Reduced Fracture Risk With Early Corticosteroid Withdrawal After Kidney Transplant

Abstract

Corticosteroid use after kidney transplantation results in severe bone loss and high fracture risk. Although corticosteroid withdrawal in the early posttransplant period has been associated with bone mass preservation, there are no published data regarding corticosteroid withdrawal and risk of fracture. We hypothesized lower fracture incidence in patients discharged from the hospital without than with corticosteroids after transplantation. From the United States Renal Data System (USRDS), 77 430 patients were identified who received their first kidney transplant from 2000 to 2006. Fracture incidence leading to hospitalization was determined from 2000 to 2007; discharge immunosuppression was determined from United Networks for Organ Sharing forms. Time-to-event analyses were used to evaluate fracture risk. Median (interquartile range) follow-up was 1448 (808–2061) days. There were 2395 fractures during follow-up; fracture incidence rates were 0.008 and 0.0058 per patient-year for recipients discharged with and without corticosteroid, respectively. Corticosteroid withdrawal was associated with a 31% fracture risk reduction (HR 0.69; 95% CI 0.59–0.81). Fractures associated with hospitalization are significantly lower with regimens that withdraw corticosteroid. As this study likely underestimates overall fracture incidence, prospective studies are needed to determine differences in overall fracture risk in patients managed with and without corticosteroids after kidney transplantation.

Kidney Transplantation with Early Corticosteroid Withdrawal

“…10,11 Several trials suggested that they are associated with a stabilization of or an increase in areal BMD at the spine and hip. [12][13][14] However, recent data suggest that management with ECSW may result in only minimal 15 or no [16][17][18] protection against fractures. These studies suggest that our understanding of fracture pathogenesis after transplantation is incomplete, that fracture risk with ECSW may be independent of changes in areal BMD measured at the spine and hip, and that ECSW may be associated with abnormalities in bone quality that are not detected by dual energy x-ray absorptiometry (DXA).…”

Paricalcitol for Secondary Hyperparathyroidism in Renal Transplantation

“…This result largely explains why, in recipients of kidney transplants, the incidence of fractures is 4-fold higher than in the general population and even exceeds the incidence observed in patients on hemodialysis. [3][4][5] Several factors involved in the pathogenesis of post-transplant CKD-MBD include immunosuppressive therapy, especially corticosteroids, 6 hormonal disturbances, and progressive deterioration of graft function. 7 Secondary hyperparathyroidism (SHPT) has been consistently reported to play a central role in posttransplant CKD-MBD.…”

Minimizationvstailoring: Where do we stand with personalized immunosuppression during renal transplantation in 2015?

“…A retrospective study conducted in the United States on re-transplant patients receiving rabbit-derived antithymocyte globulin (rATG) induction therapy [15] showed relatively low rates of acute rejections in both the steroid withdrawal and triple therapy groups. While these and other studies tend to show non-inferiority of steroidfree maintenance regimens in low risk patients -and perhaps a hint that in higher risk patients receiving induction therapy early withdrawal may be safe -it remains unclear whether the improvements in metabolic complications, including new onset diabetes [16] , skeletal complications including fracture risk [17] are sufficiently counterbalancing the risk for long-term immunological [18] and increased rates for DSA [19] in this setting. On the other hand, the possibility of increased risk for antibody-mediated rejection after steroid withdrawal in high-risk populations is currently not sufficiently explored.…”