0.808)	0.859	87.5 (61.7-98.4)	54.2 (44.8-63.3)
OSTA	0.686 (0.601-0.763)	0.2	75.0 (47.6-92.7)	55.0 (45.7-64.1)
FRAX1（%）	0.715 (0.631-0.789)	3.3	87.5 (61.7-98.4)	50.8 (41.6-60.1)
FRAX2（%）	0.697 (0.613-0.773)	2.8	81.2 (54.4-96.0)	52.5 (43.2-61.7)

Indice	BMD(L1-L4)	BMD(FN)	BMD(TH)	OSTA	FRAX1	FRAX2
L1-L4 BMD	0.309	—	—	—	—	—
FN BMD	0.476	0.460	—	—	—	—
TH BMD	0.751	0.257	0.324	—	—	—
OSTA	0.107	0.836	0.714	0.408	—	—
FRAX1	0.325	0.566	0.918	0.746	0.559	—
FRAX2	0.387	0.690	0.835	0.521	0.882	0.720