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    Home > Active Ingredient News > Endocrine System > With these 7 tips, kidney disease patients can easily cope with osteoporosis!

    With these 7 tips, kidney disease patients can easily cope with osteoporosis!

    • Last Update: 2023-02-03
    • Source: Internet
    • Author: User
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    For medical professionals only


    For patients with already fragile chronic kidney disease, it may be even worse.
    .
    .




    Written by Gui Zhi


    Osteoporosis is one of the major complications that plague patients with chronic kidney disease (CKD), seriously affecting the prognosis and quality of life of
    patients with CKD.

    With the continuous development of research on CKD combined with osteoporosis, people's understanding of it has become more and more deep, and the definition of CKD combined with osteoporosis has been updated
    .
    So, how will the coping strategy be updated and iterated?

    What is the burden of CKD combined with osteoporosis?


    At present, China lacks epidemiological survey data of CKD combined with osteoporosis, taking the United States as an example, the estimated glomerular filtration rate (eGFR) of 60ml/min is used as the dividing line, and the incidence of osteoporosis below is twice that of patients with eGFR>60ml/min, and the incidence of hip fracture in patients with CKD stage 5 dialysis is 17 times higher than that of the general population
    Several studies have shown that the occurrence of low bone mineral density (BMD) increases with the increase of kidney damage [1], and patients with CKD and osteoporosis have a higher risk of fracture than patients with osteoporosis with normal renal function [2].


    Unsurprisingly, high fracture rates in patients with CKD increase the risk of death [3].

    Therefore, it is of great significance for the diagnosis and treatment of osteoporosis in patients with CKD
    .

    How is osteoporosis evaluated in patients with CKD?


    The evaluation methods of CKD osteoporosis are mainly divided into laboratory tests (bone alkaline phosphatase, calcium, phosphorus, parathyroid hormone, 25-hydroxyvitamin D), imaging (dual-energy X-ray, peripheral high-resolution quantitative CT, quantitative ultrasonic bone detection, high-resolution MRI, infrared spectroscopy, Raman spectroscopy, electron microscopy imaging) and invasive examination (bone biopsy), in which complete laboratory evaluation includes bone metabolism biochemical indicators, bone resorption markers and bone formation markers.
    Covers the course
    of the occurrence of CKD osteoporosis.

    Under current recommendations, the frequency of monitoring laboratory tests is not clear, and it is recommended to check serum calcium, phosphorus, and alkaline phosphatase levels every 6 to 12 months, taking into account iPTH monitoring intervals as appropriate based on baseline levels of full-segment parathyroid hormone (iPTH) and progress of CKD
    .
    It is also recommended to monitor 25-hydroxyvitamin D when available, and to decide the frequency
    of monitoring based on baseline levels and interventions.
    As recommended by KDIGO 2017 Guidelines for Mineral and Bone Abnormalities in Chronic Kidney Disease (CKD-MBD) [5], patients with CKD stage 1-2 are advised to have regular lumbar spine and hip bone density measurements and evidence of CKD-MBD for CKD stages 3-5 (including dialysis) and/ or in patients at risk of osteoporosis, bone mineral density is measured to assess fracture risk
    .
    In addition to bone density assessment, fracture risk assessment for CKD patients is also very important, commonly used assessment tools include the WHO Fracture Risk Factor Assessment Tool (FRAX) and the Asian Osteoporosis Self-Screening Tool (OSTA), of which FRAX is a tool
    to assess the absolute risk of fracture within 10 years.
    Both tools can perform osteoporotic fracture risk assessment in patients with CKD stages 1 to 3, and their efficacy in patients with CKD stage 4 to 5 and hemodialysis needs to be further demonstrated
    .



    How is CKD osteoporosis treated?


    For CKD osteoporosis, medical therapy (bisphosphonates, raloxifene, teriparatide, denosumab, romosumab, etc.
    ) should be considered whenever one of the following conditions is present:


    1.
    Regardless of whether there is a history of fracture, those diagnosed with osteoporosis (BMD T value≤-2.
    5);


    2.
    Patients with more than 1 risk factor for osteoporosis and low bone mass (BMD -2.
    5< T value≤-1.
    0) regardless of whether there is a history of fracture;


    3.
    When BMD cannot be measured, those who have had fragility fractures, those with OSTA screening as high-risk, the FRAX tool calculates the probability of hip fracture ≥3%, and the
    probability of osteoporotic fracture in any major part is ≥20%.



    1.
    Bisphosphonates


    Studies have shown that oral bisphosphonates do not increase mortality in patients with moderate to severe CKD, so the use of bisphosphonates in patients with CKD according to the 2017 KDIGO guidelines can be used to exclude hypodynamic bone disease, indications:
    • CPatients with stages 1-2 KD who develop osteoporosis and/or high risk of fracture are recommended to use bisphosphonates according to the general population regimen;


    • Bisphosphonate therapy in patients with stage CKD 3-4 is effective for osteoporosis, and there is no strong evidence that bisphosphonate treatment causes non-kinetic bone disease, resulting in abnormal biochemistry of CKM-MBD and low BMD and/ or fragility fractures, it is recommended to choose whether to add bisphosphonates or other osteoporotic drugs based on the magnitude and reversibility of biochemical changes and the progression of CKD, and consider bone biopsy;


    • When treating with bisphosphonates in patients with stage CKD, special care should be taken to exclude non-motility bone disease
      based on biochemical indicators or bone biopsy.



    2.
    Calcium, active vitamin D and their analogues


    For patients with CKD who are associated with osteoporosis and/or high risk of fracture, treatment with active vitamin D and its analogues and calcium may follow these recommendations:
    • CKD stage 1-2 patients with osteoporosis and/or high risk of fracture, the method of use refers to the general population;

    • In nondialysis patients with normal stage 3-5 iPTH and low BMD and/or high fracture risk, the recommended dose of active vitamin D is 0.
      25
      - 0.
      5
      micrograms/day orally once or in 2 divided doses;

    • Active vitamins are recommended in patients with stage C KD stage 3-5 who have not received dialysis and have low BMD and/or a high risk of fracture and who have progressively elevated iPTH and remain above the upper limit of normal despite correction of modifiable factors D and its analogues were treated and the smallest starting dose was selected for intermittent or continuous administration, maintaining iPTH in the normal range;

    • Patients on stage 5 CKD dialysis with low BMD and/or high risk of fracture should be selected for active/nutritional vitamin D based on iPTH levels and considered for bone biopsy
      .



    3.
    Calcitonin


    Calcitonin therapy is recommended for patients with osteoporosis with CKD who are ineffective with other drug treatments and are in patients with hyper-transforming osteoporosis, senile osteoporosis, osteoporosis caused by hormone therapy
    , or bone pain due to osteolysis or osteopenia, or patients with severe hypercalcemia.


    4.
    Denosumab


    Studies have shown that denosumab increases bone mineral density in patients with CKD [8] and is safe and effective in hemodialysis patients [9].



    5.
    Estrogen drugs


    Estrogens can be treated with estrogen-based drugs for patients with stage 1 to 2 of CKD and osteoporosis associated with decreased sex hormones, such as perimenopausal and postmenopausal women before age 60, especially those with menopausal symptoms and urogenital atrophy
    .
     

    6.
    Estrogen receptor modulator


    These agents are represented by raloxifene, and women with postmenopausal osteoporosis diagnosed with CKD stages 1 to 2 can be treated
    with estrogen receptor modulators.
    For postmenopausal women on dialysis, estrogen receptor modulators may be considered when there is still severe osteoporosis or fracture when parathyroid hormone control is good, and it does not increase the incidence
    of breast and endometrial cancer.



    7.
    Teriparatide, abalotide, romosolumab


    Studies have shown that teriparatide can affect bone metabolism and increase bone density in patients with CKD stage 3 to 5 [10], and the use of low parathyroid hormone dialysis patients can improve lumbar spine bone density
    .
    Abalolotide has similar functions to teriparatide in increasing bone mass and leads to a lower
    risk of hypercalcaemia.
    In addition, the anti-osteosclerotic monoclonal antibody - romosozumab may increase bone density and reduce fractures in postmenopausal women, but data from patients with CKD-MBD are lacking for all three drugs
    .



    brief summary


    The incidence of osteoporosis in patients with CKD is high, and the pathogenesis is very complex, which needs to be studied
    in more depth.
    In terms of fracture risk assessment, although FRAX and OSTA have been widely used, the efficacy of their evaluation for CKD stage 4-5 and dialysis patients needs to be
    supported by evidence.
    At present, the clinical treatment of CKD-MBD is still difficult, and new drugs still need more clinical evidence
    .

    References:

    [1]Kong X, Tang L, Ma X, et al.
    Relationship between mild-to-moderate chronic kidney disease and decreased bone mineral density in Chinese adult population[J].
    International urology and nephrology, 2015, 47(9): 1547-1553.
    https://pubmed.
    ncbi.
    nlm.
    nih.
    gov/26265108/
    [2]Yenchek R H, Ix J H, Shlipak M G, et al.
    Bone mineral density and fracture risk in older individuals with CKD[J].
    Clinical Journal of the American Society of Nephrology, 2012, 7(7): 1130-1136.
    https://pubmed.
    ncbi.
    nlm.
    nih.
    gov/22516286/
    [3]Kim S M, Long J, Montez‐Rath M, et al.
    Hip fracture in patients with non‐dialysis‐requiring chronic kidney disease[J].
    Journal of Bone and Mineral Research, 2016, 31(10): 1803-1809.
    https://pubmed.
    ncbi.
    nlm.
    nih.
    gov/27145189/
    [4]Hsu C Y, Chen L R, Chen K H.
    Osteoporosis in patients with chronic kidney diseases: A systemic review[J].
    International Journal of Molecular Sciences, 2020, 21(18): 6846.
    https://pubmed.
    ncbi.
    nlm.
    nih.
    gov/32961953/
    [5]Kidney D, Improving G O K C K D M B D, Work G.
    KDIGO 2017 clinical practice guideline update for the diagnosis, evaluation, prevention, and treatment of chronic kidney disease-mineral and bone disorder (CKD-MBD)[J].
    Kidney international supplements, 2017, 7(1): 1.
    https://pubmed.
    ncbi.
    nlm.
    nih.
    gov/30675420/
    [6]Khairallah P, Nickolas T L.
    Management of Osteoporosis in CKD[J].
    Clinical Journal of the American Society of Nephrology, 2018, 13(6): 962-969.
    https://pubmed.
    ncbi.
    nlm.
    nih.
    gov/29487093/
    [7] Chapter Four: Treatment of Osteoporosis in Patients with Chronic Kidney Disease[J].
    Chinese Journal of Nephrology,2014,30(Z1):37-44.
    https://d.
    wanfangdata.
    com.
    cn/periodical/zhszb982014z1005
    [8] Fraser T R, Flogaitis I, Moore A E, et al.
    The effect of previous treatment with bisphosphonate and renal impairment on the response to denosumab in osteoporosis: A ‘real-life’study[J].
    Journal of endocrinological investigation, 2020, 43(4): 469-475.
    https://pubmed.
    ncbi.
    nlm.
    nih.
    gov/31664706/
    [9] Kunizawa K, Hiramatsu R, Hoshino J, et al.
    Denosumab for dialysis patients with osteoporosis: A cohort study[J].
    Scientific reports, 2020, 10(1): 1-[9]https://pubmed.
    ncbi.
    nlm.
    nih.
    gov/32051451/
    [10] Nishikawa A, Ishida T, Taketsuna M, et al.
    Safety and effectiveness of daily teriparatide in a prospective observational study in patients with osteoporosis at high risk of fracture in Japan[J].
    Clinical interventions in aging, 2016, 11: 913.
    https://pubmed.
    ncbi.
    nlm.
    nih.
    gov/27462147/


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