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研究生： 陳立成
Pramukti, Iqbal
論文名稱： 愛滋感染合併骨折患者之統合分析研究及十年骨折風險預測
Bone Fracture among People Living with HIV: A Meta-Analysis and 10-year Risk of Fracture Prediction
指導教授： 柯乃熒
Ko, Nai-Ying
學位類別： 博士
Doctor
系所名稱： 醫學院 - 護理學系
Department of Nursing
論文出版年： 2020
畢業學年度： 108
語文別： 英文
論文頁數： 70
外文關鍵詞： HIV, PLWH, 10-year risk of fracture, prevalence, risk factors, FRAX
相關次數： 點閱：105  下載：19 
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    • Background: As a reflection of a successful HAART program, over 33% people living with HIV (PLWH) were aged above 50 years old in 2015. This figure is predicted to increase to 73% by 2030. Risk of fracture among PLWH is higher than that of the general population. Predicting the risk of fracture and determining the associated factors are necessary to develop appropriate fracture prevention programs among PLWH.
    Purpose: This study was aimed toward estimating the global prevalence, incidence, and risk factors related to bone fracture worldwide, to estimate 10-year risk of fracture at one time point, and to identify factors associated with 10-year risk of fracture among people living with HIV.
    Method: This study consists of two parts. In part I, we conducted a systematic review and a meta-analysis to estimate global pooled prevalence, incidence rate, and fracture risk factors worldwide. We reviewed English articles from PubMed, Cochrane Library, CINAHL with Full Text, and Medline databases for studies published in English from January 2000 to February 2017. All studies reporting the prevalence and/or incidence of fracture among PLWH were included. The study quality was assessed using the Joanna Briggs Institute (JBI) appraisal tool. A random-effect model was used to calculate pooled estimates of fracture prevalence and incidence rates. In part II, a cross-sectional study design was conducted in outpatient clinic in National Cheng Kung University Hospital in Tainan, Taiwan. Data were collected at one time period. Participants were included if aged between 40 to 90 years old. Pregnant women and patients with unstable conditions, such as opportunistic infections, were excluded. IRB approval was obtained before data collection. The Fracture Risk Assessment (FRAX) standard tool was used to calculate 10-year risk of fracture. Dual X-ray absorptiometry (DXA) was used to measure the bone density of the participants. A descriptive statistical analysis, an ANOVA, and a logistic regression model were used to analyze the data.
    Results: The pooled estimated prevalence of fracture among PLWH was 6.6% (95% CI: 3.8-11.1) with pooled odds ratio of 1.9 (95%CI: 1.1-3.2) compared to the general population. The pooled estimates of fracture incidence were 11.3 (95% CI: 7.9-14.5) with incidence rate ratio (IRR) of 1.5 (95% CI: 1.3-1.8) compared to the general population. Risk factors for fracture incidence were older age (aHR 1.4, 95% CI: 1.3-1.6), smoking (aHR 1.3, 95% CI: 1.1-1.5), HIV/HCV co-infection (aHR 1.6, 95% CI: 1.3-1.9), and osteoporosis (aHR 3.3, 95% CI: 2.2-5.1). The median 10-year probability of fracture was 3.7% (IQR 2.2-6.2) for MOFs and 0.8% (IQR 0.3-2.5) for hip fractures. In addition to old age, previous fracture history, and low T-score, HCV co-infection was associated with a higher risk of hip fractures in PLWH. (Odds ratio:4.3, 95%CI: 1.29 – 14.33). Old age and low T-score were also associated with high probability of MOF.
    Conclusion and implication
    Our finding highlights a higher risk of fracture among PLWH compared to the general population. HCV co-infection among PLWH Is associated with higher hip fracture risks. It requires sustained efforts in pharmacologic and non-pharmacologic interventions in PLWH to prevent osteoporotic fractures, especially those with HCV co-infection

    Table of Contents ABSTRACT I CHAPTER ONE 1 INTRODUCTION 1 1.1 Background 1 1.2 Significance 3 1.3 Research purpose 5 CHAPTER TWO 6 LITERATURE REVIEW 6 2.1 Bone fracture among people living with HIV 6 2.1.1 Prevalence and Incidence of bone fracture 6 2.1.2 Risk factor for bone fracture associated with HIV infection 8 2.1.3 The mechanism underlying bone fracture among people living with HIV 9 2.2 Tools to estimate bone mass and bone fracture among people living with HIV 11 2.2.1 Dual Energy X-ray Absorptiometry (DXA) to estimate bone mass 11 2.2.2 Fracture Risk Assessment (FRAX) 12 CHAPTER THREE 15 METHODS 15 3.1 Part I: Systematic Review and Meta-Analysis 15 3.1.1 Study design and search strategy 15 3.1.2 Inclusion/Exclusion criteria 15 3.1.3 Data extraction 16 3.1.4 Outcome 16 3.1.5 Data analysis 16 3.2 Part II: A cross-sectional study 17 3.2.1 Study design and framework 17 3.2.2 Participants 17 3.2.3 Study outcome 20 3.2.4 Instruments and measurement 20 3.2.5 Study procedure 22 3.2.6 Data analysis 25 CHAPTER IV 26 RESULTS 26 4.1 Part I: Systematic review 26 4.1.1 Database searched 26 4.1.2 Quality assessment 26 4.1.3 Study Characteristics 29 4.1.4 Bone Fracture Prevalence 32 4.1.5 Bone Fracture Incidence 34 4.1.6 Fracture Risk Factors 37 4.1.7 Meta-regression Analysis and Publication Bias 37 4.2 Part II: A cross sectional study 40 4.2.1 Demographics data 40 4.2.2 Ten-year probability of fractures prediction 42 4.2.3 Ten-year probability of fractures prediction among PLWH with normal and low bone mineral density 44 4.2.4 Low bone mineral density (osteopenia and osteoporosis) 45 4.2.5 Risk factors for future fracture and osteoporosis 46 CHAPTER V 47 DISCUSSION 47 REFERENCES 53 APPENDICES 67 Tables Table 1. Studies on prevalence and incidence of fracture among people living with HIV 7 Table 2. Quality appraisal using the JBI Checklist Tool (n=21) 28 Table 3. Characteristic of studies reporting prevalence or incidence of bone fracture among PLWH (n=21) 30 Table 4. Prevalence of fracture among people living with HIV by demographic variable in selected studies 33 Table 5. Incidence of fracture among people living with HIV by demographic variable in selected studies 35 Table 6. Risk factor of fractures among people living with HIV 37 Table 7. Meta-regression analysis of fracture risk factors affecting heterogeneity on prevalence a 38 Table 8. Demographic data of subjects (n=288) 41 Table 9. Patient’s characteristic according to 10-year probability of fractures prediction (n = 288) 43 Table 10. Ten-year probability of fractures prediction (FRAX score) among PLWH with normal and low bone mineral density 44 Table 11. Patient characteristic according to T-score categories (n=268) 45 Table 12. Risk factors for high 10-year probability of MOFs (>10%) and hip fractures (>3%) among PLWH 46 Figures Figure 1. Research framework of 10-year risk of fracture prediction 19 Figure 2. Flow of data collection in part II 24 Figure 3. PRISMA diagram for search strategy 27 Figure 4 Forest plot for odds ratio of fracture between PLWH and general population 34 Figure 5. Forest plot for fracture incidence rate ratio between PLWH and general population 36 Figure 6. Funnel plot for publication bias test across studies 39

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