Multidisciplinary Team Evaluation of Bone Health, Fracture Risk, and Incidence of Frailty in Patients on Haemodialysis

Background: Bone disease is prevalent in patients with chronic kidney disease on dialysis (CKD-5D). It can lead to fragility fractures. The KDIGO guidelines suggest that patients with CKD G3a–G5D with evidence of mineral bone disease (MBD) and/or risk factors for osteoporosis, undergo a fracture risk assessment, if results will impact treatment decisions. Frailty is also a known risk factor for fragility fractures. The clinical frailty scale (CFS) is a nine-point validated outcome measure that is used to measure cognition, function, co-morbidities, and mobility in patients over 65 years. The aim of our service evaluation was to assess the fracture risk using the FRAX® tool for our HD patient cohort and to identify incidence of frailty using the CFS in those aged over 65 years. Methods: In total, 76 chronic haemodialysis (HD) patients were included for the assessment of fracture risk. Acute dialysis patients were excluded. The FRAX score, the use of bone protection, and results of DEXA scanning (where available) were recorded for all patients. The CFS was calculated for 37 HD patients over the age of 65 using available clinical information. eMed and local databases were used to collect data. Results: Average risk of major osteoporotic fracture was 10.1% and average risk of hip fracture was 4.03%. Out of 76 patients, 15 patients had a DEXA scan performed. Only three patients were in receipt of treatment with denosumab. A high incidence of frailty was recorded in the 37 HD patients aged >65 years, with 73% of patients recording a CFS of 5 (mild frailty) or greater which is significantly higher than the prevalence of frailty (7.0%)among community-dwelling individuals aged 60 years or older. Conclusion: This data reveals a high fracture risk amongst incident HD patients. The low proportion of patients prescribed specific treatment, such as denosumab, probably reflects the challenges of diagnosing and treating low bone mineral density (BMD) in this cohort. The prevalence of frailty was high in the subgroup of elderly HD patients. Features of frailty overlap with risk factors for fragility fractures; this highlights the importance of providing patients with an integrated, multidisciplinary management plan to reduce the risk of fragility fracture, targeting CKD-MBD, low BMD and frailty.