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Approach to the Patient with Transplantation-Related Bone Loss

Departments of Medicine (Royal Melbourne Hospital/Western Hospital) and Endocrinology, The University of Melbourne, Western Hospital, Footscray 3011, Victoria, Australia

Address all correspondence and requests for reprints to: Professor Peter R. Ebeling, M.D., FRACP, Departments of Medicine (Royal Melbourne Hospital/Western Hospital) and Endocrinology, The University of Melbourne, Western Hospital, Gordon Street, Footscray 3011, Victoria, Australia. E-mail: peterre{at}unimelb.edu.au.

Transplantation is an established therapy for end-stage diseases of the kidney, endocrine pancreas, heart, liver, lung, intestines and for many hematological disorders. Current immunosuppressive regimens with glucocorticoids and calcineurin inhibitors produce excellent patient and graft survival rates. This has resulted in both increases in transplant numbers and an increased recognition of previously neglected long-term complications of transplantation such as fractures and osteoporosis. Both pretransplantation bone disease and immunosuppressive therapy result in rapid bone loss and increased fracture rates. Patients are particularly at risk early after transplantation. The bone health of candidates for organ transplantation should be assessed with bone densitometry of the hip and spine. Spinal x-rays should be performed to diagnose prevalent fractures. Any secondary causes of osteoporosis should be identified and treated. Vitamin D deficiency should be corrected with vitamin D doses selected to achieve a serum 25-hydroxyvitamin D concentration of at least 20 ng/ml. All patients should receive calcium. Patients with kidney failure should be evaluated and treated for chronic kidney disease-mineral and bone disorder, including renal osteodystrophy. Secondary hyperparathyroidism, in particular, should be treated. Treatment is indicated in the immediate posttransplantation period irrespective of bone mineral density because further rapid bone loss will occur in the first several months after transplantation. Long-term organ transplant recipients should also have bone mass measurement and treatment of osteoporosis. Oral and iv bisphosphonates are the most promising approach for the management of transplantation osteoporosis. Active vitamin D metabolites may have additional benefits in reducing hyperparathyroidism, particularly after kidney transplantation.