Elsevier

Bone

Volume 64, July 2014, Pages 235-239
Bone

Original Full Length Article
Epidemiology and mortality of hip fracture among patients on dialysis: Taiwan National Cohort Study

https://doi.org/10.1016/j.bone.2014.04.017Get rights and content

Highlights

  • We use the Taiwan National Health Insurance Research Database to evaluate the epidemiology of hip fractures in dialysis patients.

  • The incidence of hip fractures is high in end-stage renal disease dialysis patients.

  • Patients receiving hemodialysis have a higher risk of hip fractures than those receiving peritoneal dialysis.

  • Factors increasing the risk of hip fractures included female gender, old age, osteoporosis, diabetes and liver cirrhosis.

Abstract

Chronic kidney disease increases the risk for hip fractures. Hip fractures are associated with increased mortality, decreased quality of life, and higher economic burden. To determine whether dialysis modality is associated with a higher incidence of hip fractures in patients with end-stage renal disease (ESRD), we used the Taiwan National Health Insurance Research Database to examine the records of 51,473 patients who began dialysis between 1999 and 2005. The patients were followed until death, transplantation, dialysis cessation, or 31 December 2008. The follow-up period was (mean ± SD) 4.14 ± 2.48 years. The cumulative incidence rate of hip fracture was calculated using Kaplan–Meier methods. Predictors of hip fracture were determined using Cox models. During the study period, 1903 patients had a hip fracture. The overall incidence rate of hip fracture was 89.21/10,000 patient-years. Patients on hemodialysis (HD) had a 31% higher incidence of hip fracture than those on peritoneal dialysis (PD) (HR 1.31, 95% CI: 1.01–1.70). Patients ≥ 65 years old had more than 13 times the risk of a hip fracture than did those 18–44 years old (HR: 13.65; 95% CI: 10.12–18.40). Other factors that increased the risk of a hip fracture were a prior hip fracture (HR: 1.44; 95% CI: 1.15–1.80), osteoporosis (HR: 1.24; 95% CI: 1.07–1.45), DM (HR: 1.66; 95% CI: 1.51–1.83), and liver cirrhosis (HR: 1.37, 95% CI: 1.15–1.64). The overall in-hospital mortality rate was 3.2%. The cumulative survival rates after a hip fracture were 74.6% at one year and only 29.6% at seven years. Our findings supported the notion that being on HD is a risk for hip fracture. Additionally, old age, female gender, a prior hip fracture, osteoporosis, DM and liver cirrhosis were also risk factors for hip fracture in patients with ESRD and undergoing dialysis.

Introduction

The number of people with chronic kidney disease (CKD) is increasing [1]. Hip fractures occur more frequently in patients with CKD and end-stage renal disease (ESRD) [2], and they are an important complication associated with a high mortality rate [3], decreased quality of life [4], and large economic burden [3], [5].

The mechanisms of impaired skeletal strength in patients with ESRD are either osteoporosis [3], [6], [7] or renal bone disease, such as adynamic bone disease [8], [9]. Stein et al. [6] reported a prevalence of osteopenia up to 20% at sites clinically associated with fracture in a large sample of patients on dialysis. Kosei et al. [7] also reported that low bone mineral density predicts fracture in patients on dialysis. Various bone lesions occurring in patients with CKD share the general term of renal osteodystrophy [8]. The prevalence of adynamic bone disease is high in patients with ESRD and on dialysis [9], and there is a close relationship between a higher incidence of fracture and adynamic bone disease [8], [10]. Increasing age [11], female gender [11], white race [12], diabetes [12], and duration of dialysis [12] are also risk factors for hip fractures in patients with CKD. Compared with maintenance dialysis, renal transplantation is associated with a greater risk of hip fractures within 630 days beyond transplantation [12]. However, few studies have investigated whether the modality of dialysis is a risk factor for hip fractures. We hypothesized that patients with ESRD on hemodialysis (HD) would have a higher incidence of hip fracture than those on peritoneal dialysis (PD). In addition, few studies have evaluated long-term mortality rates after hip fractures in patients with ESRD and on dialysis.

The incidence and prevalence rates of ESRD are high in Taiwan [13]. To test our hypothesis and evaluate the epidemiology and the in-hospital and long-term mortality rate of hip fractures in patients with ESRD and on dialysis, we used a large dataset from the Taiwan National Health Insurance Research Database (NHIRD) to undertake a nationwide study.

Section snippets

Database

The National Health Insurance (NHI) program has provided compulsory universal health insurance in Taiwan since 1995. With the exception of prison inmates, all citizens are enrolled in the program. All contracted medical institutions must submit standard computerized claim documents for medical expenses. Patients with ESRD are eligible for any type of renal replacement therapy free of any charge. All chronic dialysis patients are covered by the NHI.

Data were obtained from the National Health

Demographics and clinical characteristics

We enrolled 51,473 adult incident dialysis patients. The follow-up period (mean ± SD) was 4.14 ± 2.48 years. During the follow-up period, 1903 (3.70%) patients had a hip fracture (incidence rate: 89.21/10,000 patient-years; males: 3%; females: 4.3%; p < 0.001) (Table 1). The incidence of hip fractures was 75.43/10,000 patient-years in males and 101.2/10,000 patient-years in females. Only 0.6% of those 18–44 years old had a hip fracture; however, 6.1% of those ≥ 65 years old had a hip fracture (incidence

Discussion

This study used Taiwan's representative national database, the NHIRD, to investigate the incidence rates of hip fractures in patients with ESRD and undergoing dialysis. We found that patients on HD had a higher incidence of hip fractures than did those on PD. Old age, female gender, a prior hip fracture, osteoporosis, DM and liver cirrhosis were also risk factors for hip fracture. The in-hospital mortality rate was 3.2%.

The overall cumulative hip fracture incidence rate was 89.21/10,000 

Acknowledgments

The study was supported by grants CMFHR10073 and CMFHR10266 from Chi-Mei Medical Center and grant NHRI-NHIRD-99182 from the National Health Research Institutes in Taiwan.

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