Competing Risks of Fracture and Death in Older Adults with Chronic Kidney Disease

ObjectivesTo examine whether chronic kidney disease (CKD) at any stage is associated with fracture risk after adjusting for competing mortality and to determine whether age or race modify the relationship between CKD and fracture risk. DesignProspective cohort study. SettingDepartment of Veterans Affairs (VA) national healthcare system. ParticipantsMen receiving VA primary care aged 65 and older with no history of fracture or osteoporosis therapy (N = 712, 918). MeasurementsWe determined CKD stage from baseline estimated glomerular filtration rate (eGFR). Participants were followed for up to 10 years for occurrence of any fracture or death. We ascertained fractures and covariates from VA medical records and Medicare claims. ResultsOf the 356,459 older veterans with CKD (defined as eGFR <60 mL/min per 1.73 m(2)), 15.7% (n = 56,032) experienced a fracture, and 43.0% (n = 153,438) died over a median time at risk of 5.2 years. Veterans with CKD Stages 3 to 5 had a greater risk of death than those without CKD, which biased estimates from traditional survival models. Competing risk models showed that Stage 3 CKD was associated with greater hazard (adjusted subdistribution hazard ratio (sdHR) = 1.07, 95% confidence interval (CI) = 1.02-1.11) of fracture (than those without CKD) and a trend toward greater hazard for Stage 4 (sdHR = 1.07, 95% CI = 0.94-1.22) and Stage 5 (sdHR = 1.31, 95% CI = 0.97-1.77) CKD. Age, race, and bone mineral density did not modify the relationship between CKD and fracture risk. ConclusionsIn older male veterans, CKD, including Stage 3, is associated with a moderately greater fracture risk irrespective of age, race, or bone mineral density.