Kidney Res Clin Pract 2019 Jun; 38(2): 220-228  
Fracture risk in chronic kidney disease: A Korean population-based cohort study
Young Eun Kwon1,* , Hyung Yun Choi2,* , Sol Kim1 , Dong-Ryeol Ryu3 , Hyung Jung Oh4 , the ESRD Registry Committee of the Korean Society of Nephrology
1Department of Internal Medicine, Myongji Hospital, Hanyang University College of Medicine, Goyang, Korea
2The Korean Society of Nephrology, Seoul, Korea
3Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Korea
4Ewha Institute of Convergence Medicine and Research Institute for Human Health Information, Ewha Womans University, Seoul, Korea
Correspondence to: Hyung Jung Oh
Ewha Institute of Convergence Medicine and Research Institute for Human Health Information, Ewha Womans University, 1071 Anyangcheon-ro, Yangcheon-gu, Seoul 07985, Korea. E-mail:
*Young Eun Kwon and Hyung Yun Choi contributed equally to this study.
Received: August 20, 2018; Revised: December 16, 2018; Accepted: January 16, 2019; Published online: June 30, 2019.
© The Korean Society of Nephrology. All rights reserved.

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Background: Chronic kidney disease (CKD)-mineral and bone disorder (MBD) and fracture risk are both closely related to declining renal function. Controlling hyperphosphatemia with phosphate binders is a basic principle of CKD-MBD treatment. The aim of this study was to identify differences in fracture risk between pre-dialysis CKD patients and end-stage renal disease (ESRD) on dialysis, and to evaluate the effects of phosphate binders on fracture risk in ESRD patients.
Methods: Data from a total of 89,533 CKD patients comprising CKD diagnosis, dialysis, fracture history, and phosphate binder prescription history from 2012 to 2016 were retrieved from the Health Insurance Review and Assessment Service Database. Multivariate Cox regression analyses were performed to identify whether dialysis or phosphate binders were associated with an increased fracture risk.
Results: Overall, the rate of fractures in pre-dialysis CKD patients was 74 per 1,000 patient-years, while that in dialysis patients was 84 per 1,000 patient-years. The risk of fracture in ESRD patients was higher than pre-dialysis CKD patients (hazard ratio, 1.16; 95% confidence interval, 1.12–1.21; P < 0.001) after adjusting for confounding variables. In addition, the fracture risk in patients who were not taking phosphate binders was 20.0% higher compared to ESRD patients taking phosphate binders.
Conclusion: Fractures were more prevalent in ESRD patients on dialysis than pre-dialysis CKD patients. Use of phosphate binders was associated with a lower fracture risk in ESRD patients.
Keywords: Chronic renal insufficiency, Dialysis, Fracture, Phosphate binder


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