Associations of Albuminuria and Metabolic Syndrome Traits With Fracture Risk in Patients With Type 2 Diabetes: A Population‐Based Cohort Study

BACKGROUND: Type 2 diabetes is associated with an increased risk of fragility fractures. While obesity may protect against fractures, individuals with type 2 diabetes often exhibit other metabolic syndrome (MetS) traits and albuminuria. We evaluated their roles and synergistic implications on incident fractures, stratified by obesity status. METHODS: Patients with type 2 diabetes were identified from territory-wide electronic health records in Hong Kong (2000-2018). MetS-related traits included albuminuria and individual MetS traits (obesity, hypertension, low HDL-cholesterol and hypertriglyceridemia). Outcomes were hip and major osteoporotic fractures (MOF). Patients were followed until fracture, death or 31 December 2020. Adjusted hazard ratios (aHRs) were estimated using multivariable Cox models. RESULTS: Among 165 289 patients with type 2 diabetes (median age: 60.0 years; 54.2% men), 1583 (0.96%) experienced hip fractures, and 3393 (2.05%) had MOF over a median follow-up of 5.3 years. Albuminuria was the strongest risk factor for hip fractures (obese: aHR 1.33, 95% CI 1.11-1.60; non-obese: 1.54, 1.33-1.78) and MOF (obese: 1.13, 1.01-1.26; non-obese: 1.28, 1.15-1.43). Hypertension was a significant risk factor only in non-obese patients. In the non-obese group, each additional MetS-related trait was associated with an increased risk of hip fracture and MOF. When stratified by diabetes duration, albuminuria remained a significant risk factor across different diabetes durations, while suboptimal glycaemic control became a significant risk factor particularly when diabetes duration ≥ 5 years. CONCLUSIONS: In this large population-based cohort of patients with type 2 diabetes predominantly of Asian descent from Hong Kong, albuminuria emerged as an important predictor of fracture risk. MetS traits compound this risk, especially in non-obese individuals. These findings could be instrumental in shaping screening initiatives for fracture risk optimization in type 2 diabetes.