Major fractures after initiation of dialysis: Incidence, predictors and association with mortality

Abstract

Background: Major fractures (MF) are common in dialysis patients. We investigated incidence, predictors and clinical outcomes associated with first MF occurring after initiation of dialysis (MF_first).

Methods: In Swedish Renal Registry of 9714 incident (2005-2016) dialysis patients (age 68 years, 67% men), we identified all MF_first in hip, spine, humerus and forearm. Using flexible parametric hazard models and Fine-Gray analysis, we estimated incidence, mortality rates and predictors of MF_first, and, in time-dependent analysis, risk of all-cause and cardiovascular disease (CVD) mortality following MF_first.

Results: During median follow-up of 2.2 years, the crude incidence rate of MFfirst (n = 835) was 23.7/1000 patient-years and that of hip fractures (n = 470) 13.3/1000 patient-years. The multivariate-adjusted fracture incidence rates increased gradually after dialysis initiation and were 47% higher among women. Female sex, higher age, comorbidity, and previous history of MF (MF_previous) were associated with increased risk for MF_first, whereas peritoneal dialysis as compared to hemodialysis was associated with decreased risk. The adjusted fracture incidence rate of MF_first during the first 90 days following dialysis initiation was higher in patients with MF_previous than in those without MF_previous. MF_first independently predicted increased all-cause (sub-distribution hazard ratio, SHR, 1.67(95%CI 1.47-1.91)) and CVD (SHR 1.49 (95%CI 1.22-1.84)) mortality. Adjusted mortality rate following hip fractures was higher than for other types of MF. Spline curves showed that mortality following MF_first was highest during the first 6 months of follow-up.

Conclusions: MF are common and associated with increased mortality in incident dialysis patients.

Keywords: Dialysis; End-stage renal disease; Fracture; Mortality; Osteoporosis; Renal osteodystrophy.