Our exploratory observations, confirming the central role of PTH, have shown that TNF-α is associated with incident fractures in CKD -5D population. These findings generate the hypothesis that systemic inflammation might contribute to increase the bone fracture risk in these patients.
In the last two decades the biology of osteoclast activation has been intensively investigated and the RANKL/RANK pathway emerged as a fundamental modulator of osteoclastogenesis . Inflammatory cytokines are well established potent activators of the RANKL/RANK pathway [4–7] and play a direct role in osteoclastogenesis in post-menopausal women . Furthermore, recent longitudinal studies [21–23] coherently suggest that high cytokines levels may contribute to bone loss and fractures in elderly women and men.
We once again confirm that inflammation is pervasive in CKD-5D patients [12–15]. Indeed, CRP levels were above the upper limit of the normal in as much as 65% of patients at time of enrolment. In the present study TNF-α was substantially increased, being above the upper normal range in 78% of patients, a figure close to that of other biomarkers of inflammation, but it was the only cytokine linked to the fracture risk. The finding is consistent with studies showing that among the cytokines, TNFα is the most powerful stimulator of osteoclastogenesis [4–7].
Our study has limitations. First, we measured TNF-α and other cytokines only once. Since the precision of the estimate of the usual level of inflammation biomarkers increases with repeated measures, the link between TNF-α and bone fractures might be even stronger than emerged in the present analysis. On the other hand, because of the low number of events, the possibility that the TNF-α − fractures link may merely represent a false positive finding cannot be dismissed. We controlled for confounding by adopting a parsimonious approach based on bivariate Cox models and a composite risk score , and found that the relationship between TNF- α and the risk of incident fractures proved to be independent of PTH, as well as of major confounders like age, sex, previous fractures and previous kidney transplants. Notwithstanding these adjustments failed to materially change the risk of fractures associated with high TNF-α, we cannot exclude residual confounding. A second obvious limitation is that we did not measure the full set of hormones controlling mineral balance including 25 hydroxy vitamin D and 1,25 hydroxy vitamin D and FGF23. Moreover we have not evaluated serum magnesium levels and did not study the relationships between inflammation and vascular calcifications. Finally, our data collected in a single Renal Unit cannot be generalized to the greater HD population. Due to these limitations our data are merely hypothesis generating. The relationship between fractures and inflammatory cytokines in CKD-5D patients needs to be confirmed in larger cohorts gathering a substantial higher number of bone events. The issue is of relevance because bone fractures in CKD-5D patients not only engender disabling orthopaedic problems but are also associated to increased mortality .