Kidney Transplantation, Immunosuppression and the Risk of Fracture: Clinical and Economic Implications

被引:6
作者
Kuppachi, Sarat [1 ]
Cheungpasitporn, Wisit [2 ]
Li, Ruixin
Caliskan, Yasar [3 ]
Schnitzler, Mark A. [3 ]
McAdams-DeMarco, Mara [4 ]
Ahn, JiYoon B. [4 ]
Bae, Sunjae
Hess, Gregory P. [5 ,6 ]
Segev, Dorry L. [4 ]
Lentine, Krista L. [3 ,7 ]
Axelrod, David A. [1 ]
机构
[1] Univ Iowa, Organ Transplant Ctr, Iowa City, IA USA
[2] Mayo Clin, Dept Med, Rochester, MN USA
[3] St Louis Univ, St Louis Univ Transplant Ctr, St Louis, MO USA
[4] Johns Hopkins Sch Med, Dept Surg, Baltimore, MD USA
[5] Thomas Jefferson Univ, Jefferson Coll Populat Hlth, Philadelphia, PA USA
[6] Aarhus Univ, Dept Clin Epidemiol, Aarhus, Denmark
[7] St Louis Univ Transplant Ctr, 1201 S Grand Blvd, St Louis, MO 63104 USA
关键词
BONE-MINERAL DENSITY; RENAL-TRANSPLANTATION; STEROID WITHDRAWAL; GRAFT RECIPIENTS; TEMPORAL TRENDS; CYCLOSPORINE-A; METABOLISM; DISEASE; DIALYSIS; OUTCOMES;
D O I
10.1016/j.xkme.2022.100474
中图分类号
R5 [内科学]; R69 [泌尿科学(泌尿生殖系疾病)];
学科分类号
1002 ; 100201 ;
摘要
Rationale & Objective: Disorders of bone and mineral metabolism frequently develop with advanced kidney disease, may be exacerbated by immunosuppression after kidney transplantation, and increase the risk of fractures. Study Design: Retrospective database study. Setting & Participants: Kidney-only transplant recipients aged >= 18 years from 2005 to 2016 in the United States captured in US Renal Data System records, which integrate Organ Procurement and Transplantation Network/United Network for Organ Sharing records with Medicare billing claims. Exposures: Various immunosuppression regimens in the first 3 months after kidney transplantation. Outcomes: The development of fractures, as ascertained using diagnostic codes on Medicare billing claims. Analytical Approach: We used multivariable Cox regression with inverse propensity weighting to compare the incidence of fractures > 3 months-to-3 years after kidney transplantation associated with various immunosuppression regimens compared to a reference regimen of antithymocyte globulin (TMG) or alemtuzumab (ALEM) with tacrolimus + mycophenolic acid + prednisone using inverse probability treatment weighting. Results: Overall, fractures were identified in 7.5% of kidney transplant recipients (women, 8.8%; men, 6.7%; age < 55 years, 5.9%; age >= 55 years, 9.3%). In time-varying regression, experiencing a fracture was associated with a substantially increased risk of subsequent death within 3 months (adjusted hazard ratio [aHR], 3.06; 95% confidence interval [CI], 2.45-3.81). Fractures were also associated with increased Medicare spending (first year: $5,122; second year: $10,890; third year: $11,083; [P < 0.001]). Induction with TMG or ALEM and the avoidance or early withdrawal of steroids significantly reduced the risk of fractures in younger (aHR, 0.63; 95% CI, 0.54-0.73) and older (aHR, 0.83; 95% CI, 0.740.9 4) patients. The avoidance or early withdrawal of steroids with any induction was associated with a reduced risk of fractures in women. Limitations: This was a retrospective study which lacked data on immunosuppression levels. Conclusions: Fractures after kidney transplantation are associated with significantly increased mortality risk and costs. The early avoidance or early withdrawal of steroids after induction with TMG or ALEM reduces the risk of fractures after kidney transplantation and should be considered for patients at high-risk of this complication, including older adults and women.
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页数:15
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