Fragility fractures and risk factors in a peritoneal dialysis setting.

UNLABELLED: Peritoneal dialysis patients have poorly characterized fracture risk. In this retrospective cohort of 325 patients, fragility fractures were frequent, mainly asymptomatic vertebral fractures. Fracture risk is independently associated with prior fractures and vascular calcification but FRAX® underestimates fracture risk, underscoring the need for improved assessment strategies tailored to peritoneal dialysis patients. PURPOSE: Data on fracture incidence, risk factors, and fracture risk assessment tools in patients treated with peritoneal dialysis (PD) remain limited. We aimed to evaluate the prevalence, incidence, and determinants of fragility fractures in PD patients and to assess the performance of the Fracture Risk Assessment Tool (FRAX®). METHODS: Retrospective single-center cohort study including adult patients receiving PD for ≥ 12 months. Fragility fractures occurring during PD follow-up were identified through clinical records and review of spine radiographs. Vascular calcification was assessed using the Adragão vascular calcification score (VCS). FRAX® probabilities for fracture risk were calculated without bone mineral density. Logistic regression was used to identify independent predictors of fractures, and receiver operating characteristic (ROC) curves evaluated FRAX® performance. RESULTS: Among 325 patients receiving PD (mean age 53 ± 8 years, 57% male), 32 (9.8%) fragility fractures were identified, and most were asymptomatic vertebral fractures (n = 23, 7.1%). In multivariable analysis, previous fracture history (OR 4.85, 95% CI 1.22-19.27) and higher VCS (OR 2.10, 95% CI 1.10-4.03) were independently associated with fracture occurrence. FRAX® showed modest discriminatory ability for any fragility fracture (AUC 0.69) and very low sensitivity at standard intervention thresholds, even when CKD was classified as secondary osteoporosis. CONCLUSION: Patients treated with PD experience a high burden of fragility fractures, largely driven by unrecognized vertebral fractures. Fracture risk is independently associated with prior fractures and vascular calcification. FRAX® underestimates fracture risk in this population, underscoring the need for improved fracture risk assessment strategies tailored to PD patients.