Skip to main content
SpringerLink
Log in

Bone Imaging and Fracture Risk Assessment in Kidney Disease

  • Kidney and Bone (SM Moe and IB Salusky, Section Editors)
  • Published:
Current Osteoporosis Reports Aims and scope Submit manuscript

Abstract

Fractures are more common and are associated with greater morbidity and morality in patients with kidney disease than in members of the general population. Thus, it is troubling that in chronic kidney disease (CKD) patients there has been a paradoxical increase in fracture rates over the past 20 years compared to the general population. Increased fracture incidence in CKD patients may be driven in part by the lack of screening for fracture risk. In the general population, dual energy X-ray absorptiometry (DXA) is the clinical standard to stratify fracture risk, and its use has contributed to decreases in fracture incidence. In contrast, in CKD, fracture risk screening with DXA has been uncommon due to its unclear efficacy in predicting fracture and its inability to predict type of renal osteodystrophy. Recently, several prospective studies conducted in patients across the spectrum of kidney disease have demonstrated that bone mineral density measured by DXA predicts future fracture risk and that clinically relevant information regarding fracture risk is provided by application of the World Health Organization cutoffs for osteopenia and osteoporosis to DXA measures. Furthermore, novel high-resolution imaging tools, such as high-resolution peripheral quantitative computed tomography (HR-pQCT), have been used to elucidate the effects of kidney disease on cortical and trabecular microarchitecture and bone strength and to identify potential targets for strategies that protect against fractures. This review will discuss the updated epidemiology of fractures in CKD, fracture risk screening by DXA, and the utility of state-of-the art imaging methods to uncover the effects of kidney disease on the skeleton.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Nickolas TL, McMahon DJ, Shane E. Relationship between moderate to severe kidney disease and hip fracture in the United States. J Am Soc Nephrol. 2006;17(11):3223–32.

    Article  PubMed  Google Scholar 

  2. Alem AM, Sherrard DJ, Gillen DL, Weiss NS, Beresford SA, Heckbert SR, et al. Increased risk of hip fracture among patients with end-stage renal disease. Kidney Int. 2000;58(1):396–9.

    Article  CAS  PubMed  Google Scholar 

  3. Naylor KL, McArthur E, Leslie WD, Fraser LA, Jamal SA, Cadarette SM, et al. The three-year incidence of fracture in chronic kidney disease. Kidney Int. 2014;86(4):810–8.

    Article  PubMed  Google Scholar 

  4. Cummings SR, Black DM, Nevitt MC, Browner W, Cauley J, Ensrud K, et al. Bone density at various sites for prediction of hip fractures. The study of osteoporotic fractures research group. Lancet. 1993;341(8837):72–5.

    Article  CAS  PubMed  Google Scholar 

  5. Nikkel LE, Hollenbeak CS, Fox EJ, Uemura T, Ghahramani N. Risk of fractures after renal transplantation in the United States. Transplantation. 2009;87(12):1846–51.

    Article  PubMed  Google Scholar 

  6. 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(8):1336–42.

    Article  PubMed Central  PubMed  Google Scholar 

  7. 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(1):146–51.

    Article  PubMed  Google Scholar 

  8. Danese MD, Kim J, Doan QV, Dylan M, Griffiths R, Chertow GM. PTH and the risks for hip, vertebral, and pelvic fractures among patients on dialysis. Am J Kidney Dis. 2006;47(1):149–56.

    Article  PubMed  Google Scholar 

  9. Piraino B, Chen T, Cooperstein L, Segre G, Puschett J. Fractures and vertebral bone mineral density in patients with renal osteodystrophy. Clin Nephrol. 1988;30(2):57–62.

    CAS  PubMed  Google Scholar 

  10. Jamal SA, Chase C, Goh YI, Richardson R, Hawker GA. Bone density and heel ultrasound testing do not identify patients with dialysis-dependent renal failure who have had fractures. Am J Kidney Dis. 2002;39(4):843–9.

    Article  PubMed  Google Scholar 

  11. Jamal SA, Gilbert J, Gordon C, Bauer DC. Cortical pQCT measures are associated with fractures in dialysis patients. J Bone Mineral Res. 2006;21(4):543–8.

    Article  Google Scholar 

  12. Nickolas TL, Stein E, Cohen A, Thomas V, Staron RB, McMahon DJ, et al. Bone mass and microarchitecture in CKD patients with fracture. J Am Soc Nephrol. 2010;21(8):1371–80.

    Article  PubMed Central  PubMed  Google Scholar 

  13. Nickolas TL, Cremers S, Zhang A, Thomas V, Stein E, Cohen A, et al. Discriminants of prevalent fractures in chronic kidney disease. J Am Soc Nephrol. 2011;22(8):1560–72.

    Article  PubMed Central  PubMed  Google Scholar 

  14. 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(12):2805–13.

    Article  CAS  PubMed  Google Scholar 

  15. Yenchek RH, Ix JH, Shlipak MG, Bauer DC, Rianon NJ, Kritchevsky SB, et al. Bone mineral density and fracture risk in older individuals with CKD. Clin J Am Soc Nephrol. 2012;7(7):1130–6.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  16. Iimori S, Mori Y, Akita W, Kuyama T, Takada S, Asai T, 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. Nephrol Dial Transplant. 2012;27(1):345–51.

    Article  CAS  PubMed  Google Scholar 

  17. Akaberi S, Simonsen O, Lindergard B, Nyberg G. Can DXA predict fractures in renal transplant patients? Am J Transplant. 2008;8(12):2647–51.

    Article  CAS  PubMed  Google Scholar 

  18. Naylor KL, Leslie WD, Hodsman AB, Rush DN, Garg AX. FRAX predicts fracture risk in kidney transplant recipients. Transplantation. 2014;97(9):940–5.

    Article  CAS  PubMed  Google Scholar 

  19. Jamal SA, West SL, Miller PD. Bone and kidney disease: diagnostic and therapeutic implications. Curr Rheumatol Rep. 2012;14(3):217–23.

    Article  CAS  PubMed  Google Scholar 

  20. Miller PD. Bone disease in CKD: a focus on osteoporosis diagnosis and management. Am J Kidney Dis. 2014;64(2):290–304.

  21. Beaubrun AC, Kilpatrick RD, Freburger JK, Bradbury BD, Wang L, Brookhart MA. Temporal trends in fracture rates and postdischarge outcomes among hemodialysis patients. J Am Soc Nephrol. 2013;24(9):1461–9.

    Article  PubMed Central  PubMed  Google Scholar 

  22. 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(4):747–54.

    Article  PubMed  Google Scholar 

  23. Ball AM, Gillen DL, Sherrard D, Weiss NS, Emerson SS, Seliger SL, et al. Risk of hip fracture among dialysis and renal transplant recipients. JAMA: J Am Med Assoc. 2002;288(23):3014–8.

    Article  Google Scholar 

  24. Vautour LM, Melton 3rd LJ, Clarke BL, Achenbach SJ, Oberg AL, McCarthy JT. Long-term fracture risk following renal transplantation: a population-based study. Osteoporos Int. 2004;15(2):160–7.

    Article  PubMed  Google Scholar 

  25. Nikkel LE, Mohan S, Zhang A, McMahon DJ, Boutroy S, Dube G, Tanriover B, Cohen D, Ratner L, Hollenbeak CS, Leonard MB, Shane E, Nickolas TL. Reduced fracture risk with early corticosteroid withdrawal after kidney transplant. Am J Transplant. 2012;12(3):649–59.

  26. Perrin P, Caillard S, Javier RM, Braun L, Heibel F, Borni-Duval C, et al. Persistent hyperparathyroidism is a major risk factor for fractures in the five years after kidney transplantation. Am J Transplant. 2013;13(10):2653–63.

    Article  CAS  PubMed  Google Scholar 

  27. Abbott KC, Oglesby RJ, Hypolite IO, Kirk AD, Ko CW, Welch PG, et al. Hospitalizations for fractures after renal transplantation in the United States. Ann Epidemiol. 2001;11(7):450–7.

    Article  CAS  PubMed  Google Scholar 

  28. Wiktorowicz ME, Goeree R, Papaioannou A, Adachi JD, Papadimitropoulos E. Economic implications of hip fracture: health service use, institutional care and cost in Canada. Osteoporos Int. 2001;12(4):271–8.

    Article  CAS  PubMed  Google Scholar 

  29. Moe S, Drueke T, Cunningham J, Goodman W, Martin K, Olgaard K, et al. Definition, evaluation, and classification of renal osteodystrophy: a position statement from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int. 2006;69(11):1945–53.

    Article  CAS  PubMed  Google Scholar 

  30. Parfitt AM. A structural approach to renal bone disease. J Bone Miner Res. 1998;13(8):1213–20.

    Article  CAS  PubMed  Google Scholar 

  31. Jee WS. The past, present, and future of bone morphometry: its contribution to an improved understanding of bone biology. J Bone Mineral Metab. 2005;23 Suppl:1-10.

  32. Kanis JA, McCloskey EV, Johansson H, Strom O, Borgstrom F, Oden A. How to decide who to treat. Best Pract Res Clin Rheumatol. 2009;23(6):711–26.

    Article  CAS  PubMed  Google Scholar 

  33. Klawansky S, Komaroff E, Cavanaugh Jr PF, Mitchell DY, Gordon MJ, Connelly JE, et al. Relationship between age, renal function and bone mineral density in the US population. Osteoporos Int. 2003;14(7):570–6.

    Article  CAS  PubMed  Google Scholar 

  34. Jamal SA, West SL, Nickolas TL. The clinical utility of FRAX to discriminate fracture status in men and women with chronic kidney disease. Osteoporos Int. 2014;25(1):71–6.

    Article  CAS  PubMed  Google Scholar 

  35. West SL, Jamal SA, Lok CE. Tests of neuromuscular function are associated with fractures in patients with chronic kidney disease. Nephrol Dial Transplant. 2012;27(6):2384–8.

    Article  PubMed  Google Scholar 

  36. Maruyama Y, Taniguchi M, Kazama JJ, Yokoyama K, Hosoya T, Yokoo T, et al. A higher serum alkaline phosphatase is associated with the incidence of hip fracture and mortality among patients receiving hemodialysis in Japan. Nephrol Dial Transplant. 2014;29(8):1532–8.

  37. Leonard MB. A structural approach to skeletal fragility in chronic kidney disease. Semin Nephrol. 2009;29(2):133–43.

    Article  PubMed Central  PubMed  Google Scholar 

  38. Denburg MR, Tsampalieros AK, de Boer IH, Shults J, Kalkwarf HJ, Zemel BS, et al. Mineral metabolism and cortical volumetric bone mineral density in childhood chronic kidney disease. J Clin Endocrinol Metab. 2013;98(5):1930–8.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  39. 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(4):882–90.

    PubMed  Google Scholar 

  40. 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(5):1733–40.

    Article  CAS  PubMed  Google Scholar 

  41. Liu XS, Stein EM, Zhou B, Zhang CA, Nickolas TL, Cohen A, et al. 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(2):263–72.

    Article  PubMed Central  PubMed  Google Scholar 

  42. Cejka D, Patsch JM, Weber M, Diarra D, Riegersperger M, Kikic Z, et al. Bone microarchitecture in hemodialysis patients assessed by HR-pQCT. Clin J Am Soc Nephrol. 2011;6(9):2264–71.

    Article  PubMed Central  PubMed  Google Scholar 

  43. Trombetti A, Stoermann C, Chevalley T, Van Rietbergen B, Herrmann FR, Martin PY, et al. Alterations of bone microstructure and strength in end-stage renal failure. Osteoporos Int. 2013;24(5):1721-32.

  44. Nickolas TL, Stein EM, Dworakowski E, Nishiyama KK, Komandah-Kosseh M, Zhang CA, et al. Rapid cortical bone loss in patients with chronic kidney disease. J Bone Miner Res. 2013;28(8):1811–20.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  45. Iyer SP, Nikkel LE, Nishiyama KK, Dworakowski E, Cremers S, Zhang C, McMahon DJ, Boutroy S, Liu XS, Ratner LE, Cohen DJ, 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.

  46. Boutroy SN T, 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.

    Google Scholar 

  47. Nishiyama KK, Pauchard Y, Nikkel LE, Iyer S, Zhang C, McMahon DJ, et al. Longitudinal HR-pQCT and image registration detects endocortical bone loss in kidney transplantation patients. J Bone Miner Res. 2015;30(3):456–63.

Download references

Compliance with Ethics Guidelines

Conflict of Interest

SA Jamal and TL Nickolas both declare no conflicts 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.

Author information

Authors and Affiliations

  1. Women’s College Research Institute, University of Toronto, Toronto, Canada

    Sophie A. Jamal

  2. Department of Medicine, Nephrology, Columbia University Medical Center, 622 West 168th Street, PH4-124, New York, NY, 10032, USA

    Thomas L. Nickolas

Authors
  1. Sophie A. Jamal
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Thomas L. Nickolas
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Thomas L. Nickolas.

Additional information

This article is part of the Topical Collection on Kidney and Bone

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Jamal, S.A., Nickolas, T.L. Bone Imaging and Fracture Risk Assessment in Kidney Disease. Curr Osteoporos Rep 13, 166–172 (2015). https://doi.org/10.1007/s11914-015-0262-3

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11914-015-0262-3

Keywords

Search

Navigation