Management of mineral and bone disorder after kidney transplantation

Curr Opin Nephrol Hypertens. 2012 Jul;21(4):389-403. doi: 10.1097/MNH.0b013e3283546ee0.

Abstract

Purpose of review: Mineral and bone disorders (MBDs), inherent complications of moderate and advanced chronic kidney disease, occur frequently in kidney transplant recipients. However, much confusion exists about the clinical application of diagnostic tools and preventive or treatment strategies to correct bone loss or mineral disarrays in transplanted patients. We have reviewed the recent evidence about prevalence and consequences of MBD in kidney transplant recipients and examined diagnostic, preventive and therapeutic options to this end.

Recent findings: Low turnover bone disease occurs more frequently after kidney transplantation according to bone biopsy studies. The risk of fracture is high, especially in the first several months after kidney transplantation. Alterations in minerals (calcium, phosphorus and magnesium) and biomarkers of bone metabolism (parathyroid hormone, alkaline phosphatase, vitamin D and FGF-23) are observed with varying impact on posttransplant outcomes. Calcineurin inhibitors are linked to osteoporosis, whereas steroid therapy may lead to both osteoporosis and varying degrees of osteonecrosis. Sirolimus and everolimus might have a bearing on osteoblast proliferation and differentiation or decreasing osteoclast-mediated bone resorption. Selected pharmacologic interventions for the treatment of MBD in transplant patients include steroid withdrawal, and the use of bisphosphonates, vitamin D derivatives, calcimimetics, teriparatide, calcitonin and denosumab.

Summary: MBD following kidney transplantation is common and characterized by loss of bone volume and mineralization abnormalities, often leading to low turnover bone disease. Although there are no well established therapeutic approaches for management of MBD in renal transplant recipients, clinicians should continue individualizing therapy as needed.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Review

MeSH terms

  • Animals
  • Biomarkers / blood
  • Biopsy
  • Bone Density Conservation Agents / therapeutic use
  • Bone Diseases, Metabolic / blood
  • Bone Diseases, Metabolic / drug therapy*
  • Bone Diseases, Metabolic / etiology
  • Bone Diseases, Metabolic / metabolism
  • Bone Diseases, Metabolic / pathology
  • Bone Remodeling
  • Bone and Bones / drug effects
  • Bone and Bones / metabolism*
  • Bone and Bones / pathology
  • Calcimimetic Agents / therapeutic use
  • Humans
  • Immunosuppressive Agents / adverse effects
  • Kidney Transplantation / adverse effects*
  • Minerals / metabolism*
  • Risk Assessment
  • Risk Factors
  • Steroids / adverse effects
  • Treatment Outcome
  • Vitamins / therapeutic use

Substances

  • Biomarkers
  • Bone Density Conservation Agents
  • Calcimimetic Agents
  • Immunosuppressive Agents
  • Minerals
  • Steroids
  • Vitamins