Abstract
Purpose of Review
In this paper, we review the epidemiology, diagnosis, and pathogenesis of fractures and renal osteodystrophy.
Recent Findings
The role of bone quality in the pathogenesis of fracture susceptibility in chronic kidney disease (CKD) is beginning to be elucidated. Bone quality refers to bone material properties, such as cortical and trabecular microarchitecture, mineralization, turnover, microdamage, and collagen content and structure. Recent data has added to our understanding of the effects of CKD on alterations to bone quality, emerging data on the role of abnormal collagen structure on bone strength, the potential of non-invasive methods to inform our knowledge of bone quality, and how we can use these methods to inform strategies that protect against bone loss and fractures. However, more prospective data is required.
Summary
CKD is associated with abnormal bone quality and strength which results in high fracture incidence.
Similar content being viewed by others
References
Papers of particular interest, published recently, have been highlighted as: • Of importance
Moe S, Drueke T, Cunningham J, Goodman W, Martin K, Olgaard K, Ott S, Sprague S, Lameire N, Eknoyan G, Kidney Disease: Improving Global, O. Definition, evaluation, and classification of renal osteodystrophy: a position statement from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int. 2006;69:1945–53. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/16641930
Nickolas TL, Stein E, Cohen A, Thomas V, Staron RB, McMahon DJ, Leonard MB, Shane E. Bone mass and microarchitecture in CKD patients with fracture. J Am Soc Nephrol. 2010;21:1371–80. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20395370
Nickolas TL, McMahon DJ, Shane E. Relationship between moderate to severe kidney disease and hip fracture in the United States. J AmSocNephrol. 2006;17:3223–32.
Alem AM, Sherrard DJ, Gillen DL, Weiss NS, Beresford SA, Heckbert SR, Wong C, Stehman-Breen C. Increased risk of hip fracture among patients with end-stage renal disease. Kidney Int. 2000;58:396–9. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/10886587
Dooley AC, Weiss NS, Kestenbaum B. Increased risk of hip fracture among men with CKD. Am J Kidney Dis. 2008;51:38–44. Retrieved from http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=18155531
• Naylor KL, McArthur E, Leslie WD, Fraser LA, Jamal SA, Cadarette SM, Pouget JG, Lok CE, Hodsman AB, Adachi JD, Garg AX. The three-year incidence of fracture in chronic kidney disease. Kidney Int. 2014;86(4):810–8. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/24429401. This study uses administrative data from Canada to describe fracture incidence stratified by CKD stage and gender. It demonstrates that fracture rates are higher in patients with more severe kidney disease
Isakova T, Craven TE, Scialla JJ, Nickolas TL, Schnall A, Barzilay J, Schwartz AV, Action to Control Cardiovascular Risk in Diabetes, T. Change in estimated glomerular filtration rate and fracture risk in the Action to Control Cardiovascular Risk in Diabetes Trial. Bone. 2015;78:23–7. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/25937184
Arneson TJ, Li S, Liu J, Kilpatrick RD, Newsome BB, St Peter WL. Trends in hip fracture rates in US hemodialysis patients, 1993-2010. Am J Kidney Dis. 2013;62:747–54. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/23631997
Wagner J, Jhaveri KD, Rosen L, Sunday S, Mathew AT, Fishbane S. Increased bone fractures among elderly United States hemodialysis patients. Nephrol Dial Transplant. 2014;29:146–51. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/24078333
Nikkel LE, Hollenbeak CS, Fox EJ, Uemura T, Ghahramani N. Risk of fractures after renal transplantation in the United States. Transplantation. 2009;87:1846–51. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/19543063
Ball AM, Gillen DL, Sherrard D, Weiss NS, Emerson SS, Seliger SL, Kestenbaum BR, Stehman-Breen C. Risk of hip fracture among dialysis and renal transplant recipients. JAMA. 2002;288:3014–8. Retrieved from http://jama.ama-assn.org/cgi/content/abstract/288/23/3014
Vautour LM, Melton LJ 3rd, Clarke BL, Achenbach SJ, Oberg AL, Mccarthy JT. Long-term fracture risk following renal transplantation: a population-based study. Osteoporos Int. 2004;15:160–7. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/14666400
Perrin, P, Kiener, C, Javier, RM, Braun, L, Cognard, N, Gautier-Vargas, G, Heibel, F, Muller, C, Olagne, J, Moulin, B, Caillard, S. Recent changes in chronic kidney disease-mineral and bone disorders (CKD-MBD) and associated fractures after kidney transplantation. Transplantation 2016. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/27547867
Mittalhenkle A, Gillen DL, Stehman-Breen CO. Increased risk of mortality associated with hip fracture in the dialysis population. Am J Kidney Dis. 2004;44:672–9.
Abbott KC, Oglesby RJ, Hypolite IO, Kirk AD, Ko CW, Welch PG, Agodoa LY, Duncan WE. Hospitalizations for fractures after renal transplantation in the United States. Ann Epidemiol. 2001;11:450–7. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/11557176
Tentori F, McCullough K, Kilpatrick RD, Bradbury BD, Robinson BM, Kerr PG, Pisoni RL. High rates of death and hospitalization follow bone fracture among hemodialysis patients. Kidney Int. 2014;85:166–73. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/23903367
Kim SM, Long J, Montez-Rath M, Leonard M, Chertow GM. Hip fracture in patients with non-dialysis-requiring chronic kidney disease. J Bone Miner Res. 2016;31(10):1803–9. doi:10.1002/jbmr.2862.
Nair SS, Mitani AA, Goldstein BA, Chertow GM, Lowenberg DW, Winkelmayer WC. Temporal trends in the incidence, treatment, and outcomes of hip fracture in older patients initiating dialysis in the United States. Clin J Am Soc Nephrol. 2013;8:1336–42. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/23660182
Burr DB. The complex relationship between bone remodeling and the physical and material properties of bone. Osteoporos Int. 2015;26:845.
Bala Y, Seeman E. Bone’s material constituents and their contribution to bone strength in health, disease, and treatment. Calcif Tissue Int. 2015;97:308–26.
Schaffler MB, Choi K, Milgrom C. Aging and matrix microdamage accumulation in human compact bone. Bone. 1995;17:521–5. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/8835305
Reilly GC, Currey JD. The effects of damage and microcracking on the impact strength of bone. J Biomech. 2000;33:337–43.
Vashishth D, Gibson G, Khoury J, Schaffler M, Kimura J, Fyhrie DP. Influence of nonenzymatic glycation on biomechanical properties of cortical bone. Bone. 2001;28:195–201.
Akkus O, Adar F, Schaffler MB. Age-related changes in physicochemical properties of mineral crystals are related to impaired mechanical function of cortical bone. Bone. 2004;34:443–53.
Yenchek RH, Ix JH, Shlipak MG, Bauer DC, Rianon NJ, Kritchevsky SB, Harris TB, Newman AB, Cauley JA, Fried LF. Bone mineral density and fracture risk in older individuals with CKD. Clin J Am Soc Nephrol. 2012;7:1130–6. Retrieved from http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=22516286
West SL, Lok CE, Langsetmo L, Cheung AM, Szabo E, Pearce D, Fusaro M, Wald R, Weinstein J, Jamal SA. Bone mineral density predicts fractures in chronic kidney disease. J Bone Miner Res. 2015;30:913–9. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/25400209
Iimori S, Mori Y, Akita W, Kuyama T, Takada S, Asai T, Kuwahara M, Sasaki S, Tsukamoto Y. 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. 2012;27:345–51. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21652550
Akaberi S, Simonsen O, Lindergard B, Nyberg G. Can DXA predict fractures in renal transplant patients? Am J Transplant. 2008;8:2647–51. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/18853956
Jamal SA, Gilbert J, Gordon C, Bauer DC. Cortical pQCT measures are associated with fractures in dialysis patients. J Bone MinerRes. 2006;21:543–8.
Leonard MB. A structural approach to skeletal fragility in chronic kidney disease. Semin Nephrol. 2009;29:133–43. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/19371804
Denburg MR, Tsampalieros AK, de Boer IH, Shults J, Kalkwarf HJ, Zemel BS, Foerster D, Stokes D, Leonard MB. Mineral metabolism and cortical volumetric bone mineral density in childhood chronic kidney disease. J Clin Endocrinol Metab. 2013;98:1930–8. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/23547048
Nishiyama KK, Macdonald HM, Buie HR, Hanley DA, Boyd SK. Postmenopausal women with osteopenia have higher cortical porosity and thinner cortices at the distal radius and tibia than women with normal aBMD: an in vivo HR-pQCT study. J Bone Miner Res. 2010;25:882–90. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/19839766
Nishiyama KK, Macdonald HM, Hanley DA, Boyd SK. Women with previous fragility fractures can be classified based on bone microarchitecture and finite element analysis measured with HR-pQCT. Osteoporos Int. 2013;24:1733–40. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/23179565
Liu XS, Stein EM, Zhou B, Zhang CA, Nickolas TL, Cohen A, Thomas V, McMahon DJ, Cosman F, Nieves J, Shane E, Guo XE. Individual trabecula segmentation (ITS)-based morphological analyses and microfinite element analysis of HR-pQCT images discriminate postmenopausal fragility fractures independent of DXA measurements. J Bone Miner Res. 2012;27:263–72. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22072446
• 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. Discriminants of prevalent fractures in chronic kidney disease. J Am Soc Nephrol. 2011;22:1560–72. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21784896. This cross sectional study in patients with moderate to severe CKD demonstrated that bone imaging by DXA and higher levels of bone turnover markers discriminated fractures, and that discrimination by DXA was improved by combining measures of bone mineral density with bone turnover markers
Jamal S, Cheung AM, West S, Lok C. Bone mineral density by DXA and HR pQCT can discriminate fracture status in men and women with stages 3 to 5 chronic kidney disease. Osteoporos Int. 2012;23:2805–13. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22297732
Cejka D, Patsch JM, Weber M, Diarra D, Riegersperger M, Kikic Z, Krestan C, Schueller-Weidekamm C, Kainberger F, Haas M. Bone microarchitecture in hemodialysis patients assessed by HR-pQCT. Clin J Am Soc Nephrol. 2011;6:2264–71. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21737853
Trombetti A, Stoermann C, Chevalley T, Van Rietbergen B, Herrmann FR, Martin PY, Rizzoli R. Alterations of bone microstructure and strength in end-stage renal failure. Osteoporos Int. 2012;24(5):1721–32. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/23100118
• Nickolas TL, Stein EM, Dworakowski E, Nishiyama KK, Komandah-Kosseh M, Zhang CA, McMahon DJ, Liu XS, Boutroy S, Cremers S, Shane E. Rapid cortical bone loss in patients with chronic kidney disease. J Bone Miner Res. 2013;28:1811–20. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/23456850. This propsective study in patients demonstarted that in patients with moderate to severe CKD bone loss occurred in the cortical rather than the trabecular compartments, and that elevated levels of PTH and bone turnover markers predicted the severity of cortical losses
Iyer S, Nikkel L, Nishiyama K, Dworakowski E, Cremers S, Zhang A, DJ MM, Boutroy S, Liu XS, Ratner L, Cohen D, Guo XE, Shane E, Nickolas TL. Kidney transplantation with early corticosteroid withdrawal: paradoxical effects at the central and peripheral skeleton. J Am Soc Nephrol. 2014;25(6):1331–41.
Boutroy SNT, Stein EM, Cohen A, Shane E. Impaired cortical bone in predialysis CKD patients is even more marked in those with fragility fracture. San Diego: ASN; 2010.
Parfitt AM. A structural approach to renal bone disease. J Bone Miner Res. 1998;13:1213–20.
Jee, WS. The past, present, and future of bone morphometry: its contribution to an improved understanding of bone biology. J Bone Miner Metab 2005;23 Suppl: 1–10. Retrieved from http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=15984407.
Jamal SA, Ljunggren O, Stehman-Breen C, Cummings SR, McClung MR, Goemaere S, Ebeling PR, Franek E, Yang YC, Egbuna OI, Boonen S, Miller PD. Effects of denosumab on fracture and bone mineral density by level of kidney function. J Bone Miner Res. 2011;26:1829–35. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21491487
Miller PD, Schwartz EN, Chen P, Misurski DA, Krege JH. Teriparatide in postmenopausal women with osteoporosis and mild or moderate renal impairment. Osteoporos Int. 2007;18:59–68. Retrieved from http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=17013567
Miller PD, Roux C, Boonen S, Barton IP, Dunlap LE, Burgio DE. Safety and efficacy of risedronate in patients with age-related reduced renal function as estimated by the Cockcroft and Gault method: a pooled analysis of nine clinical trials. J Bone Miner Res. 2005;20:2105–15.
Couttenye MM, D’Haese PC, Van Hoof VO, Lemoniatou E, Goodman W, Verpooten GA, De Broe ME. Low serum levels of alkaline phosphatase of bone origin: a good marker of adynamic bone disease in haemodialysis patients. Nephrol Dial Transplant. 1996;11:1065–72. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/8671970
Bervoets AR, Spasovski GB, Behets GJ, Dams G, Polenakovic MH, Zafirovska K, Van HV, De Broe ME, D’Haese PC. Useful biochemical markers for diagnosing renal osteodystrophy in predialysis end-stage renal failure patients. AmJ Kidney Dis. 2003;41:997–1007.
Coen G, Ballanti P, Bonucci E, Calabria S, Centorrino M, Fassino V, Manni M, Mantella D, Mazzaferro S, Napoletano I, Sardella D, Taggi F. Bone markers in the diagnosis of low turnover osteodystrophy in haemodialysis patients. Nephrol Dial Transplant. 1998;13:2294–302.
Lehmann G, Ott U, Kaemmerer D, Schuetze J, Wolf G. Bone histomorphometry and biochemical markers of bone turnover in patients with chronic kidney disease stages 3-5. Clin Nephrol. 2008;70:296–305. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/18826854
Lehmann G, Stein G, Huller M, Schemer R, Ramakrishnan K, Goodman WG. Specific measurement of PTH (1-84) in various forms of renal osteodystrophy (ROD) as assessed by bone histomorphometry. Kidney Int. 2005;68:1206–14. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/16105052
Herberth J, Branscum AJ, Mawad H, Cantor T, Monier-Faugere MC, Malluche HH. Intact PTH combined with the PTH ratio for diagnosis of bone turnover in dialysis patients: a diagnostic test study. Am J Kidney Dis. 2010;55:897–906. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20347512
Sprague SM, Bellorin-Font E, Jorgetti V, Carvalho AB, Malluche HH, Ferreira A, D’Haese PC, Drueke TB, Du H, Manley T, Rojas E, Moe SM. Diagnostic accuracy of bone turnover markers and bone histology in patients with CKD treated by dialysis. Am J Kidney Dis. 2015;67(4):559–66. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/26321176
Perrin P, Caillard S, Javier RM, Braun L, Heibel F, Borni-Duval C, Muller C, Olagne J, Moulin B. Persistent hyperparathyroidism is a major risk factor for fractures in the five years after kidney transplantation. Am J Transplant. 2013;13:2653–63. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/24034142
Diez-Perez A, Guerri R, Nogues X, Caceres E, Pena MJ, Mellibovsky L, Randall C, Bridges D, Weaver JC, Proctor A, Brimer D, Koester KJ, Ritchie RO, Hansma PK. Microindentation for in vivo measurement of bone tissue mechanical properties in humans. J Bone Miner Res. 2010;25:1877–85. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20200991
Bridges D, Randall C, Hansma PK. A new device for performing reference point indentation without a reference probe. Rev Sci Instrum. 2012;83:044301. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22559552
Farr JN, Drake MT, Amin S, Melton LJ 3rd, McCready LK, Khosla S. In vivo assessment of bone quality in postmenopausal women with type 2 diabetes. J Bone Miner Res. 2014;29:787–95. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/24123088
Furst JR, Bandeira LC, Fan WW, Agarwal S, Nishiyama KK, McMahon DJ, Dworakowski E, Jiang H, Silverberg SJ, Rubin MR. Advanced glycation endproducts and bone material strength in type 2 diabetes. J Clin Endocrinol Metab. 2016;101:2502–10. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/27115060
Mellibovsky L, Prieto-Alhambra D, Mellibovsky F, Guerri-Fernandez R, Nogues X, Randall C, Hansma PK, Diez-Perez A. Bone tissue properties measurement by reference point indentation in glucocorticoid-induced osteoporosis. J Bone Miner Res. 2015;30:1651–6. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/25736591
Malgo F, Hamdy NA, Papapoulos SE, Appelman-Dijkstra NM. Bone material strength as measured by microindentation in vivo is decreased in patients with fragility fractures independently of bone mineral density. J Clin Endocrinol Metab. 2015;100:2039–45. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/25768670
Duarte Sosa D, Vilaplana L, Guerri R, Nogues X, Wang-Fagerland M, Diez-Perez A, Eriksen FE. Are the high hip fracture rates among Norwegian women explained by impaired bone material properties? J Bone Miner Res. 2015;30:1784–9. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/25900016
Allen MR, McNerny EMB, Organ JM, Wallace JM. True gold or pyrite: a review of reference point indentation for assessing bone mechanical properties in vivo. J Bone Miner Res. 2015;30:1539–50. doi:10.1002/jbmr.2603.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of Interest
Thomas Nickolas and Erin McNerny declare no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Additional information
This article is part of the Topical Collection on Kidney and Bone
Rights and permissions
About this article
Cite this article
McNerny, E.M.B., Nickolas, T.L. Bone Quality in Chronic Kidney Disease: Definitions and Diagnostics. Curr Osteoporos Rep 15, 207–213 (2017). https://doi.org/10.1007/s11914-017-0366-z
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11914-017-0366-z