Temporal Trends in Fracture Rates and Postdischarge Outcomes among Hemodialysis Patients : Journal of the American Society of Nephrology

Journal Logo

Clinical Epidemiology

Temporal Trends in Fracture Rates and Postdischarge Outcomes among Hemodialysis Patients

Beaubrun, Anne C.*; Kilpatrick, Ryan D.; Freburger, Janet K.; Bradbury, Brian D.†,§; Wang, Lily; Brookhart, M. Alan

Author Information
Journal of the American Society of Nephrology 24(9):p 1461-1469, September 2013. | DOI: 10.1681/ASN.2012090916
  • Free
  • SDC


Fractures are an important public health concern associated with substantial morbidity, mortality, and costs among patients with ESRD.14 Compared with the general population, dialysis patients are at an increased risk of any fracture and are 4.4–14 times more likely to experience a hip fracture.1,5,6 The consequences of hip fracture, in particular, are substantial. In the general population, this type of fracture is associated with permanent disability, admission to long-term care facilities, and a mortality rate ranging from 15% to 40%.7,8

Several factors may contribute to the elevated fracture rate in dialysis patients relative to their age-, race-, and sex-matched peers not undergoing dialysis. These include a high prevalence of polypharmacy, large comorbidity burden, decreased muscle strength, and increased susceptibility to falls.911 Additionally, secondary hyperparathyroidism and renal osteodystrophy, common among patients with ESRD, directly affect bone turnover and mineralization and are associated with pain and low-trauma fractures.12,13

Currently available information on the incidence of fractures in dialysis patients is dated, has primarily focused on hip fracture, and is based on small, select groups of patients.1,5,1417 Furthermore, outcomes after discharge from a fracture hospitalization have not been analyzed in detail. We sought to characterize the clinical burden of fracture in the hemodialysis population, including both contemporary fracture rates and short- and long-term consequences after hospital discharge. Specifically, we estimated the adjusted quarterly incidence rates of select categories of high-burden inpatient and outpatient fracture types over time and among relevant patient subgroups. We hypothesized that pharmaceutical advances in the treatment of bone health and increases in the use of intravenous vitamin D use over the past decade18 may have decreased fracture rates in this population.

Additionally, for fractures resulting in hospitalization, we estimated the hospital length of stay, discharge destination, and various postdischarge outcomes, including subsequent hospitalizations and 1-year mortality.


Table 1 describes the demographic and clinical characteristics of the dialysis population at risk for outpatient and inpatient fractures in the first quarter (Q1) of the first (2000), middle (2004), and last (2009) years of observation. The number of patients at risk increased over time. In each successive interval, patients at risk had a longer average number of years on dialysis. Otherwise, the selected demographic and clinical characteristics of the patients changed little over time.

Table 1:
Demographic and clinical characteristics of population at risk for outpatient and inpatient fractures in 2000, 2004, and 2009

The adjusted quarterly incidence of fracture is presented in Figure 1, A and B, overall and limited to those occurring in the inpatient setting. All fracture types studied were more likely to result in an inpatient admission than to be identified through outpatient claims. Across all calendar years, pelvis/hip fracture was the most common fracture type, followed by vertebral and lower leg fractures, representing 42.2%, 18.7%, and 12.4% of all fractures respectively, in the fourth quarter (Q4) of 2009. Over time, pelvis/hip fractures declined slightly from 29.6/1000 patient-years in Q1 2000 to 20.6/1000 patient-years in Q4 2009, but the incidence of all other fracture rates remained relatively constant throughout the study period.

Figure 1:
Adjusted fracture incidence rates remained constant in the years 2000–2009. Rates were highest for pelvis/hip, vertebral, and lower leg fracture categories. All trend lines were adjusted for age, race, sex, cause of ESRD, and years on dialysis. (A) Inpatient and outpatient fractures. (B) Inpatient fractures only.

Figure 2 displays the adjusted incidence rates for the three most frequently observed fracture types (pelvis/hip, vertebral, and lower leg) within subgroups defined by age, sex, race, cause of ESRD, and years on dialysis in Q4 of 2009. Generally, fractures were more common among older patients and among women compared with men. A large imbalance among race groups was observed; the incidence of pelvis/hip fractures was 3.1 times greater among white than nonwhite patients. With regard to specific fracture types, across all strata, fractures of the pelvis/hip were most common. The increase in the rate of vertebral fractures with increasing age was greater than that observed for lower leg fractures and so represented a larger proportion of fractures among older patients than among younger patients.

Figure 2:
Adjusted fracture incidence rates by strata for the top three most prevalent fracture categories (pelvis/hip, vertebral, lower leg) in years 2000–2009. Rates were adjusted for age, race, sex, cause of ESRD and years on dialysis. The subgroup of interest was omitted from the adjustment for each respective subgroup category.

Patients discharged from a fracture hospitalization were more likely to be female, white, and older; had a longer time on dialysis; and generally had a higher prevalence of comorbid conditions, particularly with regard to history of falls or walking disability and use of a wheelchair, walker, or cane, compared with patients with a nonfracture hospitalization (Table 2). The median LOS for patients hospitalized for fracture (all types) was longer than for the comparator patients (Table 3). Patients with femur, pelvis/hip, and vertebral fractures had the longest LOS at a median of 8, 7, and 7 days, respectively, versus 4 days for comparator patients. The in-hospital death rate was higher for patients who experienced a fracture event (with the exception of lower leg and forearm/wrist fractures) than for the nonfracture hospitalization comparator group. For those who survived the initial hospitalization, use of a skilled-nursing facility and other post–acute care services (e.g., inpatient rehabilitation facility, long-term care hospital, swing bed) was considerably higher among patients experiencing a fracture hospitalization relative to the comparator group. The highest rate was seen for patients experiencing a pelvis/hip fracture; 66.8% of these patients were discharged to a skilled-nursing facility or other post–acute care facility. Only 14.2% were discharged to their home compared with 77.5% of comparator patients.

Table 2:
Demographic and clinical characteristics of patients’ index hospitalization for any fracture versus comparator group in 2009
Table 3:
Median length of hospital stay and discharge destination by fracture category for index fracture hospitalizationsa in 2000–2009

Given the differences in characteristics between patients with a fracture and those in the comparator group, 1-year postdischarge outcomes were adjusted by patient case-mix (Table 4). With and without adjustment, postdischarge mortality, hospitalizations, hospital days, admissions to a skilled-nursing facility, and skilled-nursing facility days were substantively higher for all fracture categories relative to the comparator group. The 1-year adjusted mortality rate after a fracture hospitalization ranged from 0.43/patient-year (95% confidence interval, 0.38 to 0.49) for forearm/wrist fractures to 0.91/patient-year (95% confidence interval, 0.85 to 0.96) for vertebral fractures versus 0.38/patient-year (95% confidence interval, 0.38 to 0.39) for the comparator group. Similarly, adjusted hospitalization rates and hospital days during the year after a fracture hospitalization were highest among patients with vertebral fractures and lowest among those with forearm/wrist fractures and were all greater than the rates observed for the comparator group. Adjusted rates of skilled-nursing facility admissions were higher for all fracture types compared with the comparator group. Patients hospitalized for a pelvis/hip or femur fracture spent the most days in a skilled-nursing facility in the year after their discharge.

Table 4:
Postdischarge consequences (events per patient-year) by fracture category in 2000–2009

We further examined the postdischarge consequences in the pelvis/hip fracture group (the most common fracture type) within strata defined by age, sex, race, cause of ESRD, and years on dialysis (Figure 3). In all instances, the burden was considerably higher for patients experiencing a pelvis/hip fracture than for the comparator group. For both groups, mortality, hospitalization, and rates of admission to a skilled-nursing facility increased with age, were similar for men and women, and, in general, were modestly higher for whites than nonwhites.

Figure 3:
Following discharge from pelvis/hip fracture hospitalization, rates of mortality, readmission, and SNF admission increased with age, were similar for both sexes, and were slightly higher for whites than other races in years 2000–2009. Events per patient-year are presented for each respective event.


We used contemporary data to examine the incidence of fractures, both in the inpatient and the outpatient setting, and to characterize postdischarge outcomes among the hemodialysis population in the United States. Overall, we observed a relatively constant rate of fractures over time, with evidence of a slight decline in the rate of pelvis/hip fractures in the most recent years. We investigated a range of postdischarge outcomes, including hospitalization, death, and use of post–acute care services, which have not been previously described. The postdischarge consequences of all types of fractures are substantial. Many patients are discharged to a skilled-nursing facility or other post–acute care setting and have a high rate of hospitalizations during the year after fracture. Postdischarge mortality rates in the first year after fracture were also more than twice as high as the mortality rate in the general dialysis population. Compared with a reference group of hemodialysis patients with a first hospitalization for any nonfracture reason, we observed higher rates of mortality and use of health care (e.g., hospital, skilled-nursing facility, other post–acute care service) in the year after a fracture-related hospital discharge, highlighting the clinical consequences of major fracture events in the dialysis population.

The modest decline in the incidence of pelvis/hip fracture reported herein is consistent with findings on hip fracture incidence from the general Medicare population.1925 However, the rates we observed for hospitalized fractures are substantially higher than rates previously documented in the nondialysis population.1 Some suggested explanations for the decline in hip fracture rates in the general population include increased physical activity and functional ability among the elderly, greater body mass, decline in smoking,23,25 and increased use of antiresorptive agents, such as bisphosphonates,21 but the effect of these factors in the dialysis population has not been explicitly studied. Use of bisphosphonates is not likely to explain the slight decline in pelvis/hip fractures in dialysis patients because they are not generally prescribed these drugs as a result of concerns over drug toxicity related to impaired renal excretion.2628

In the general population, many factors increase an individual’s likelihood of fracture, independent of their bone mineral density.29 Similarly, while bone disease is common in dialysis patients, due to secondary hyperparathyroidism and other forms of renal osteodystrophy, including osteomalacia and adynamic bone disease,30 other factors, such as smoking status, may affect fracture risk independently of bone density.

In the dialysis population, various therapeutic interventions, including vitamin D sterols, calcium-based phosphate binders, and calcimimetics are used to decrease levels of parathyroid hormone, which directly affects bone resorption.31,32 The use of these interventions has increased sizably over the past decade33 in an effort to reduce parathyroid hormone, as well as calcium and phosphorus levels, which are associated with increased risk of adverse clinical outcomes, including fracture and mortality.2,3335 Despite increased use of these therapeutic advances in treating bone mineral metabolism disturbances and despite fracture risk factor awareness, we document only a small decline in fracture rates since 2000. Claims for calcium-based phosphate binders are in Medicare Part D records, a drug program in effect only since 2006 and, therefore, not included in this analysis.

We observed variations in fracture rates by age, sex, and race, consistent with previous studies.1,4 In particular, the fracture rate among nonwhite patients was roughly half that of their white counterparts, and this difference persisted over time. Blacks have consistently been shown to have increased bone mass relative to whites. In the general nondialysis population, differences in the vitamin D–endocrine system among blacks results in greater circulating levels of 1,25(OH)2D and higher levels of PTH, which in turn increases reabsorption of calcium in the renal tubule. This has been proposed as a potential causal factor for higher bone mass.36 On dialysis, the higher parathyroid hormone among blacks relative to whites decreases the likelihood of low bone turnover, a fracture risk factor, and may therefore also help protect against fracture in these patients.13 Because black patients are disproportionately represented in dialysis (approximately 33% versus 13% in the general population),37 this may contribute to more pronounced racial differences in fracture rates within the dialysis population.4

The clinical consequences after hospitalization for fracture observed in this study were sizable and are consistent with previous work showing decreased functional ability even several months after fracture.11 Following a fracture, patients may need care at a skilled-nursing facility or other post–acute care facility and assistance with activities of daily living.11 We observed high rates of hospitalization and skilled-nursing facility admission after discharge, but possibly most striking was the time spent in these centers. Among patients with a pelvis/hip fracture, the mean time spent in a skilled-nursing facility, after adjustment for variation in patient characteristics, was approximately 2 months compared with 2 weeks for the incident hospitalization comparator group. These results are consistent with those of Braithwaite et al., who estimated that 32%–80% of elderly patients experience permanent disability after an initial hospitalization for hip fracture, with up to 60% requiring treatment in a long-term skilled-nursing facility.8

We also observed high mortality rates after fracture, with the highest event rates for those with a vertebral, shoulder/upper arm, or pelvis/hip fracture. These results are consistent with previous estimates of elevated post–hip fracture mortality risk ranging from two- to three-fold higher relative to patients not experiencing a fracture.3,4 With regards to race, nonwhites had lower mortality rates after fracture in our sample, which is contrary to findings in the general population.38 These results suggest that the apparent survival advantage of nonwhites on dialysis39,40 may persist even after fracture and is potentially related to increased access to health care due to universal Medicare coverage or unobserved clinical differences, whereby increases in lipids and other cardiovascular risk factors may actually be protective.41

This study has limitations. Fracture events were derived from Medicare claims data and are therefore subject to some misclassification. Certain fracture definitions may be specific, but not sensitive, likely leading to some underascertainment. It is also possible that patients do not receive medical care for certain categories of fractures. However, for serious fractures, such as those at the pelvis/hip, the outcome definitions will probably be both specific and sensitive because most of these fractures are likely to result in a hospitalization. To identify rule-out fracture diagnoses, patients in the outpatient setting were required to have at least two fracture diagnosis codes within a 28-day span (arbitrarily chosen) for a respective fracture category, possibly contributing to underascertainment of certain fractures. As with any analysis of administrative claims, we identified comorbid conditions according to International Classification of Diseases, Ninth Revision, diagnosis codes. Such an approach may not have completely captured the differences between the fracture and comparator groups, although we did notice substantial differences between the groups with regard to history of falls, walking disability, and use of assistive devices. We also did not control for place of residence (e.g., long-term care facility) before fracture.

In summary, we document that fracture rates among patients with ESRD have remained high and that postfracture morbidity and mortality remain substantial. Future research is needed to increase our understanding of how to improve fracture prevention, improve postfracture outcomes across all race and sex groups, increase continuity of postfracture care, and optimize postfracture rehabilitation in order to ameliorate the clinical burden and economic impact of all fracture types in this population.

Concise Methods

We used data from the U.S. Renal Data System42 for the period January 1, 2000, to December 31, 2009, to identify all incident and prevalent in-center hemodialysis patients, 18 years and older, who had Medicare as their primary payer and both Part A and B coverage. Patients with a history of renal transplantation were excluded. Quarterly patient cohorts were used to estimate adjusted fracture rates.

Patients hospitalized for an inpatient fracture who survived their inpatient stay were followed for 1 year after discharge to assess postfracture outcomes. For all outcomes other than mortality, patients were censored if one of the following events occurred: (1) death, (2) kidney transplantation, (3) Medicare no longer the primary payer, or (4) switch to peritoneal dialysis. Patients were administratively censored on December 31, 2009.

Identification of Fractures and Calculation of Incidence Rates

We identified fractures according to International Classification of Diseases, Ninth Revision, diagnosis codes, which we grouped into seven categories: (1) vertebral; (2) pelvis/hip (femoral neck); (3) femur (excluding neck); (4) tibia, fibula, patella, and ankle (lower leg); (5) ribs and sternum; (6) humerus, scapula, and clavicle (shoulder and upper arm); and (7) forearm (radius and ulna) and wrist. This classification excluded fractures of the hands and feet (due to minimal consequences of these fractures), fractures of multiple areas, of the skull/trunk (likely indicating severe or blunt trauma), and ill-defined, unspecified fractures.

We examined both inpatient and outpatient claims for fracture diagnoses in any field. To mitigate the likelihood of mistakenly classifying a “rule-out” fracture diagnosis in the outpatient setting as an actual fracture occurrence, patients were required to have at least two outpatient fracture diagnosis codes within a 28-day span. Only the first occurrence (inpatient or outpatient) of a particular fracture type (i.e., bone or joint area) contributed to the fracture incidence rate analyses. Patients were then no longer eligible to contribute data on that fracture type but could contribute to other types of fracture.

For each specific fracture type and overall, quarterly, crude fracture incidence rates were estimated by dividing the total number of fractures during the quarter by the total patient time at risk (Supplemental Figure S1). To derive fracture rates adjusted for secular trends, we computed a standardized mortality ratio–weighted model with a weight of 1 for patients hospitalized for a fracture in Q1 2000 (the comparator group) and a weight of (p/[1 − p]) for patients hospitalized for a fracture in all other quarters (Q2 2000–Q4 2009). Here, p represented the probability that the patient was hospitalized for a fracture in Q1 of 2000 given a combination of covariates used for adjustment. All trend lines were adjusted for age, race, sex, cause of ESRD, and years on dialysis.

Rates were calculated overall and within strata of patient characteristics (age, sex, race, cause of ESRD, and years on dialysis). We also examined adjusted fracture rates over time by diabetes status (Supplemental Figure S2).

Assessment of Postfracture Outcomes

We examined postfracture outcomes for inpatient fractures only. Hemodialysis patients who were hospitalized during the study period (2000–2009) were required to have survived at least 270 days after the initiation of dialysis therapy (90 days after the initiation of dialysis to allow for stability in Medicare claims processing and 180 days to allow for a 6-month baseline period). Patients whose first hospitalization during the period was for a fracture event formed the fracture cohort, and patients whose first hospitalization for any reason other than fracture served as the comparator group. Demographic and clinical characteristics of both groups over time are described in Supplemental Table S1.

The 180-day period immediately preceding the index hospitalization was used to identify comorbid conditions. We calculated the median LOS for the index fracture admission and assessed whether the patient died in the hospital or was discharged to one of the following: home, skilled-nursing facility, other post–acute care facility, or other. For those who survived and were discharged, we estimated both crude (Supplemental Table S2) and adjusted rates of mortality, hospitalization, and skilled-nursing facility admission during the 1 year after hospital discharge. Rates and days were adjusted to the distribution of the comparator group using negative binomial regression models adjusting for a range of characteristics. Postdischarge outcomes for pelvis/hip fractures were evaluated within patient strata.

Statistical analyses were performed using SAS software, version 9.2 (SAS Institute, Inc., Cary, NC).


M.A.B. has received grant support from Amgen and has sat on advisory boards for Pfizer, Amgen, and Rockwell Medical (honoraria declined, given to institution, or donated). He has received consulting fees from DaVita, RxAnte, Foundation for the National Institutes of Health, and World Health Information Consultants. R.D.K. and B.D.B. work in the Center for Observational Research at Amgen, Inc. J.K.F. has received grant support from Amgen. L.W. has no competing financial interests to report. At the time the paper was written, A.B. had no competing financial interests.

We wish to thank Dr. Abhijit V. Kshirsagar for his thoughtful review of the manuscript.

This research was partially supported by a National Research Service Award Pre-Doctoral Traineeship from the Agency for Healthcare Research and Quality sponsored by the Cecil G. Sheps Center for Health Services Research, University of North Carolina (UNC) at Chapel Hill, grant no. T32-HS000032. This study was supported by a research contract from Amgen, Inc., to UNC Chapel Hill. The contract placed no restrictions on publication.

An abstract detailing results from this paper was presented at the International Society of Nephrology (ISN) Nexus Symposium meeting in Copenhagen, Denmark (September 2012) and the American Society of Nephrology (ASN) Kidney Week meeting in San Diego, CA (November 2012).

The data reported here have been supplied by the U.S. Renal Data System (USRDS). The interpretation and reporting of these data are the responsibility of the authors and in no way should be seen as an official policy or interpretation of the United States government.

Published online ahead of print. Publication date available at www.jasn.org.

This article contains supplemental material online at http://jasn.asnjournals.org/lookup/suppl/doi:10.1681/ASN.2012090916/-/DCSupplemental.


1. Alem AM, Sherrard DJ, Gillen DL, Weiss NS, Beresford SA, Heckbert SR, Wong C, Stehman-Breen C: Increased risk of hip fracture among patients with end-stage renal disease. Kidney Int 58: 396–399, 2000
2. Danese MD, Kim J, Doan QV, Dylan M, Griffiths R, Chertow GM: PTH and the risks for hip, vertebral, and pelvic fractures among patients on dialysis. Am J Kidney Dis 47: 149–156, 2006
3. Mittalhenkle A, Gillen DL, Stehman-Breen CO: Increased risk of mortality associated with hip fracture in the dialysis population. Am J Kidney Dis 44: 672–679, 2004
4. Coco M, Rush H: Increased incidence of hip fractures in dialysis patients with low serum parathyroid hormone. Am J Kidney Dis 36: 1115–1121, 2000
5. Ball AM, Gillen DL, Sherrard D, Weiss NS, Emerson SS, Seliger SL, Kestenbaum BR, Stehman-Breen C: Risk of hip fracture among dialysis and renal transplant recipients. JAMA 288: 3014–3018, 2002
6. Nickolas TL, McMahon DJ, Shane E: Relationship between moderate to severe kidney disease and hip fracture in the United States. J Am Soc Nephrol 17: 3223–3232, 2006
7. Tierney GS, Goulet JA, Greenfield ML, Port FK: Mortality after fracture of the hip in patients who have end-stage renal disease. J Bone Joint Surg Am 76: 709–712, 1994
8. Braithwaite RS, Col NF, Wong JB: Estimating hip fracture morbidity, mortality and costs. J Am Geriatr Soc 51: 364–370, 2003
9. Jamal SA, Leiter RE, Jassal V, Hamilton CJ, Bauer DC: Impaired muscle strength is associated with fractures in hemodialysis patients. Osteoporos Int 17: 1390–1397, 2006
10. Rossier A, Pruijm M, Hannane D, Burnier M, Teta D: Incidence, complications and risk factors for severe falls in patients on maintenance haemodialysis. Nephrol Dial Transplant 27: 352–357, 2012
11. Leinau L, Perazella MA: Hip fractures in end-stage renal disease patients: Incidence, risk factors, and prevention. Semin Dial 19: 75–79, 2006
12. Dennis VC, Albertson GL: Doxercalciferol treatment of secondary hyperparathyroidism. Ann Pharmacother 40: 1955–1965, 2006
13. Malluche HH, Mawad HW, Monier-Faugere MC: Renal osteodystrophy in the first decade of the new millennium: Analysis of 630 bone biopsies in black and white patients. J Bone Miner Res 26: 1368–1376, 2011
14. Jadoul M, Albert JM, Akiba T, Akizawa T, Arab L, Bragg-Gresham JL, Mason N, Prutz KG, Young EW, Pisoni RL: Incidence and risk factors for hip or other bone fractures among hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study. Kidney Int 70: 1358–1366, 2006
15. Inaba M, Okuno S, Kumeda Y, Yamakawa T, Ishimura E, Nishizawa Y: Increased incidence of vertebral fracture in older female hemodialyzed patients with type 2 diabetes mellitus. Calcif Tissue Int 76: 256–260, 2005
16. Yamaguchi T, Kanno E, Tsubota J, Shiomi T, Nakai M, Hattori S: Retrospective study on the usefulness of radius and lumbar bone density in the separation of hemodialysis patients with fractures from those without fractures. Bone 19: 549–555, 1996
17. U.S. Renal Data System: USRDS 2004: Annual Data Report, Bethesda, MD, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 2004
18. Beaubrun AC, Brookhart MA, Sleath B, Wang L, Kshirsagar AV: Trends and variations in intravenous vitamin D use among hemodialysis patients in the United States. Ren Fail 35: 1–8, 2013
19. Brown CA, Starr AZ, Nunley JA: Analysis of past secular trends of hip fractures and predicted number in the future 2010-2050. J Orthop Trauma 26: 117–122, 2012
20. Leslie WD, O’Donnell S, Jean S, Lagacé C, Walsh P, Bancej C, Morin S, Hanley DA, Papaioannou AOsteoporosis Surveillance Expert Working Group: Trends in hip fracture rates in Canada. JAMA 302: 883–889, 2009
21. Gehlbach SH, Avrunin JS, Puleo E: Trends in hospital care for hip fractures. Osteoporos Int 18: 585–591, 2007
22. Nieves JW, Bilezikian JP, Lane JM, Einhorn TA, Wang Y, Steinbuch M, Cosman F: Fragility fractures of the hip and femur: Incidence and patient characteristics. Osteoporos Int 21: 399–408, 2010
23. Brauer CA, Coca-Perraillon M, Cutler DM, Rosen AB: Incidence and mortality of hip fractures in the United States. JAMA 302: 1573–1579, 2009
24. Kannus P, Niemi S, Parkkari J, Palvanen M, Vuori I, Järvinen M: Nationwide decline in incidence of hip fracture. J Bone Miner Res 21: 1836–1838, 2006
25. Stevens JA, Anne Rudd R: Declining hip fracture rates in the United States. Age Ageing 39: 500–503, 2010
26. Jamal SA, West SL, Miller PD: Bone and kidney disease: Diagnostic and therapeutic implications. Curr Rheumatol Rep 14: 217–223, 2012
27. Cunningham J: Bisphosphonates in the renal patient. Nephrol Dial Transplant 22: 1505–1507, 2007
28. Fan SL, Cunningham J: Bisphosphonates in renal osteodystrophy. Curr Opin Nephrol Hypertens 10: 581–588, 2001
29. Donaldson MG, Palermo L, Schousboe JT, Ensrud KE, Hochberg MC, Cummings SR: FRAX and risk of vertebral fractures: The fracture intervention trial. J Bone Miner Res 24: 1793–1799, 2009
30. Jamal SA, Hayden JA, Beyene J: Low bone mineral density and fractures in long-term hemodialysis patients: a meta-analysis. Am J Kidney Dis 49: 674–681, 2007
31. Khan S: Vitamin D deficiency and secondary hyperparathyroidism among patients with chronic kidney disease. Am J Med Sci 333: 201–207, 2007
32. Joy MS, Karagiannis PC, Peyerl FW: Outcomes of secondary hyperparathyroidism in chronic kidney disease and the direct costs of treatment. J Manag Care Pharm 13: 397–411, 2007
33. St Peter WL, Li Q, Liu J, Persky M, Nieman K, Arko C, Block GA: Cinacalcet use patterns and effect on laboratory values and other medications in a large dialysis organization, 2004 through 2006. Clin J Am Soc Nephrol 4: 354–360, 2009
34. Piraino B, Chen T, Cooperstein L, Segre G, Puschett J: Fractures and vertebral bone mineral density in patients with renal osteodystrophy. Clin Nephrol 30: 57–62, 1988
35. Stehman-Breen CO, Sherrard DJ, Alem AM, Gillen DL, Heckbert SR, Wong CS, Ball A, Weiss NS: Risk factors for hip fracture among patients with end-stage renal disease. Kidney Int 58: 2200–2205, 2000
36. Bell NH, Greene A, Epstein S, Oexmann MJ, Shaw S, Shary J: Evidence for alteration of the vitamin D-endocrine system in blacks. J Clin Invest 76: 470–473, 1985
37. Gaston RS, Ayres I, Dooley LG, Diethelm AG: Racial equity in renal transplantation. The disparate impact of HLA-based allocation. JAMA 270: 1352–1356, 1993
38. Penrod JD, Litke A, Hawkes WG, Magaziner J, Doucette JT, Koval KJ, Silberzweig SB, Egol KA, Siu AL: The association of race, gender, and comorbidity with mortality and function after hip fracture. J Gerontol A Biol Sci Med Sci 63: 867–872, 2008
39. Myers OB, Adams C, Rohrscheib MR, Servilla KS, Miskulin D, Bedrick EJ, Zager PG: Age, race, diabetes, blood pressure, and mortality among hemodialysis patients. J Am Soc Nephrol 21: 1970–1978, 2010
40. Kalantar-Zadeh K, Kovesdy CP, Derose SF, Horwich TB, Fonarow GC: Racial and survival paradoxes in chronic kidney disease. Nat Clin Pract Nephrol 3: 493–506, 2007
41. Norris K, Mehrotra R, Nissenson AR: Racial differences in mortality and ESRD. Am J Kidney Dis 52: 205–208, 2008
42. U.S. Renal Data System: USRDS 2011: Annual Data Report, Bethesda, MD, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 2011
Copyright © 2013 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.