BMD and Fracture Risk in CKD: Where Should We Go from Here?

[摘要] In patients without kidney disease, measurement of areal bone mineral density (aBMD) by dual energy x-ray absorptiometry (DXA) is a surrogate marker of bone strength and is the clinical standard for assessing fracture risk in postmenopausal women and older men. Multiple prospective studies have demonstrated its utility in the diagnosis, treatment, and monitoring of osteoporosis and the prediction of incident fragility fractures. However, the utility of aBMD measurement by DXA as a tool for fracture risk assessment in patients with CKD remains controversial for several reasons. Cross-sectional studies conducted in patients both before (1–3) and after (4–8) initiation of renal replacement therapy have been inconsistent regarding the ability of DXA to discriminate between CKD patients with and without fracture. The few prospective trials assessing the fracture prediction characteristics of DXA in CKD-mineral and bone disorder (CKD-MBD) patients are also inconsistent (9–11). Moreover, the spectrum of bone turnover and mineralization abnormalities that characterize renal osteodystrophy may be associated with low, normal, or high BMD (7,12,13). For these reasons, the 2009 Kidney Disease Improving Global Outcomes (KDIGO) Guidelines consensus statement on fracture risk assessment in CKD-MBD does not recommend using aBMD by DXA to screen patients for osteoporosis or to predict fracture risk (14). Given the current CKD epidemic, the absence of proven and effective fracture screening methods is a major clinical problem. Although we know that patients with CKD are at increased risk for fracture, we lack appropriate tools to assess fracture risk, and this in turn limits our ability to design appropriate studies focused on prevention of fractures and their associated high morbidity and mortality (15). To date, few studies have evaluated methods to optimize fracture risk assessment in this highly vulnerable population (1,16). In the current issue of CJASN, Yenchek et al. (17) provide us with important evidence that measurement of aBMD by DXA is predictive of incident fractures to a comparable extent in older adults with and without CKD.

[学科分类] 泌尿医学

[关键词] Bone marrow necrosis;Sickle cell disease;Hyperhemolysis syndrome