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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2014  |  Volume : 25  |  Issue : 1  |  Page : 38-43
Mean bone mineral density and frequency of occurrence of osteopenia and osteoporosis in patients on hemodialysis: A single-center study

1 Nuclear Medicine Division, King Abdul Aziz Specialist Hospital, Taif, Saudi Arabia
2 Nuclear Medicine Section, King Fahd Hospital, King AbdulAziz Medical City, Riyadh, Saudi Arabia
3 Department of Radiology, King Abdul Aziz Specialist Hospital, Taif, Saudi Arabia
4 Kidney Centre, King Abdul Aziz Specialist Hospital, Taif, Saudi Arabia
5 Department of Internal Medicine, King Abdul Aziz Specialist Hospital, Taif, Saudi Arabia

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Date of Web Publication7-Jan-2014


Chronic renal disease changes both quality and quantity of bone through multi-factorial influences on bone metabolism, leading to osteopenia, osteoporosis and increased risk of fracture. The objectives of our present cross-sectional study were to determine the mean bone mineral density (BMD) and frequency of occurrence of osteoporosis and osteopenia in Saudi patients on hemodialysis (HD) for longer than 1 year. Forty-two male and 78 female patients with age between 20 and 50 years were enrolled in this study. The BMD of the lumbar vertebral spine (LV) and the neck of femur (FN) were measured in all patients. Data were analyzed using SPSS version 17.0 software and the level of significance was considered as P <0.05. The mean BMD in the LV (L2-L4) was 1.155 ± 0.026 g/cm 2 in male and 1.050 ± 0.025 g/cm 2 in female patients (P = 0.016). The mean BMD in the FN was 1.010 ± 0.023 g/cm 2 in male and 0.784 ± 0.020 g/cm 2 in female patients (P = 0.00). Based on the World Health Organization criteria, 73.8% of the male and 44.9% of the female patients in our study had normal BMD (P = 0.002); 16.7% male and 28.2% female patients had osteopenia (P = 0.14), while 9.5% male and 26.9% female patients had osteoporosis (P = 0.01). This study showed a marked decrease in mean BMD in the cortical bone (FN) compared with trabecular bone (LV) (P = 0.00) as well as in female patients on HD compared with male patients (P = 0.016 for LV and P = 0.00 for FN).

How to cite this article:
Khan MI, Syed GM, Khan AI, Sirwal IA, Anwar SK, Al-Oufi AR, Balbaid KA. Mean bone mineral density and frequency of occurrence of osteopenia and osteoporosis in patients on hemodialysis: A single-center study. Saudi J Kidney Dis Transpl 2014;25:38-43

How to cite this URL:
Khan MI, Syed GM, Khan AI, Sirwal IA, Anwar SK, Al-Oufi AR, Balbaid KA. Mean bone mineral density and frequency of occurrence of osteopenia and osteoporosis in patients on hemodialysis: A single-center study. Saudi J Kidney Dis Transpl [serial online] 2014 [cited 2022 Nov 26];25:38-43. Available from: https://www.sjkdt.org/text.asp?2014/25/1/38/124477

   Introduction Top

The reported prevalence of chronic renal fai­lure (CRF) in the Kingdom of Saudi Arabia (KSA) is 80-120 patients per million population. [1] The incidence and prevalence of CRF has been shown to have increased by 10-15 fold in the KSA in the past 20 years. [2] Impair­ment of kidney function has multifactorial influence on bone metabolism, leading to osteopenia, osteoporosis and increased risk of fractures. [3] Renal osteodystrophy is one of the most important clinical problems in patients on main­tenance hemodialysis (HD), and predominantly affects the cortical bone. [3],[4] Bone biopsy is con­sidered the gold standard for the definitive diagnosis of renal osteodystrophy; however, it is not suitable for routine clinical practice due to its invasive nature. [4] Intact parathyroid hor­mone (iPTH) and bone alkaline phosphatase (ALP) are reliable markers of bone turnover; [4] however, the correlation between biochemical markers of bone turnover and bone mineral density (BMD) is not clear. [4],[5] There are several reports suggesting that BMD does not corre­late with the duration on HD, patient's age or any biochemical parameters. [6],[7] Secondary hyper-parathyroidism and adynamic bone disease or osteomalacia, which constitute the main bone-related problems in CRF, can cause reduction of BMD in affected patients and can result in an increased risk of fractures. Dual-energy X-ray absorptiometry (DEXA) is a preferred me­thod of measuring mean BMD due to its high precision and accuracy, short scan time and low radiation dose. [8]

Measurement of BMD is a good non-invasive screening test for renal osteodystrophy, but cannot discriminate between the types of bone disease. [9] BMD measurement helps to assess the presence of osteopenia and osteoporosis and is considered to be the most accurate predictor of risk of bone fracture. [10],[11]

The rationale of the present study was to determine the mean BMD as well as the mag­nitude of osteopenia and osteoporosis in Saudi patients with CRF on HD.

   Materials and Methods Top

A cross-sectional study was performed to evaluate the mean BMD in patients with CRF on HD for longer than one year. The sampling technique used was non-probability purposive. Forty-two male and 78 female patients with age between 20 and 50 years and on HD for at least one year were enrolled in this study from the dialysis center of the King Abdul Aziz Specialist Hospital, Taif, Saudi Arabia. In­formed consent was obtained from all patients. Demographic information like age, sex and duration on HD was collected from the pa­tients' medical records.

Post-menopausal women, patients with pri­mary hyperparathyroidism, subjects who were on medical treatment for conditions known to affect bone metabolism (such as hyperthyroidism, history of previous transplant, liver di­sease, collagen disease or ovarian tumor) and patients who had undergone hysterectomy were excluded from the study. Patients with history of symptomatic fracture of the hip, radius or vertebra were also excluded. The BMD of the lumbar vertebral spine (LV) and left femur neck (FN) area was measured in all patients by using GE lunar DEXA scanner. The BMD was expressed as gm/cm 2 and was calculated as ratio of weight (kg)/height (m 2 ). Height (m) and weight were recorded using a stadiometer and a weight scale, respectively.

Hemodialysis treatment

Hemodialysis treatment was performed three times weekly, 3-5 h per session. Dialysis fluid contained 2.5 mEq/L calcium and 1.5 mEq/L magnesium, without aluminum contamination. Heparin (2500-6500 units) was routinely admi­nistered during all dialysis sessions. In addi­tion to cardiac and anti-hypertensive therapy, patients received oral calcitriol and calcium carbonate (CaCO 3 ) adjusted to keep the serum calcium concentration between 8.5 and 10.5 mg/dL and serum phosphorus concentration lower than 7 mg/dL. All patients having ane­mia were given erythropoietin intravenously (1500-3000 units) after each dialysis session to maintain hematocrit values at about 30%.

   Data Analysis Top

Descriptive findings like BMD values, age, height, weight and body mass index (BMI) are reported as mean ± SD. Frequency and percen­tages of normal BMD, osteopenia and osteo­porosis are calculated. Data were analyzed using SPSS version 17.0 software. Compa­risons between male and female patients were made with the Mann-Whitney U-test. Compa­rison of mean BMD in the same sex at LV and FN sites was made using Wilcoxon's signed-ranks test. The level of significance was con­sidered as P <0.05.

   Results Top

The demographic parameters and clinical characteristics of patients are presented in [Table 1]. The mean age of the study patients was 37.9 ± 11.8 years (mean ± SD) in male and 40.2 ± 9.4 years in female patients (P = 0.363). The mean duration on HD was 6.7 ± 2.8 years in male and 9.4 ± 5.9 years in fe­male patients (P = 0.075). No significant diffe­rence was found with respect to age (P = 0.288) and duration on HD (P = 0.075) bet­ween male and female patients.
Table 1: Demographic parameters and clinical characteristics of male and female patients on hemodialysis.

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The mean BMD was significantly lower in female patients when compared with male patients at both the LV level (1.155 ± 0.026 g/cm 2 vs 1.050 ± 0.025 g/cm 2 , P = 0.16) and the FN area (1.010 ± 0.023 g/cm 2 vs. 0.784 ± 0.020 g/cm 2 , P = 0.00) [Table 2].
Table 2: Comparison of mean ± SD of bone mineral density in L2-L4 vertebrae and femur neck (FN) in male and female patients.

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When the mean BMD measured at L2-L4 was compared with BMD measured in the FN [Table 2], we observed that the BMD was higher at L2-L4 than in the FN (male: 1.155 ± 0.026 g/cm 2 vs 1.010 ± 0.023 g/cm 2 , respec­tively, P = 0.000; female: 1.050 ± 0.025 g/cm 2 vs 0.784 ± 0.020 g/cm 2 , respectively, P = 0.000).

According to the World Health Organization (WHO) categorization based on T-score [Table 3], [12] 73.8%, 16.7% and 4% of the male pa­tients in our study were classified to have normal BMD, osteopenia and osteoporosis, respectively. Among the female patients, 44.9%, 28.2% and 26.9% were classified to have nor­mal BMD, osteopenia and osteoporosis, respec­tively [Figure 1].
Figure 1: Percentages of normal bone, osteopenia and osteoporosis in male and female patients on HD.

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Table 3: The World Health Organization classification of osteoporosis.

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   Discussion Top

Renal osteodystrophy is a common and inca­pacitating disorder in patients with CRF on maintenance HD. [13] Data from the United States Renal Data System (USRDS) have shown that compared with fracture rates in the general population, the risk of fracture of hip is approximately four-fold greater in patients with stage 5 CRF, independent of age and sex. [14] A meta-analysis has further suggested that the BMD is lower in CRF patients on HD who have fractures. [15] Therefore, early and pre­cise assessment of biomechanical stability of the skeleton is mandatory to reduce morbidity and mortality.

In our study, there was no significant diffe­rence in the mean age (P = 0.363) and mean duration on HD (P = 0.075) between male and female patients; the mean BMD was signifi­cantly lower in female compared with male patients. This is in agreement with previous studies. [3],[12],[16],[17] Leuiseto et al have reported lower femoral and lumbar spine BMD in females. [18] Petrauskiene et al also reported that females had significantly lower BMD than males (0.361 g/cm 2 and 0.425 g/cm 2 , respec­tively; P = 0.006). [19] It has been reported that the BMD is better preserved in male HD pa­tients as compared with female HD patients. [3] The reason for this difference is not very clear, but may be explained by significant abnor­malities associated with hypophysis/gonadal function in uremic women. [12] Another possible contributing factor may be less exposure of Saudi females to sun light compared with males.

Because of cultural and religious reasons, female patients mostly remain indoors and wear a veil whenever they go outside thus reducing exposure to sunlight and limiting physical activity. In summary, gonadal dys­function, less exposure to sunlight and less physical activity might all contribute to rela­tively lower BMD in female patients on HD.

In our present study, we found that the BMD measured in the L2-L4 region was signifi­cantly higher than that in the FN in both gen­ders (P = 0.00). This is in agreement with most previous studies. [3],[4],[14],[20] Grzegorzewska et al observed that in patients on HD, the BMD was higher in the L2-L4 region than in the FN (males: 1.156 ± 0.306 g/cm 2 vs 0.849 ± 0.160 g/cm 2 , respectively, P = 0.003; females: 1.020 ± 0.218 g/cm 2 vs 0.790 ± 0.140 g/cm 2 , respec­tively, P = 0.000). [3] Patients on HD have signi­ficantly lower BMD values in cortical bone areas, cortical thickness, moment of inertia and polar moment of inertia than age-matched controls. [18] The relatively high BMD in the lumbar vertebrae is probably due to the effect created by spinal osteophytes and aortic calcification, which may spuriously elevate the lumbar BMD. [21]

To elucidate the influence of the duration on HD, we divided the patients into two groups; one group of patients on HD for 59 months or less (41 patients) and the other group on HD for 60 months or more (79 patients). We did not find any significant effect of duration on dialysis on the mean BMD.

Previous studies have reported two contro­versial and opposite findings concerning re­duction of BMD in HD patients. There is a report that radial-BMD correlated negatively with the duration on HD in male patients, whereas female patients showed strong and negative correlations between patient age and each of the absolute BMD values. [16] Nakai et al found a significant correlation between BMD and the duration on HD in male patients only. [13] Hasegawa et al observed that prolonged HD will cause skeletal complications. [20] In contrast, however, there are several reports that BMD did not correlate with the duration on HD, patient age or with any other biochemical parameters. [6],[7]

In our study, we found that about 45% of the patients (26% male and 55% female) had low BMD with T-score below -1.0, and were cate­gorized as having either osteopenia or osteo­porosis. In a multicenter study conducted in Saudi Arabia by Huraib et al in patients on HD, it was found that about 65% of the pa­tients had low BMD. [22] Nasir et al reported that, in HD patients, 42% had osteoporosis and 52% had osteopenia. [23] Petrauskiene et al have also reported in their study that 72% of the pa­tients had either osteopenia or osteoporosis. [17] Sit et al have also reported low BMD with T-score in the range of osteopenia/osteoporosis in 78% of their patients. [24] In contrast to the studies mentioned above, we found a slightly lower prevalence of osteopenia and osteopo­rosis in our patients. This might be explained on the basis of the selection criteria in which we included only patients with an age range of 20-50 years. Grzegorzewska et al have repor­ted that older age, which is more frequently associated with protein malnutrition, inflam­mation and glucose abnormalities, and hor­monal deficiencies are also important factors influencing loss of BMD in dialysis patients. [3] As relatively older patients of either sex were excluded in our study, the effects of age-related decrease in BMD were probably minimized.

This study showed that measurement of BMD is a good non-invasive screening test for renal bone disease and that a high number of pa­tients with CRF on HD have markedly de­creased BMD. Female patients on HD are more vulnerable to bone loss at a higher rate. BMD was relatively preserved in the lumbar vertebrae as compared with the femoral neck area. This data could be utilized in setting guidelines to screen patients on HD on a re­gular basis. With this, a management protocol could be initiated at an early stage, thereby reducing the morbidity and mortality asso­ciated with increased fracture risk.

   Limitations Top

Only BMD measurement by a DEXA scanner was used for assessment of biomechanical stability of the skeleton, and BMD was not correlated with biochemical markers of bone turnover.

   Acknowledgment Top

The authors wish to acknowledge the support of the Kidney Center and Statistical Depart­ment of King Abdul Aziz Specialist Hospital for their excellent support for the study.

   References Top

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12.WHO Study Group on Assessment of Fracture Risk and Its Application to Screening for Post-menopausal Osteoporosis. Technical report 843. Geneva: World Health Organization; 1994.  Back to cited text no. 12
13.Nakai T, Masuhara K, Kato K, Kanbara N. Longitudinal measurement of bone mineral density at the radius in hemodialysis patients using dual-energy X-ray absorptiometry. J Musculoskel Neuron Interact 200;22:163-5.  Back to cited text no. 13
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23.Nasir BD, Nurettin G. Risk factors leading to reduced bone mineral density in hemodialysis patients with metabolic syndrome. Ren Fail 2010;32:469-74.  Back to cited text no. 23
24.Sit D, Kadiroglu AK, Kaybasi H, Atay AE, Yilmaz Z, Yilmaz ME. Relationship between bone mineral density and biochemical markers of bone turnover in hemodialysis patients. Adv Ther 2007;24:987-95.  Back to cited text no. 24

Correspondence Address:
Mohammad I Khan
Nuclear Physician, Nuclear Medicine Division, Department of Medical Imaging, King Fahd Specialist Hospital, Dammam
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.124477

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  [Figure 1]

  [Table 1], [Table 2], [Table 3]

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