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Impaired muscle strength is associated with fractures in hemodialysis patients

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Abstract

Introduction

Fractures are extremely common among hemodialysis (HD) patients.

Methods

To assess if bone mineral density (BMD) and/or tests of muscle strength were associated with fractures, we studied 37 men and 15 women, 50 years and older, on HD for at least 1 year. We excluded subjects with prior renal transplants and women taking hormone replacement therapy. We inquired about low-trauma fractures since starting dialysis. Subjects underwent BMD testing with a Lunar DPX-L densitometer. Tests of muscle strength included: timed up and go (TUG), 6-min walk, functional reach, and grip strength. Lateral and thoracic radiographs of the spine were obtained and reviewed for prevalent vertebral fractures. We used logistic regression to examine associations between fracture (prevalent vertebral, self-reported low trauma since starting dialysis and/or both) and BMD, and fracture and muscle-strength tests. Analyses were adjusted for age, weight, and gender.

Results

Mean age was 66±9.0 years, mean weight was 72.9±15.2 kg, and most (35 of 52) participants were Caucasian. Average duration of dialysis was 40.2 (interquartile range: 24–61.2) months. The most common cause of renal failure was diabetes (16 subjects). There were no differences by gender or fracture. Of the 52 subjects, 27 had either a vertebral fracture or low trauma fracture. There was no association between fractures, hip or spine BMD, or grip strength. In contrast, greater functional reach [odds ratio (OR) per standard deviation (SD) increase: 0.29; 95% CI: 0.13–0.69), quicker TUG (OR per SD decrease: 0.14; 95% CI: 0.11–0.23), and a greater distance walked in 6 min (OR per SD increase: 0.10; 95% CI: 0.03–0.36) were all associated with a reduced risk of fracture.

Conclusions

Impaired neuromuscular function is associated with fracture in hemodialysis patients.

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Conflict of interest statement

None of the authors have any conflict of interest to declare.

Author information

Authors and Affiliations

  1. Department of Medicine, Division of Endocrinology and Metabolism, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada

    S. A. Jamal, R. E. Leiter & C. J. Hamilton

  2. Department of Medicine, Division of Nephrology, The University Health Network, University of Toronto, Toronto, ON, Canada

    V. Jassal

  3. Departments of Epidemiology and Biostatistics and Medicine, University of California, San Francisco, CA, USA

    D. C. Bauer

Authors
  1. S. A. Jamal
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  2. R. E. Leiter
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  3. V. Jassal
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  4. C. J. Hamilton
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  5. D. C. Bauer
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Corresponding author

Correspondence to S. A. Jamal.

Appendix 1

Appendix 1

Description of tests of neuromuscular function

Functional reach

For the functional reach test, participants were asked to stand upright close to a wall such that their shoulder was aligned with a 1-m rule secured to the wall. The participant was then asked to extend their arm, with the forearm pronated and the hand clenched in a fist. The position of the third metacarpal was measured on the meter rule (position 1). The participant was then asked to reach forward as far as they could in the horizontal plane without losing balance or taking a step. At this point, the position of the third metacarpal was again measured on the meter rule (position 2). The distance between position 1 and position 2 is considered the functional reach. Participants completed two practice trials and then three test trials. Functional reach, expressed in centimeters, was the average of the three test trials [46].

Timed up and go

The TUG test evaluates balance and basic functional mobility. The participant is seated in a standard arm chair (46-cm seat height to the ground), rises, walks 3 m at a comfortable pace, turns, walks back to the chair, and sits down. The time it takes to perform this task, measured with a standard stopwatch, is the TUG result [47].

Grip strength

We tested grip strength in the nonfistula hand using a Jamar dynamometer. Grip strength evaluated hand and forearm strength. Participants were seated comfortably in a chair, with the shoulder adducted and neutrally rotated, the elbow flexed at 90º, and the forearm and wrist in a neutral position. The participant was asked to squeeze the dynamometer bulb to maximal effort, and their grip strength was recorded. Each participant was given one practice session and three test trials with a minimum 5-s rest period between trials. The mean of the three trials was reported in kilograms [48].

The 6-min walk

The 6-min walk is used to evaluate exercise endurance. Participants are instructed to walk from end to end of a corridor, covering as much ground as possible in 6 min. Participants are told that they may rest if they become too short of breath or too tired to continue but to resume walking when they are able to do so. At the end of 6 min, the participants are told to stop. Distance walked and number and duration of rests are measured [49].

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Jamal, S.A., Leiter, R.E., Jassal, V. et al. Impaired muscle strength is associated with fractures in hemodialysis patients. Osteoporos Int 17, 1390–1397 (2006). https://doi.org/10.1007/s00198-006-0133-y

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