The diagnostic efficiency and application value of fracture risk assessment tools in maintenance hemodialysis patients

doi:10.16150/j.1671-2870.2023.01.008

Abstract

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

CLC Number:

R459.5
R683

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.

Figures/Tables 8

Figure 1

Table 1

Figure 2

Figure 3

Figure 4

Table 2

Table 3

Figure 5

References 22

[1]	HAMPSON G, ELDER G J, COHEN-SOLAL M, et al. A review and perspective on the assessment, management and prevention of fragility fractures in patients with osteoporosis and chronic kidney disease[J]. Endocrine, 2021, 73(3):509-529. doi: 10.1007/s12020-021-02735-9 pmid: 33974225
[2]	JAFARI M, ANWAR S, KOUR K, et al. T Scores, FRAX, Frailty Phenotype, Falls, and Its Relationship to Fractures in Patients on Maintenance Hemodialysis[J]. Can J Kidney Health Dis, 2021, 8:20543581211041184.
[3]	COHEN-SOLAL M, FUNCK-BRENTANO T, UREÑA TORRES P. Bone fragility in patients with chronic kidney disease[J]. Endocr Connect, 2020, 9(4):R93-R101. doi: 10.1530/EC-20-0039 URL
[4]	Kidney Disease: Improving Global Outcomes KDIGO CKD-MBD Update Work Group. KDIGO 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD)[J]. Kidney Int Suppl, 2017, 7:1-59. doi: 10.1038/ki.1975.1 URL
[5]	LESLIE W D, SCHOUSBOE J T, MORIN S N, et al. Fracture risk following high-trauma versus low-trauma fracture: a registry-based cohort study[J]. Osteoporos Int, 2020, 31(6):1059-1067. doi: 10.1007/s00198-019-05274-2 pmid: 32173782
[6]	JIRASIRIRAK S, DISTHABANCHONG S, ONGPHIPH-ADHANAKUL B, et al. Prevalence and predictors of asymptomatic vertebral fracture in patients with end-stage renal disease[J]. Heliyon, 2022, 8(3):e09158. doi: 10.1016/j.heliyon.2022.e09158 URL
[7]	中华医学会放射学分会骨关节学组, 中国医师协会放射医师分会肌骨学组, 中华医学会骨科学分会骨质疏松学组, 等. 骨质疏松的影像学与骨密度诊断专家共识[J]. 中国骨质疏松杂志, 2020, 26(9):1249-1256.
	Bone and Joint Group of Chinese Society of Radiology, Chinese Association; Musculoskeletal Radiology Society of Chinese Medical Association; Osteoporosis Group of Chinese Orthopedic Association, Medical Association, et al. Consensus on the diagnosis of osteoporosis by imaging and bone mineral density measurement[J]. Chin J Osteoporos, 2020, 26(9):1249-1256.
[8]	WHITLOCK R H, LESLIE W D, SHAW J, et al. The Fracture Risk Assessment Tool (FRAX^®) predicts fracture risk in patients with chronic kidney disease[J]. Kidney Int, 2019, 95(2):447-454. doi: S0085-2538(18)30775-0 pmid: 30579724
[9]	EL MIEDANY Y. FRAX: re-adjust or re-think[J]. Arch Osteoporos, 2020, 15(1):150. doi: 10.1007/s11657-020-00827-z pmid: 32989561
[10]	FAN Z, LI X, ZHANG X, et al. Comparison of OSTA, FRAX and BMI for Predicting Postmenopausal Osteoporosis in a Han Population in Beijing: A Cross Sectional Study[J]. Clin Interv Aging, 2020, 15:1171-1180. doi: 10.2147/CIA.S257166 pmid: 32764904
[11]	YOON H E, LEE Y H, LEE J E, et al. Seasonality in hip fracture among haemodialysis patients and kidney transplant recipients in South Korea[J]. Nephrology (Carlton), 2022, 27(12):925-933. doi: 10.1111/nep.v27.12 URL
[12]	WAKASUGI M, KAZAMA J J, KIKUCHI K, et al. Hemodialysis Product and Hip Fracture in Hemodialysis Patients: A Nationwide Cohort Study in Japan[J]. Ther Apher Dial, 2019, 23(6):507-517. doi: 10.1111/tap.v23.6 URL
[13]	GOTO N A, WESTSTRATE A C G, OOSTERLAAN F M, et al. The association between chronic kidney disease, falls, and fractures: a systematic review and meta-analysis[J]. Osteoporos Int, 2020, 31(1):13-29. doi: 10.1007/s00198-019-05190-5 pmid: 31720721
[14]	AMBRUS C, ALMASI C, BERTA K, et al. Vitamin D insufficiency and bone fractures in patients on maintenance hemodialysis[J]. Int Urol Nephrol, 2011, 43(2):475-482. doi: 10.1007/s11255-010-9723-x pmid: 20237846
[15]	IIMORI S, MORI Y, AKITA W, et al. Diagnostic usefulness of bone mineral density and biochemical markers of bone turnover in predicting fracture in CKD stage 5D patients--a single-center cohort study[J]. Nephrol Dial Transplant, 2012, 27(1):345-351. doi: 10.1093/ndt/gfr317 URL
[16]	中华医学会骨科学分会. 骨质疏松性骨折诊疗指南(2022年版)[J]. 中华骨科杂志, 2022, 42(22):1473-1491.
	Chinese Orthopaedic Association. Guidelines for the dia-gnosis and treatment of osteoporotic fractures (2022 edition)[J]. Chin J Orthop, 2022, 42(22):1473-1491.
[17]	张燕妮, 夏梦迪, 王宝福, 等. 初步探讨超声测量BMD、FRAX(R)和OSTA评定维持性血液透析患者骨折风险[J]. 临床肾脏病杂志, 2018, 18(1):38-42.
	ZHANG Y N, XIA M D, WANG B F, et al. Ultrasonic measurement of BMD, FRAX(R) and OSTA in the prediction of fracture risk in maintenance hemodialysis[J]. J Clin Nephrol, 2018, 18(1):38-42.
[18]	PATRO S K, PAWAR N, BISWAS D. A study to predict fracture risk using bone mineral density and FRAX score in patients on chronic maintenance haemodialysis[J]. J Family Med Prim Care, 2022, 11(1):170-175. doi: 10.4103/jfmpc.jfmpc_901_21 pmid: 35309612
[19]	王琰, 罗静, 苗金红. 血液净化中心维持性血液透析患者骨质疏松危险因素分析及骨折风险预测[J]. 热带医学杂志, 2022, 22(3):373-377.
	WANG Y, LUO J, MIAO J H. Risk factors of osteoporosis in maintenance hemodialysis patients in blood purification center and prediction of fracture risk[J]. J Trop Med, 2022, 22(3):373-377.
[20]	左薇, 费琦, 杨雍, 等. BMD、OSTA与FRAX^®预测绝经后女性骨质疏松性骨折风险的比较研究[J]. 中国骨质疏松杂志, 2015(1):48-52.
	ZUO W, FEI Q, YANG Y, et al. Comparative study of BMD, OSTA, and FRAX in the prediction of osteoporotic fracture risk in postmenopausal women[J]. Chin J Osteoporos, 2015, 21(1):48-52.
[21]	朱再胜, 章振林. 骨折风险评估工具(FRAX^®)对绝经后低骨量女性骨折的预测价值[J]. 中华骨质疏松和骨矿盐疾病杂志, 2013, 6(3):213-218.
	ZHU Z S, ZHANG Z L. Fracture predictive values of FRAX^® for low bone mass of postmenopausal women[J]. Chin J Osteoporos Bone Miner Res, 2013, 6(3):213-218.
[22]	JAFARI M, ANWAR S, KOUR K, et al. T Scores, FRAX, Frailty Phenotype, Falls, and Its Relationship to Fractures in Patients on Maintenance Hemodialysis[J]. Can J Kidney Health Dis, 2021, 8:20543581211041184.

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