**2. Elevated risk for fracture in end-stage kidney disease**

Table 1 Elevated fracture risk in ESKD

Compared with general population, the risk for fracture is reported to be much higher in endstage kidney disease (ESKD) (Table 1) [10-14]. A multicenter cohort study in the US having more than 320,000 dialysis patients, 13.6 in women and 7.5 in men had an incident hip fracture among 1,000 person-years [10].The incidence ratio standardized with age was about 4.4 times higher than that of healthy subjects. Another study in a single institution in the US having 1,272 dialysis patients, 13.9 (24.1 in women and 11.7 in men) had an incident hip fracture among 1,000 person-years, which was 17.4 times higher than that of general population [11]. Increased risk of hip fracture was shown among Japanese hemodialysis (HD) patients, in which the risk was about 5 times higher than that of general population [12]. Facture risk of HD patients was increased in the west part of Japan, which showed similar results to the general population [12, 15]. A multicenter prospective study (DOPPS II) in 12,782 patients from 12 countries showed that 8.9/1,000 person-years had a hip fracture [13]. In addition, risk for fracture may even be higher for 3 years after kidney transplantation [16].


**Table 1.** Elevated fracture risk in ESKD

Mean age of incident fracture in dialysis patients is reported to be 61.4 in women and 64.4 in men, which are much younger than those of general population (74 and 80, respectively), indicating that dialysis patients apt to suffer from bone fractures at younger age [11]. The incidence of hip fracture in dialysis patients of 60 and 70 years old is comparable to those of 75 and 80 years, respectively [13, 14].

CKD is not only at risk for fracture but also at mortality risk after fracture [11, 17, 18]. Coco et al. reported the mortality rate was 64% a year after hip fracture in HD patients, whereas it was about 20% in the healthy subjects [11]. Among HD patients, mortality rate was showed to be 2.7 times greater in patients with incident fracture, compared to those without fracture [17]. Moreover, significant elevation of fracture-associated mortality risk was found in patients even before the initiation of HD therapy [18].Although bisphosphonates may not be recommended in ESKD patients, they are useful in osteoporotic patients with great risk reduction for fracture [19]. PTH agent such as teriparatide, and selective estrogen receptor modulator (SERM) are also established therapies with 50% or more of relative risk reduction [20, 21].Thus, early starts of therapy for osteoporosis will prevent fracture. These findings suggest that clinicians need to evaluate bone status and initiate osteoporosis therapy in patients with CKD in early stages.
