Advertisement

Calcified Tissue International

, Volume 93, Issue 1, pp 39–47 | Cite as

High Prevalence of Vertebral Fractures Assessed by Quantitative Morphometry in Hemodialysis Patients, Strongly Associated with Vascular Calcifications

  • Maria Fusaro
  • Giovanni Tripepi
  • Marianna Noale
  • Nicola Vajente
  • Mario Plebani
  • Martina Zaninotto
  • Giuseppe Guglielmi
  • Diego Miotto
  • Luca Dalle Carbonare
  • Angela D’Angelo
  • Daniele Ciurlino
  • Riccarda Puggia
  • Davide Miozzo
  • Sandro Giannini
  • Maurizio Gallieni
Original Research

Abstract

Few studies have provided information on the prevalence of vertebral fractures (VFs) and their risk factors in hemodialysis patients. A multicenter, cross-sectional, observational study was carried out to assess the prevalence of VFs and vascular calcifications (VCs) in 387 hemodialysis patients (mean age 64.2 ± 14.1 years, 63 % males) and in a control group of 51 osteoporotic subjects. Biochemical tests included 25(OH) vitamin D, bone Gla protein (total and undercarboxylated), and total matrix Gla protein. Vertebral quantitative morphometry was carried out centrally for the detection of VF, defined as reduction by ≥20 % of one of the vertebral body dimensions. In the same radiograph, aortic and iliac VC scores were calculated. Prevalence of VF was 55.3 % in hemodialysis patients and 51.0 % in the control group. Multivariate analysis disclosed that male gender (59.8 vs. 47.6 %, p = 0.02; OR = 1.78, 95 % CI 1.15–2.75) and age (mean ± SD 66.7 ± 13.1 vs. 61.0 ± 14.7 years, p < 0.001; OR = 1.03, 95 % CI 1.01–1.05) were significantly associated with VF. The prevalence of aortic VC was significantly higher in hemodialysis patients than in controls (80.6 vs. 68.4 %, p = 0.001). The factors with the strongest association with VC, apart from atrial fibrillation, were serum 25(OH)vitamin D levels below 29 ng/mL for aortic VC (OR = 1.85, 95 % CI 1.04–3.29) and VF both for aortic (OR = 1.77, 95 % CI 1.00–3.14) and iliac (OR = 1.96, 95 % CI 1.27–3.04) VC. In conclusion, the prevalence of VF, especially in males, and VC, in both genders, is high in hemodialysis patients. VF is associated with VC. Vitamin D deficiency is also associated with VC. Further longitudinal studies are warranted to investigate fractures in renal patients.

Keywords

Vertebral fracture Vascular calcification Hemodialysis Prevalence Vitamin D 

Notes

Acknowledgments

The authors thank Jennifer Hartwig, MD, medical writer, for manuscript editing. The study was funded by the Consiglio Nazionale delle Ricerche (CNR), Aging Section, Institute of Neuroscience, Padua, Italy. The authors also state that they have full control of all primary data and that they agree to allow the journal to review their data if requested.

References

  1. 1.
    Pendras JP, Erickson RV (1966) Clinical experience with sixteen patients on chronic hemodialysis. Trans Am Soc Artif Intern Organs 11:238–241CrossRefGoogle Scholar
  2. 2.
    Alem MA, Sherrad DJ, Gillen DL, Weiss NS, Beresford SA, Heckbert SR, Wong C, Stehman-Breen C (2000) Incidence and risk of hip fracture among patients with end-stage renal disease. Kidney Int 58:396–399PubMedCrossRefGoogle Scholar
  3. 3.
    Jadoul M, Albert JM, Akiba T, Akizawa T, Arab L, Bragg-Gresham JL, Mason N, Prutz KG, Young EW, Pisoni RL (2006) Incidence and risk factors for hip or other bone fractures among hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study. Kidney Int 70:1358–1366PubMedCrossRefGoogle Scholar
  4. 4.
    Nickolas TL, McMahon DJ, Shane E (2006) Relationship between moderate to severe kidney disease and hip fracture in the United States. J Am Soc Nephrol 17:3223–3232PubMedCrossRefGoogle Scholar
  5. 5.
    Nitsch D, Mylne A, Roderick PJ, Smeeth L, Hubbard R, Fletscher A (2009) Chronic kidney disease and hip fracture–related mortality in older people in the UK. Nephrol Dial Transplant 24:1539–1544PubMedCrossRefGoogle Scholar
  6. 6.
    Kinsella S, Chavrimootoo S, Molloy MG, Eustace JA (2010) Moderate chronic kidney disease in women in associated with fracture occurrence independently of osteoporosis. Nephron Clin Pract 116:c256–c262PubMedCrossRefGoogle Scholar
  7. 7.
    Atsumi K, Kushida K, Yamazaki K, Shimizu S, Ohmura A, Inoue T (1999) Risk factors for vertebral fractures in renal osteodystrophy. Am J Kidney Dis 33:287–293PubMedCrossRefGoogle Scholar
  8. 8.
    Rodriguez-Garcia M, Gomez Alonso C, Navez Diaz M, Diaz Lopez JB, Megido J, Gago E, Forascepi R, Cannata Andia JB (2003) Prevalence of vertebral fractures and aortic calcifications in hemodialysis patients: comparison with a population of the same age and sex. Nefrologia 23(Suppl 2):106–111PubMedGoogle Scholar
  9. 9.
    Jamal SA, Gilbert J, Gordon C, Bauer DC (2006) Cortical pQCT measures are associated with fractures in dialysis patients. J Bone Miner Res 21:543–548PubMedCrossRefGoogle Scholar
  10. 10.
    Rodriguez-Garcia M, Gomez-Alonso C, Naves-Diaz M, Diaz-Lopez JB, Diaz-Corte C, Cannata-Andia JB, Asturias Study Group (2009) Vascular calcifications, vertebral fractures and mortality in haemodialysis patients. Nephrol Dial Transplant 24:239–246PubMedCrossRefGoogle Scholar
  11. 11.
    Iimori S, Mori Y, Akita W, Kuyama T, Takada S, Asai T, Kuwahara M, Sasaki S, Tsukamoto Y (2012) 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. Nephrol Dial Transplant 27:345–351PubMedCrossRefGoogle Scholar
  12. 12.
    Danese MD, Kim J, Doan QV, Dylan M, Griffiths R, Chertow GM (2006) PTH and the risks for hip, vertebral and pelvic fractures among patients on dialysis. Am J Kidney Dis 47:149–156PubMedCrossRefGoogle Scholar
  13. 13.
    Coco M, Rush H (2000) Increased incidence of hip fractures in dialysis patients with low serum parathyroid hormone. Am J Kidney Dis 36:1115–1121PubMedCrossRefGoogle Scholar
  14. 14.
    Rudser KD, De Boer IH, Dooley A, Young B, Kestenbaum B (2007) Fracture risk after parathyroidectomy among chronic hemodialysis patients. J Am Soc Nephrol 18:2401–2407PubMedCrossRefGoogle Scholar
  15. 15.
    Stehman-Breen CO, Sherrad DJ, Alem AM, Gillen DL, Heckbert SR, Wong CS, Ball A, Weiss NS (2000) Risk factors for hip fracture among patients with end-stage renal disease. Kidney Int 58:2200–2205PubMedCrossRefGoogle Scholar
  16. 16.
    Price PA (1988) Role of vitamin-K-dependent proteins in bone metabolism. Annu Rev Nutr 8:565–583PubMedCrossRefGoogle Scholar
  17. 17.
    Krueger T, Westenfeld R, Ketteler M, Schurgers LJ, Floege J (2009) Vitamin K deficiency in CKD patients: a modifiable risk factor risk for vascular calcification? Kidney Int 76:18–22PubMedCrossRefGoogle Scholar
  18. 18.
    Schurgers LJ, Cranenburg EC, Vermeer C (2008) Matrix Gla-protein: the calcification inhibitor in need of vitamin K. Thromb Haemost 100:593–603PubMedGoogle Scholar
  19. 19.
    Fusaro M, Crepaldi G, Maggi S, Galli F, D’Angelo A, Calò L, Giannini S, Miozzo D, Gallieni M (2011) Vitamin K, bone fractures, and vascular calcifications in chronic kidney disease: an important but poorly studied relationship. J Endocrinol Invest. 34:317–323PubMedGoogle Scholar
  20. 20.
    Fusaro M, Noale M, Viola V, Galli F, Tripepi G, Vajente N, Plebani M, Zaninotto M, Guglielmi G, Miotto D, Dalle Carbonare L, D’Angelo A, Naso A, Grimaldi C, Miozzo D, Giannini S, Gallieni M, for the Vitamin K Italian (VIKI) Dialysis Study Investigators (2012) Vitamin K, vertebral fractures, vascular calcifications and mortality: Vitamin K Italian (VIKI) Study. J Bone Miner Res 27:2271–2278PubMedCrossRefGoogle Scholar
  21. 21.
    Souberbille JC, Roth H, Fouque DP (2010) Parathyroid hormone measurement in CKD. Kidney Int 77:93–100CrossRefGoogle Scholar
  22. 22.
    Genant HK, Wu CY, van Kuijk C, Nevitt MC (1993) Vertebral fracture assessment using a semiquantitative technique. J Bone Miner Res 8:1137–1148PubMedCrossRefGoogle Scholar
  23. 23.
    Guglielmi G, Palmieri F, Placentino MG, D’Errico F, Stoppino LP (2009) Assessment of osteoporotic vertebral fractures using specialized workflow software for 6-point morphometry. Eur J Radiol 70:142–148PubMedCrossRefGoogle Scholar
  24. 24.
    Guglielmi G, Stoppino LP, Placentino MG, D’Errico F, Palmieri F (2009) Reproducibility of a semi-automatic method for 6-point vertebral morphometry in a multi-centre trial. Eur J Radiol 69:173–178PubMedCrossRefGoogle Scholar
  25. 25.
    Diacinti D, Guglielmi G, Tomei E, D’Erasmo E, Minisola S, Valentini C, David V (2001) Vertebral morphometry: evaluation of osteoporosis caused fractures. Radiol Med 101:140–144PubMedGoogle Scholar
  26. 26.
    Witteman JC, Grobbee DE, Valkenburg HA, Van Hemert AM, Stijnen T, Burger H, Hofman A (1994) J-shaped relation between change in diastolic blood pressure and progression of aortic atherosclerosis. Lancet 343:504–507PubMedCrossRefGoogle Scholar
  27. 27.
    Arboleya L, Diaz-Curiel M, Del Rio L, Blanch J, Díez-Pérez A, Guañabens N, Quesada JM, Sosa M, Gómez C, Muñoz-Torres M, Ramírez E, Combalia J, OSTEOXPRESS Study Investigators (2010) Prevalence of vertebral fracture in postmenopausal women with lumbar osteopenia using MorphoXPress (OSTEOXPRESS Study). Aging Clin Exp Res 22:419–426PubMedGoogle Scholar
  28. 28.
    Giannini S, Sella S, Silva Netto F, Cattelan C, Dalle Carbonare L, Lazzarin R, Marchini F, Rigotti P, Marcocci C, Cetani F, Pardi E, D’Angelo A, Realdi G, Bonfante L (2010) Persistent secondary hyperparathyroidism and vertebral fractures in kidney transplantation: role of calcium-sensing receptor polymorphism and vitamin D deficiency. J Bone Miner Res 25:841–848PubMedGoogle Scholar
  29. 29.
    Cooper C, Atkinson EJ, O’Fallon WM, Melton LJ (1992) Incidence of clinically diagnosed vertebral fractures: a population-based study in Rochester, Minnesota, 1985–1989. J Bone Miner Res 7:221–227PubMedCrossRefGoogle Scholar
  30. 30.
    Ismail AA, Cooper C, Felsenberg D, Varlow J, Kanis JA, Silman AJ, O’Neill TW (1999) Number and type of vertebral deformities: epidemiological characteristics and relation to back pain and height loss. Osteoporos Int 9:206–213PubMedCrossRefGoogle Scholar
  31. 31.
    Oury F, Sumara G, Sumara O, Ferron M, Chang H, Smith CE, Hermo L, Suarez S, Roth BL, Ducy P, Karsenty G (2011) Endocrine regulation of male fertility by the skeleton. Cell 144:796–809PubMedCrossRefGoogle Scholar
  32. 32.
    Foresta C, Strapazzon G, De Toni L, Gianesello L, Bruttocao A, Scarda A, Plebani M, Garolla A (2011) Androgens modulate osteocalcin release by human visceral adipose tissue. Clin Endocrinol (Oxf) 75:64–69CrossRefGoogle Scholar
  33. 33.
    Saylor PJ, Morton RA, Hancock ML, Barnette KG, Steiner MS, Smith MR (2011) Factors associated with vertebral fractures in men treated with androgen deprivation therapy for prostate cancer. J Urol 186:482–486PubMedCrossRefGoogle Scholar
  34. 34.
    Mazziotti G, Porcelli T, Mormando M, De Menis E, Bianchi A, Mejia C, Mancini T, De Marinis L, Giustina A (2011) Vertebral fractures in males with prolactinoma. Endocrine 39:288–293PubMedCrossRefGoogle Scholar
  35. 35.
    Idelevich A, Rais Y, Monsonego-Ornan E (2011) Bone Gla protein increases HIF-1alpha-dependent glucose metabolism and induces cartilage and vascular calcification. Arterioscler Thromb Vasc Biol 31(9):e55–e71PubMedCrossRefGoogle Scholar
  36. 36.
    Nickolas TL, Cremers S, Zhang A, Thomas V, Stein E, Cohen A, Chauncey R, Nikkel L, Yin MT, Liu XS, Boutroy S, Staron RB, Leonard MB, McMahon DJ, Dworakowski E, Shane E (2011) Discriminants of prevalent fractures in chronic kidney disease. J Am Soc Nephrol 22:1560–1572PubMedCrossRefGoogle Scholar
  37. 37.
    Zittermann A, Koerfer R (2008) Protective and toxic effects of vitamin D on vascular calcification: clinical implications. Mol Aspects Med 29:423–432PubMedCrossRefGoogle Scholar
  38. 38.
    Holick MF, Binkley NC, Bischoff-Ferrari HA, Gordon CM, Hanley DA, Heaney RP, Murad MH, Weaver CM, Endocrine Society (2011) Evaluation, treatment, and prevention of vitamin D deficiency: an endocrine society clinical practice guideline. J Clin Endocrinol Metab 96:1911–1930PubMedCrossRefGoogle Scholar
  39. 39.
    Naves M, Rodriguez-Garcia M, Diaz-Lopez JB, Gomez-Alonso C, Cannata-Andia JB (2008) Progression of vascular calcifications is associated with greater bone loss and increased bone fractures. Osteoporos Int 19:1161–1166PubMedCrossRefGoogle Scholar
  40. 40.
    Schulz E, Arfai K, Liu X, Sayre J, Gilsanz V (2004) Aortic calcification and the risk of osteoporosis and fractures. J Clin Endocrinol Metab 89:4246–4253PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Maria Fusaro
    • 1
  • Giovanni Tripepi
    • 2
  • Marianna Noale
    • 1
  • Nicola Vajente
    • 3
  • Mario Plebani
    • 3
  • Martina Zaninotto
    • 3
  • Giuseppe Guglielmi
    • 4
    • 5
  • Diego Miotto
    • 6
  • Luca Dalle Carbonare
    • 7
  • Angela D’Angelo
    • 8
  • Daniele Ciurlino
    • 9
  • Riccarda Puggia
    • 10
  • Davide Miozzo
    • 8
  • Sandro Giannini
    • 11
  • Maurizio Gallieni
    • 12
  1. 1.Aging SectionConsiglio Nazionale delle Ricerche (CNR)—Institute of NeurosciencePaduaItaly
  2. 2.Clinical Epidemiology and Physiopathology of Renal Diseases and HypertensionCNR-Istituto di BiometeorologiaReggio CalabriaItaly
  3. 3.Dipartimento di Medicina di LaboratorioUniversity Hospital of PaduaPaduaItaly
  4. 4.Department of RadiologyUniversity of FoggiaFoggiaItaly
  5. 5.Department of RadiologyScientific Institute Hospital “Casa Sollievo della Sofferenza”San Giovanni RotondoItaly
  6. 6.Dipartimento di Medicina, Sezione di RadiologiaUniversity of PaduaPaduaItaly
  7. 7.Department of Medicine, Medicina Interna DUniversity of VeronaVeronaItaly
  8. 8.Nephrology UnitUniversity of PaduaPaduaItaly
  9. 9.Renal UnitIRCCS MultimedicaMilanItaly
  10. 10.Nephrology and Dialysis UnitOspedale S. Maria di Ca’ FoncelloTrevisoItaly
  11. 11.Department of Clinical and Experimental Medicine, Medical Clinic 4University of PaduaPaduaItaly
  12. 12.Nephrology and Dialysis UnitOspedale San Carlo BorromeoMilanItaly

Personalised recommendations