Fracture Risk Prediction in CKD: Comparing Bone Turnover Markers and Bone Mineral Density (BMD) Performance in Dialysis and Nondialysis Populations

Background: Bone mineral density (BMD) is a recognized predictor of fracture risk in the general population, but its utility in patients with chronic kidney disease (CKD) remains uncertain due to heterogeneous bone turnover. This study evaluated the prognostic value of BMD and bone turnover markers (BTMs)—parathyroid hormone (PTH), C-terminal telopeptide of type I collagen (CTX), and bone-specific alkaline phosphatase (bone ALP)—for fracture risk in CKD patients, both with and without dialysis. Methods: We retrospectively analyzed 853 adult patients with CKD who underwent BMD and BTM assessments between 2010 and 2024. Patients were stratified by dialysis status (RRT: n=514; non-RRT: n=339). Cox proportional hazards models adjusted for clinical covariates were used to assess fracture risk across tertiles of each marker and BMD category. Time-dependent receiver operating characteristic (ROC) curves were used to compare predictive performance for 5-year fracture risk. Results: Fracture risk did not differ significantly across tertiles of PTH, CTX, or bone ALP in either RRT or non-RRT groups. Spline analysis likewise demonstrated no meaningful nonlinear associations. In contrast, BMD was significantly associated with fracture risk in both groups: patients with osteoporosis (T-score ≤ −2.5) had markedly elevated risk in the RRT (adjusted HR 17.7, 95% CI 2.24–2288.2) and non-RRT (HR 14.5, 95% CI 1.80–1885.3) groups. Time-dependent ROC analysis confirmed the superior predictive performance of BMD over BTMs for 5-year fracture risk, with AUCs of 0.712 (RRT) and 0.641 (non-RRT). No BTM outperformed BMD in either group. Conclusion: BMD was a strong predictor of fracture risk in CKD patients, regardless of dialysis status. In contrast, bone turnover markers were not associated with fracture risk. These results support the role of BMD assessment in fracture risk evaluation in CKD.Time-dependent ROC Curves for 5-year fracture risk prediction in RRT (left) and non-RRT (right) patients.