Nationwide In-Hospital Mortality Following Major Fractures among Hemodialysis Patients and the General Population: An Observational Cohort Study

Abstract Backgrounds End-stage kidney disease (ESKD) is associated with increased risk of fracture and subsequent morbidity and mortality. However, fracture site-specific mortality in ESKD patients have yet to be elucidated in comparison with the general population. Methods In this population-based cohort derived from the Diagnosis Procedure Combination database of Japan from 2012 to 2014, we included 9,320 ESKD patients undergoing hemodialysis and 547,726 patients without ESKD who were hospitalized for five major fractures, including hip (proximal femur), spine, forearm, upper arm, and leg (distal femur and proximal tibia). Overall and site-specific risks of in-hospital death were determined by logistic regression models. Results The age- and sex-adjusted mortality rates were 4.91% (95% confidence interval [CI], 4.46–5.37) and 1.02% (95% CI, 0.99–1.06) in the hemodialysis and general population groups, respectively. The multivariate odds ratio (OR) of death in hemodialysis patients versus the general population was 2.48 (95% CI, 2.25–2.74) for overall fractures, and was particularly high for a subgroup of upper arm fracture (OR 4.82, 95% CI, 3.19–7.28). The site-specific odds of death (95% CI) among hip, spine, forearm, upper arm, and leg (reference) fractures were 1.77 (0.98–3.18), 1.48 (0.79–2.75), 0.19 (0.04–0.86), and 2.01 (1.01–4.01) in hemodialysis patients, and 1.28 (1.13–1.45), 1.00 (0.88–1.14), 0.13 (0.10–0.17), and 0.83 (0.70–0.97) in the general population, respectively. Conclusion Hemodialysis patients experienced a 4.8-fold higher mortality rate after fractures than the general population. Mortality after upper arm fracture was specifically high in patients on hemodialysis, likely due to the involvement of vascular access located on the fractured arm.