骨折风险评估工具在评估维持性血液透析患者骨折风险中的效能

The diagnostic efficiency and application value of fracture risk assessment tools in maintenance hemodialysis patients

目的:比较亚洲人骨质疏松自我筛查工具(osteoporosis self-screening tool for Asians,OSTA)、世界卫生组织骨折风险评估工具1(fracture risk assessment tool 1,FRAX1)(不包含BMD)和FRAX2(包含BMD)这3种骨折风险评估工具评估维持性血液透析(maintenance hemodialysis,MHD)患者发生骨折风险的效能。方法:选取2014年12月至2016年12月在上海交通大学医院院附属瑞金医院进行MHD的患者136例,随访36个月,其间收集患者的影像学资料。根据随访中是否发生骨折,将患者分为骨折组与非骨折组,采用双能X射线吸收法(dual-energy Xray,DXA)测定所有患者腰椎、股骨颈及髋部的骨密度值(bone mineral density,BMD)。根据BMD的测定值以及3种骨折风险评估工具,即OSTA、FRAX1和FRAX2的评估骨折概率计算结果,绘制受试者操作特征曲线(receiver operator characteristic curve,ROC曲线),比较其评估MHD患者发生骨折风险的效能。结果:136例患者中,男性80例,女性56例,年龄59(47~67)岁,透析龄55(26~87)个月,共有16例发生骨折,占11.76%。ROC曲线分析显示,三部位BMD[腰椎(1~4)、股骨颈、全髋]、OSTA、FRAX1及FRAX2评估MHD患者骨折风险的曲线下面积分别为0.669(95%CI为0.583~0.747)、0.708(95%CI为0.624~0.783)、0.736(95%CI为0.654~0.808)、0.686(95%CI为0.601~0.763)、0.715(95%CI为0.631~0.789)、0.697(95%CI为0.613~0.773);三部位BMD最佳临界值分别为0.973 g/cm^(2)、0.719 g/cm^(2)、0.859 g/cm^(2),而OSTA、FRAXI和FRAX2的最佳临界值为0.2%、3.3%、2.8%。OSTA、FRAX1及FRAX2在评估MHD患者骨折风险的效能间差异无统计学意义,但高于BMD(P<0.05)。结论:在MHD患者中,OSTA、FRAX1及FRAX2这3种骨折风险评估工具均可用于评估骨折风险。包含了BMD的FRAX2诊断效能并未见优势,故临床在没有条件行BMD检查的情况下,OSTA和FRAX1也适用于MHD患者骨折风险评估。

Objective:To compare the diagnostic efficiency and application value of three widely-used fracture risk assessment tools[osteoporosis self-assessment tool for Asians(OSTA)],WHO fracture risk assessment tool FRAX1[non-bone mineral density(BMD)model]and FRAX2(BMD model)to identify fracture status in maintenance hemodialysis(MHD)patients.Methods:A total of 136 patients accepting MHD during December 2014 to December 2016 were enrolled in this study.All patients were divided into fracture group and non-fracture group according to BMD results at lumbar spine and hip region tested with dual-energy X-ray(DXA).OSTA was calculated on weight and age,and FRAX score was obtained through the website.Capacity of BMD,OSTA,FRAX1 and FRAX2 for predicting fracture status were assessed with receiver operator characteristic(ROC)curve analysis.Results:Among 136 MHD patients,the average age was 59(47-67)years and duration of dialysis was 55(26-87)months.There were 16 fractures(11.76%)in those MHD patients.Areas under the curves of BMD(lumbar spine L1-L4,femoral neck,total hip),OSTA,FRAX1 and FRAX2 for predicting fracture were 0.669(95%CI:0.583-0.747,P=0.0234),0.708(95%CI:0.624-0.783,P=0.0014),0.736(95%CI:0.654-0.808,P=0.0003),0.686(95%CI:0.601-0.763,P=0.0078),0.715(95%CI:0.631-0.789,P=0.0004),and 0.697(95%CI:0.613-0.773,P>0.05),respectively.And cutoff value of BMD of lumbar spine L1-L4,femoral neck,total hip for predicting fracture were 0.973 g/cm^(2),0.719 g/cm^(2),0.859 g/cm^(2),and while cutoff value of OSTA,FRAX1 and FRAX2 were 0.2,3.3%,2.8%,respectively Conclusions:BMD,OSTA and FRAX have the same ability to predict fracture status in MHD patients.FRAX2(BMD model)has no advantage over FRAX1(non-BMD model)in predicting fracture.OSTA and FRAX1 are able to assess fracture status in MHD patient without BMD detection.