Post-Transplant Bone Disease in Kidney Transplant Recipients: Diagnosis and Management

Abstract

Kidney transplantation is the preferred gold standard modality of treatment for kidney failure. Bone disease after kidney transplantation is highly prevalent in patients living with a kidney transplant and is associated with high rates of hip fractures. Fractures are associated with increased healthcare costs, morbidity and mortality. Post-transplant bone disease (PTBD) includes renal osteodystrophy, osteoporosis, osteonecrosis and bone fractures. PTBD is complex as it encompasses pre-existing chronic kidney disease–mineral bone disease and compounding factors after transplantation, including the use of immunosuppression and the development of de novo bone disease. After transplantation, the persistence of secondary and tertiary hyperparathyroidism, renal osteodystrophy, relative vitamin D deficiency and high levels of fibroblast growth factor-23 contribute to post-transplant bone disease. Risk assessment includes identifying both general risk factors and kidney-specific risk factors. Diagnosis is complex as the gold standard bone biopsy with double-tetracycline labelling to diagnose the PTBD subtype is not always readily available. Therefore, alternative diagnostic tools may be used to aid its diagnosis. Both non-pharmacological and pharmacological therapy can be employed to treat PTBD. In this review, we will discuss pathophysiology, risk assessment, diagnosis and management strategies to manage PTBD after kidney transplantation.

Pharmacological prevention of bone loss and fractures following solid organ transplantations: Protocol for a systematic review and network meta-analysis

“…Our secondary outcome measures will include: 1) changes in femoral neck, lumbar spine, and total hip BMD from baseline, 2) incidence of adverse events, and 3) incidence of serious adverse events (SAEs). Fracture was chosen as a patient-important efficacy outcome for bone loss and osteoporosis, while BMD is chosen as a widely-recognized and commonly reported surrogate measure of fracture risk, osteoporosis severity, and bone health [13][14][15]. We will evaluate all outcomes based on data collected at the latest follow-up visit.…”

Vertebral fractures in patients with CKD and the general population: a call for diagnosis and action

“…Other factors predisposing to fractures (with an RR between 1 and 2) include current smoking, alcohol consumption (>3 units per day), early menopause, hypogonadism, diseases associated with bone loss, medical treatment leading to bone loss, and risk factors for falls [ 63 ]. Patients with CKD may also have traditional risk factors for fractures and osteoporosis, as among the diseases and treatments associated with a higher risk of fracture development include organ transplantation, CKD with eGFR <60 ml/min/1.73 m 2 , and hyperparathyroidism [ 15 , 63 ]. Thus, patients with CKD, especially individuals with kidney transplantation, tend to have several causes of secondary osteoporosis [ 15 ].…”

“…Patients with CKD may also have traditional risk factors for fractures and osteoporosis, as among the diseases and treatments associated with a higher risk of fracture development include organ transplantation, CKD with eGFR <60 ml/min/1.73 m 2 , and hyperparathyroidism [ 15 , 63 ]. Thus, patients with CKD, especially individuals with kidney transplantation, tend to have several causes of secondary osteoporosis [ 15 ].…”

“…In addition, the potential utility of 18F-NaF PET/CT for non-invasive assessment of bone turnover and volume in CKD-MBD (with an area under the curve of 0.87 for discriminating adynamic bone disease) has recently been published [ 14 ]. Some authors recommend the use of bone turnover markers (or a combination thereof) as surrogate markers for bone turnover and/or fracture risk estimation [ 15–17 ]. In fact, the diagnostic performance of biochemical markers of bone turnover is considered acceptable, with clinical utility in ruling out both high and low turnover bone disease [ 17 ].…”