Pérez-Sáez María José, Prieto-Alhambra Daniel, Barrios Clara, Crespo Marta, Redondo Dolores, Nogués Xavier, Díez-Pérez Adolfo, Pascual Julio
Department of Nephrology, Hospital del Mar, Barcelona, Spain.
Institut Mar d'Investigacions Mediques, Barcelona, Spain; Idiap Jordi Gol Primary Care Research Institute, Universitat Autonoma de Barcelona, Barcelona, Spain; Musculoskeletal Epidemiology Unit, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
Bone. 2015 Apr;73:154-9. doi: 10.1016/j.bone.2014.12.020. Epub 2014 Dec 27.
Many studies have shown a correlation between chronic kidney disease (CKD) and fracture. However, increased mortality in CKD patients is a competing risk scenario not accounted for in previous studies. Our aim was to investigate the true impact of CKD on hip fracture after accounting for a competing risk with death.
We conducted a population-based cohort study to determine the impact of CKD on hip fractures in individuals aged ≥50years old registered in the SIDIAP(Q) database (representative of 1.9 million people in Catalonia, Spain). Cox regression was used to estimate hazard ratio (HR) for death and hip fracture according to CKD status. A competing risk (Fine and Gray) model was fitted to estimate sub-HR for hip fracture in CKD or CKD-free patients accounting for differential mortality.
A total of 873,073 (32,934 (3.8%) CKD) patients were observed for 3 years. During follow-up, 4,823 (14.6%) CKD and 36,328 (4.3%) CKD-free participants died (HR, 1.83 [95% CI, 1.78-1.89]), whilst 522 (1.59%) and 6,292 (0.75%) sustained hip fractures, respectively. Adjusted Cox models showed a significantly increased risk of hip fractures for the CKD group (HR, 1.16 [1.06-1.27]), but this association was attenuated in competing risk models accounting for mortality (SHR, 1.14 [1.03-1.27]).
Both death and hip fracture rates are increased (by 83% and 16%, respectively) in CKD patients. However, the association between CKD and hip fractures is attenuated when an excess of mortality is taken into account. A competing risk with death must be considered in future analyses of association between CKD and any health outcomes.
许多研究表明慢性肾脏病（CKD）与骨折之间存在关联。然而，CKD患者死亡率增加是先前研究未考虑到的竞争风险情况。我们的目的是在考虑死亡这一竞争风险后，研究CKD对髋部骨折的真正影响。
我们进行了一项基于人群的队列研究，以确定CKD对SIDIAP（Q）数据库中登记的年龄≥50岁个体髋部骨折的影响（该数据库代表西班牙加泰罗尼亚的190万人）。采用Cox回归根据CKD状态估计死亡和髋部骨折的风险比（HR）。拟合竞争风险（Fine和Gray）模型以估计CKD或无CKD患者髋部骨折的亚风险比（sub-HR），同时考虑不同的死亡率。
共观察了873,073名患者（32,934名（3.8%）患有CKD），为期3年。随访期间，4,823名（14.6%）患有CKD的参与者和36,328名（4.3%）无CKD的参与者死亡（HR，1.83 [95% CI，1.78 - 1.89]），而分别有522名（1.59%）和6,292名（0.75%）发生髋部骨折。调整后的Cox模型显示CKD组髋部骨折风险显著增加（HR，1.16 [1.06 - 1.27]），但在考虑死亡率的竞争风险模型中，这种关联减弱（亚风险比，1.14 [1.03 - 1.27]）。
CKD患者的死亡率和髋部骨折率均升高（分别升高83%和16%）。然而，当考虑到过高的死亡率时，CKD与髋部骨折之间的关联减弱。在未来关于CKD与任何健康结局之间关联的分析中，必须考虑死亡这一竞争风险。
