Fractures in patients with rheumatoid arthritis and end-stage renal disease

Summary: Having rheumatoid arthritis (RA) or end-stage renal disease (ESRD) can lead to fractures. RA independently increases the risk of hip or other femur fracture in dialysis patients. Use of corticosteroids is a potentially modifiable risk factor for fractures among persons with RA and ESRD on dialysis. Purpose: Rheumatoid arthritis (RA) and end-stage renal disease (ESRD) both independently increase fracture risk; however, how RA and ESRD interplay to affect fracture risk is unknown. We aim to determine the association of RA with fracture in ESRD and identify risk factors for fracture in patients with RA and ESRD. Methods: A retrospective cohort study was conducted using the United States Renal Data System (USRDS) to identify ESRD adults with and without a history of RA who initiated dialysis in 2005–2008. International Classification of Diseases, 9th Revision (ICD-9) codes were used to identify fractures following start of dialysis. Risk for incident fracture was compared between those with and without RA. Potential risk factors for fracture among persons with RA and ESRD were analyzed. Results: There were 754 persons with ESRD and RA, of whom 126 (17%) had any incident fracture. In multivariable adjusted final models, among ESRD patients, RA was an independent risk factor for hip/femur fracture (RR 1.28, 95% CI 1.01–1.64). Among persons with RA and ESRD, in final models, only corticosteroid use was a significant risk factor for both any incident (RR 2.00, 95% CI 1.40–2.87) and hip/femur (RR 1.97, 95% CI 1.24–3.11) fracture. Those with higher body mass index had a lower relative risk of hip/femur fracture (RR 0.95, 95% CI 0.91–0.99). Conclusion: Among ESRD patients, those with RA have a 28% increased risk for hip or other femur fracture. Use of corticosteroids is a potentially modifiable risk factor for fractures among persons with RA and ESRD.