Pocock Nicholas
St Vincent's Hospital, Darlinghurst, Australia.
University of New South Wales, Kensington.
Nephrology (Carlton). 2017 Mar;22 Suppl 2:19-21. doi: 10.1111/nep.13016.
In subjects with chronic kidney disease (CKD) who suffer a minimal trauma fracture, the problem is to differentiate between osteoporosis and the various forms of renal bone disease associated with CKD-mineral and bone disorder. This problem is exacerbated by the fact that renal osteodystrophy may coexist with osteoporosis. The World Health Organization's bone mineral density (BMD) criteria for osteopenia ( -2.5 < T-score < -1.0) and osteoporosis (a T-score ≤ -2.5) may be used in patients with CKD stages 1-3. In CKD stages 4-5, BMD by dual-energy X-ray absorptiometry (DXA) is less predictive and may underestimate fracture risk. The development of absolute fracture risk (AFR) algorithms, such as FRAX® and the Garvan absolute fracture risk calculator, to predict risk of fracture over a given time (usually 10 years) aims to incorporate non-BMD risk factors into the clinical assessment. FRAX® has been shown to be useful to assess fracture risk in CKD but may underestimate fracture risk in advanced CKD. The trabecular bone score is a measure of grey scale homogeneity obtained from spine DXA, which correlates to trabecular microarchitecture and is an independent risk factor for fracture. Recent data demonstrate the potential utility of the trabecular bone score adjustment of AFR through the FRAX® algorithm in subjects with CKD. Parameters of bone microarchitecture using peripheral quantitative computed tomography (pQCT) or high-resolution pQCT are also able to discriminate fracture status in subjects with CKD. However, there are at present no convincing data that the addition of pQCT or high-resolution pQCT parameters to DXA BMD improves fracture discrimination. More advanced estimates of bone strength derived from measurements of micro-architecture, by QCT-derived finite element analysis may be incorporated into AFR algorithms in the future.
在患有慢性肾脏病（CKD）且发生轻微创伤性骨折的患者中，问题在于区分骨质疏松症与与CKD - 矿物质和骨代谢紊乱相关的各种形式的肾性骨病。由于肾性骨营养不良可能与骨质疏松症共存，这一问题变得更加复杂。世界卫生组织关于骨量减少（-2.5＜T值＜-1.0）和骨质疏松症（T值≤-2.5）的骨密度（BMD）标准可用于CKD 1 - 3期患者。在CKD 4 - 5期，双能X线吸收法（DXA）测量的BMD预测性较差，可能会低估骨折风险。开发绝对骨折风险（AFR）算法，如FRAX®和加尔万绝对骨折风险计算器，以预测给定时间（通常为10年）内的骨折风险，旨在将非BMD风险因素纳入临床评估。FRAX®已被证明可用于评估CKD患者的骨折风险，但在晚期CKD中可能会低估骨折风险。小梁骨评分是从脊柱DXA获得的灰度均匀性测量值，与小梁微结构相关，是骨折的独立危险因素。最近的数据表明，通过FRAX®算法对CKD患者的AFR进行小梁骨评分调整具有潜在效用。使用外周定量计算机断层扫描（pQCT）或高分辨率pQCT的骨微结构参数也能够区分CKD患者的骨折状态。然而，目前尚无令人信服的数据表明，在DXA BMD基础上增加pQCT或高分辨率pQCT参数可改善骨折鉴别。未来，通过QCT衍生的有限元分析对微结构测量得出的更先进的骨强度估计值可能会纳入AFR算法。
