Original Full Length ArticleEpidemiology and mortality of hip fracture among patients on dialysis: Taiwan National Cohort Study
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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Zhe-Zhong Lin and Jhi-Joung Wang contributed equally and are first authors for this article.