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Georgopoulou GA, Papasotiriou M, Ntrinias T, Savvidaki E, Goumenos DS, Papachristou E. Impact of bisphosphonate treatment on bone mineral density after kidney transplant. World J Transplant 2024; 14:92335. [DOI: 10.5500/wjt.v14.i3.92335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 03/04/2024] [Accepted: 07/02/2024] [Indexed: 07/31/2024] Open
Abstract
BACKGROUND Mineral bone disease is associated with chronic kidney disease and persists after kidney transplantation. Immunosuppressive treatment contributes to the pathogenesis of this disease. Bisphosphonate treatments have shown positive but indefinite results.
AIM To evaluate the effectiveness and safety of bisphosphonate treatment on post kidney transplantation bone mineral density (BMD).
METHODS We included kidney transplant recipients (KTRs) whose BMD was measured after the operation but before the initiation of treatment and their BMD was measured at least one year later. We also evaluated the BMD of KTRs using two valid measurements after transplantation who received no treatment (control group).
RESULTS Out of 254 KTRs, 62 (39 men) were included in the study. Bisphosphonates were initiated in 35 KTRs in total (20 men), 1.1 ± 2.4 years after operation and for a period of 3.9 ± 2.3 years while 27 (19 men) received no treatment. BMD improved significantly in KTRs who received bisphosphonate treatments (from -2.29 ± 1.07 to -1.66 ± 1.09, P < 0.0001). The control group showed a non-significant decrease in BMD after 4.2 ± 1.4 years of follow-up after surgery. Kidney function was not affected by bisphosphonate treatment. In KTRs with established osteoporosis, active treatment had a similar and significant effect on those with osteopenia or normal bone mass.
CONCLUSION In this retrospective study of KTRs receiving bisphosphonate treatment, we showed that active treatment is effective in preventing bone loss irrespective of baseline BMD.
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Affiliation(s)
| | - Marios Papasotiriou
- Department of Nephrology and Kidney Transplantation, University Hospital of Patras, Patras 26504, Greece
| | - Theodoros Ntrinias
- Department of Nephrology and Kidney Transplantation, University Hospital of Patras, Patras 26504, Greece
| | - Eirini Savvidaki
- Department of Nephrology and Kidney Transplantation, University Hospital of Patras, Patras 26504, Greece
| | - Dimitrios S Goumenos
- Department of Nephrology and Kidney Transplantation, University Hospital of Patras, Patras 26504, Greece
| | - Evangelos Papachristou
- Department of Nephrology and Kidney Transplantation, University Hospital of Patras, Patras 26504, Greece
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Palmer SC, Chung EYM, McGregor DO, Bachmann F, Strippoli GFM. Interventions for preventing bone disease in kidney transplant recipients. Cochrane Database Syst Rev 2019; 10:CD005015. [PMID: 31637698 PMCID: PMC6803293 DOI: 10.1002/14651858.cd005015.pub4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND People who have chronic kidney disease (CKD) have important changes to bone structure, strength, and metabolism. Children experience bone deformity, pain, and delayed or impaired growth. Adults experience limb and vertebral fractures, avascular necrosis, and pain. The fracture risk after kidney transplantation is four times that of the general population and is related to Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD) occurring with end-stage kidney failure, steroid-induced bone loss, and persistent hyperparathyroidism after transplantation. Fractures may reduce quality of life and lead to being unable to work or contribute to community roles and responsibilities. Earlier versions of this review have found low certainty evidence for effects of treatment. This is an update of a review first published in 2005 and updated in 2007. OBJECTIVES This review update evaluates the benefits and harms of interventions for preventing bone disease following kidney transplantation. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 16 May 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA RCTs and quasi-RCTs evaluating treatments for bone disease among kidney transplant recipients of any age were eligible. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial risks of bias and extracted data. Statistical analyses were performed using random effects meta-analysis. The risk estimates were expressed as a risk ratio (RR) for dichotomous variables and mean difference (MD) for continuous outcomes together with the corresponding 95% confidence interval (CI). The primary efficacy outcome was bone fracture. The primary safety outcome was acute graft rejection. Secondary outcomes included death (all cause and cardiovascular), myocardial infarction, stroke, musculoskeletal disorders (e.g. skeletal deformity, bone pain), graft loss, nausea, hyper- or hypocalcaemia, kidney function, serum parathyroid hormone (PTH), and bone mineral density (BMD). MAIN RESULTS In this 2019 update, 65 studies (involving 3598 participants) were eligible; 45 studies contributed data to our meta-analyses (2698 participants). Treatments included bisphosphonates, vitamin D compounds, teriparatide, denosumab, cinacalcet, parathyroidectomy, and calcitonin. Median duration of follow-up was 12 months. Forty-three studies evaluated bone density or bone-related biomarkers, with more recent studies evaluating proteinuria and hyperparathyroidism. Bisphosphonate therapy was usually commenced in the perioperative transplantation period (within 3 weeks) and regardless of BMD. Risks of bias were generally high or unclear leading to lower certainty in the results. A single study reported outcomes among 60 children and adolescents. Studies were not designed to measure treatment effects on fracture, death or cardiovascular outcomes, or graft loss.Compared to placebo, bisphosphonate therapy administered over 12 months in transplant recipients may prevent fracture (RR 0.62, 95% CI 0.38 to 1.01; low certainty evidence) although the 95% CI included the possibility that bisphosphonate therapy might make little or no difference. Fracture events were principally vertebral fractures identified during routine radiographic surveillance. It was uncertain whether any other drug class decreased fracture (low or very low certainty evidence). It was uncertain whether interventions for bone disease in kidney transplantation reduce all-cause or cardiovascular death, myocardial infarction or stroke, or graft loss in very low certainty evidence. Bisphosphonate therapy may decrease acute graft rejection (RR 0.70, 95% CI 0.55 to 0.89; low certainty evidence), while it is uncertain whether any other treatment impacts graft rejection (very low certainty evidence). Bisphosphonate therapy may reduce bone pain (RR 0.20, 95% CI 0.04 to 0.93; very low certainty evidence), while it was very uncertain whether bisphosphonates prevent spinal deformity or avascular bone necrosis (very low certainty evidence). Bisphosphonates may increase to risk of hypocalcaemia (RR 5.59, 95% CI 1.00 to 31.06; low certainty evidence). It was uncertain whether vitamin D compounds had any effect on skeletal, cardiovascular, death, or transplant function outcomes (very low certainty or absence of evidence). Evidence for the benefits and harms of all other treatments was of very low certainty. Evidence for children and young adolescents was sparse. AUTHORS' CONCLUSIONS Bisphosphonate therapy may reduce fracture and bone pain after kidney transplantation, however low certainty in the evidence indicates it is possible that treatment may make little or no difference. It is uncertain whether bisphosphonate therapy or other bone treatments prevent other skeletal complications after kidney transplantation, including spinal deformity or avascular bone necrosis. The effects of bone treatment for children and adolescents after kidney transplantation are very uncertain.
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Affiliation(s)
- Suetonia C Palmer
- University of Otago ChristchurchDepartment of Medicine2 Riccarton AvePO Box 4345ChristchurchNew Zealand8140
| | - Edmund YM Chung
- Royal North Shore HospitalDepartment of Medicine48 Provincial RoadSydneyNSWAustralia2070
| | - David O McGregor
- Christchurch HospitalDepartment of NephrologyPrivate Bag 4710ChristchurchNew Zealand8001
| | - Friederike Bachmann
- Charité University Medicine BerlinDepartment of Nephrology and Medical Intensive CareCharitéplatz 1BerlinGermany10117
| | - Giovanni FM Strippoli
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- DiaverumMedical Scientific OfficeLundSweden
- Diaverum AcademyBariItaly
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
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Anastasilakis AD, Tsourdi E, Makras P, Polyzos SA, Meier C, McCloskey EV, Pepe J, Zillikens MC. Bone disease following solid organ transplantation: A narrative review and recommendations for management from The European Calcified Tissue Society. Bone 2019; 127:401-418. [PMID: 31299385 DOI: 10.1016/j.bone.2019.07.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 07/07/2019] [Accepted: 07/08/2019] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Solid organ transplantation is an established therapy for end-stage organ failure. Both pre-transplantation bone disease and immunosuppressive regimens result in rapid bone loss and increased fracture rates. METHODS The European Calcified Tissue Society (ECTS) formed a working group to perform a systematic review of existing literature on the consequences of end-stage kidney, liver, heart, and lung disease on bone health. Moreover, we assessed the characteristics of post-transplant bone disease and the skeletal effects of immunosuppressive agents and aimed to provide recommendations for the prevention and treatment of transplantation-related osteoporosis. RESULTS Characteristics of bone disease may differ depending on the organ that fails, but patients awaiting solid organ transplantation frequently depict a wide spectrum of bone and mineral abnormalities. Common features are a decreased bone mass and impaired bone strength with consequent high fracture risk, all of which are aggravated in the early post-transplantation period. CONCLUSION Both the underlying disease leading to end-stage organ failure and the immunosuppression regimens implemented after successful organ transplantation have detrimental effects on bone mass, quality and strength. Given existing ample data confirming the high frequency of bone disease in patients awaiting solid organ transplantation, we recommend that all transplant candidates should be assessed for osteoporosis and fracture risk and, if indicated, treated before and after transplantation. Since bone loss in the early post-transplantation period occurs in virtually all solid organ recipients and is associated with glucocorticoid administration, the goal should be to use the lowest possible dose and to taper and withdraw glucocorticoids as early as possible.
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Affiliation(s)
| | - Elena Tsourdi
- Department of Medicine III, Technische Universität Dresden Medical Center, Dresden, Germany; Center for Healthy Aging, Technische Universität Dresden Medical Center, Dresden, Germany
| | - Polyzois Makras
- Department of Endocrinology and Diabetes, 251 Hellenic Force & VA General Hospital, Athens, Greece
| | - Stergios A Polyzos
- First Department of Pharmacology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Christian Meier
- Division of Endocrinology, Diabetology and Metabolism, University Hospital and University of Basel, Switzerland
| | - Eugene V McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK; Centre for Integrated research in Musculoskeletal Ageing (CIMA), Mellanby Centre for Bone Research, University of Sheffield, Sheffield, UK
| | - Jessica Pepe
- Department of Internal Medicine and Medical Disciplines, "Sapienza" University, Rome, Italy
| | - M Carola Zillikens
- Bone Center, Department of Internal Medicine, Erasmus MC, Rotterdam, the Netherlands.
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Yang Y, Qiu S, Deng L, Tang X, Li X, Wei Q, Fu P. Outcomes of bisphosphonate and its supplements for bone loss in kidney transplant recipients: a systematic review and network meta-analysis. BMC Nephrol 2018; 19:269. [PMID: 30340537 PMCID: PMC6194739 DOI: 10.1186/s12882-018-1076-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 10/05/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Mineral bone disease constitutes a common complication of post-kidney transplantation, leading to great disability. As there is no consensus on the optimal treatment for post-kidney transplant recipients (KTRs), we aimed to evaluate the efficacy and safety of bisphosphonate and its combined therapies. METHODS We incorporated relevant trials to perform a network meta-analysis from direct and indirect comparisons. We searched PubMed, Embase and the CENTRAL and the reference lists of relevant articles up to August 1, 2017, for randomized controlled trials. The primary outcome was bone mineral density (BMD) change at the femoral neck and the lumbar spine. RESULTS From a total of 864 citations, 18 randomized controlled trials with a total of 1200 participants were included. Five different regimens were considered. Bisphosphonate plus calcium revealed a significant gain in percent BMD change than calcium alone at the femoral neck (mean difference (MD), 5.83; 95% credible interval (CrI), 1.61 to 9.27). No significant difference was detected when restricting to absolute terms. At the lumbar spine, bisphosphonate and calcium with or without vitamin D analogs outperformed calcium solely (MD, 0.07; 95% CrI, 0.00 to 0.13; MD, 0.06; 95% CrI, 0.02 to 0.09). Compared to calcium with vitamin D analogs, adding bisphosphonate was associated with marked improvement (MD, 0.03; 95% CrI, 0.00 to 0.05). Considering percent terms, combination of bisphosphonate with calcium and vitamin D analogs showed greater beneficial effects than calcium alone or with either vitamin D analogs or calcitonin (MD, 10.51; 95% CrI, 5.92 to 15.34; MD, 5.48; 95% CrI, 2.57 to 8.42; MD, 6.39; 95% CrI, 0.55 to 12.89). Both bisphosphonate and vitamin D analogs combined with calcium displayed a notable improvement compared to calcium alone (MD, 7.24; 95% CrI, 3.73 to 10.69; MD, 5.02; 95% CrI, 1.20 to 8.84). CONCLUSIONS Our study suggested that additional use of bisphosphonate was well-tolerated and more favorable in KTRs to improve BMD.
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Affiliation(s)
- Yan Yang
- Kidney Research Laboratory, Division of Nephrology, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, Sichuan, People's Republic of China, 610041.,Department of Nephrology, The First People's Hospital of Changzhou, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, People's Republic of China, 213000
| | - Shi Qiu
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Linghui Deng
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Xi Tang
- Kidney Research Laboratory, Division of Nephrology, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, Sichuan, People's Republic of China, 610041
| | - Xinrui Li
- Kidney Research Laboratory, Division of Nephrology, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, Sichuan, People's Republic of China, 610041
| | - Qiang Wei
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Ping Fu
- Kidney Research Laboratory, Division of Nephrology, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, Sichuan, People's Republic of China, 610041.
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Yang Y, Qiu S, Tang X, Li XR, Deng LH, Wei Q, Fu P. Efficacy and Safety of Different Bisphosphonates for Bone Loss Prevention in Kidney Transplant Recipients: A Network Meta-Analysis of Randomized Controlled Trials. Chin Med J (Engl) 2018; 131:818-828. [PMID: 29578126 PMCID: PMC5887741 DOI: 10.4103/0366-6999.228252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Mineral and bone disorder is one of the severe complications in kidney transplant recipients (KTRs). Previous studies showed that bisphosphonates had favorable effects on bone mineral density (BMD). We sought to compare different bisphosphonate regimens and rank their strategies. METHODS We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) up to April 01, 2017, for randomized controlled trials (RCTs) comparing bisphosphonate treatments in adult KTRs. The primary outcome was BMD change. We executed the tool recommended by the Cochrane Collaboration to evaluate the risk of bias. We performed pairwise meta-analyses using random effects models and network meta-analysis (NMA) using Bayesian models and assessed the quality of evidence. RESULTS A total of 21 RCTs (1332 participants) comparing 6 bisphosphonate regimens were included. All bisphosphonates showed a significantly increased percentage change in BMD at the lumbar spine compared to calcium except clodronate. Pamidronate with calcium and Vitamin D analogs showed improved BMD in comparison to clodronate with calcium (mean difference [MD], 9.84; 95% credibility interval [CrI], 1.06-19.70). The combination of calcium and Vitamin D analogs had a significantly lower influence than adding either pamidronate or alendronate (MD, 6.34; 95% CrI, 2.59-11.01 and MD, 6.16; 95% CrI, 0.54-13.24, respectively). In terms of percentage BMD change at the femoral neck, both pamidronate and ibandronate combined with calcium demonstrated a remarkable gain compared with calcium (MD, 7.02; 95% CrI, 0.30-13.29 and MD, 7.30; 95% CrI, 0.32-14.22, respectively). The combination of ibandronate with calcium displayed a significant increase in absolute BMD compared to any other treatments and was ranked best. CONCLUSIONS Our NMA suggested that new-generation bisphosphonates such as ibandronate were more favorable in KTRs to improve BMD. However, the conclusion should be treated with caution due to indirect comparisons.
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Affiliation(s)
- Yan Yang
- Division of Nephrology, Kidney Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Shi Qiu
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Xi Tang
- Division of Nephrology, Kidney Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Xin-Rui Li
- Division of Nephrology, Kidney Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Ling-Hui Deng
- Department of Neurology, Stroke Clinical Research Unit, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Qiang Wei
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Ping Fu
- Division of Nephrology, Kidney Research Institute, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
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Toth-Manikowski SM, Francis JM, Gautam A, Gordon CE. Outcomes of bisphosphonate therapy in kidney transplant recipients: a systematic review and meta-analysis. Clin Transplant 2016; 30:1090-6. [PMID: 27327448 DOI: 10.1111/ctr.12792] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2016] [Indexed: 11/30/2022]
Abstract
Mineral and bone disorders that precede kidney transplantation are exacerbated in the post-transplant setting by tertiary hyperparathyroidism and immunosuppressive regimens. Bone mineral density (BMD) decreases following transplantation, leading to increased fracture risk. The effect of bisphosphonates on fracture is unknown. The aim of this study was to update estimates of change in BMD and fracture rates in bisphosphonate-treated kidney transplant recipients through meta-analysis. Studies comparing bisphosphonate therapy to standard of care were included if follow-up duration was more than 6 months. We performed random-effects meta-analysis to determine the effect of bisphosphonates on lumbar spine and femoral neck BMD and fracture rates. Bisphosphonates improved femoral neck and lumbar spine BMD compared with controls (0.055 g/cm(2) , 95% CI 0.012-0.099 and 0.053 g/cm(2) , 95% CI 0.032-0.074, respectively) without adversely affecting serum creatinine or calcium. This corresponded to an unweighted improvement in BMD of 6.0% and 7.4%, respectively. There was no difference in fracture incidence in the two groups. Bisphosphonate therapy in kidney transplant recipients is associated with a statistically significant improvement in BMD at the lumbar spine and femoral neck. There was no difference in fracture incidence. Bisphosphonates did not adversely affect allograft dysfunction or serum calcium levels.
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Affiliation(s)
- Stephanie M Toth-Manikowski
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA.,Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jean M Francis
- Renal Section and Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Amitabh Gautam
- Section of Transplant Surgery, Department of Surgery, Boston University School of Medicine, Boston, MA, USA
| | - Craig E Gordon
- Renal Section and Department of Medicine, Boston University School of Medicine, Boston, MA, USA.
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Kan SL, Ning GZ, Chen LX, Zhou Y, Sun JC, Feng SQ. Efficacy and Safety of Bisphosphonates for Low Bone Mineral Density After Kidney Transplantation: A Meta-Analysis. Medicine (Baltimore) 2016; 95:e2679. [PMID: 26844505 PMCID: PMC4748922 DOI: 10.1097/md.0000000000002679] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
In patients with low bone mineral density (BMD) after kidney transplantation, the role of bisphosphonates remains unclear. We performed a systematic review and meta-analysis to investigate the efficacy and safety of bisphosphonates.We retrieved trials from PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception through May 2015. Only randomized controlled trials that compared bisphosphonate-treated and control groups of patients with low bone mineral density after kidney transplantation were included. The primary outcomes were the percent change in BMD, the absolute change in BMD, and the BMD at the end of study at the lumbar spine. The results were expressed as the mean difference (MD) or relative risk (RR) with the 95% confidence interval (CI). We used a random-effects model to pool the outcomes.We included 17 randomized controlled trials with 1067 patients. Only 1 included trial was found to be at low risk of bias. The rest of the included studies were found to have high to uncertain risk of bias. Compared with the control group, those who received bisphosphonates had a significant increase in percent change in BMD (mean difference [MD] = 5.51, 95% confidence interval [CI] 3.22-7.79, P < 0.00001) and absolute change in BMD (MD = 0.05, 95% CI 0.04-0.05, P < 0.00001), but a nonsignificant increase in BMD at the end of the study (MD = 0.02, 95% CI -0.01 to 0.05, P = 0.25) at the lumbar spine. Bisphosphonates resulted in a significant improvement in percent change in BMD (MD = 4.95, 95% CI 2.57-7.33, P < 0.0001), but a nonsignificant improvement in absolute change in BMD (MD = 0.03, 95% CI -0.00 to 0.06, P = 0.07) and BMD at the end of the study (MD = -0.01, 95% CI -0.04 to 0.02, P = 0.40) at the femoral neck. No significant differences were found in vertebral fractures, nonvertebral fractures, adverse events, and gastrointestinal adverse events.Bisphosphonates appear to have a beneficial effect on BMD at the lumbar spine and do not significantly decrease fracture events in recipients. However, the results should be interpreted cautiously due to the lack of robustness and the heterogeneity among studies.
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Affiliation(s)
- Shun-Li Kan
- From the Department of Orthopaedics, Tianjin Medical University General Hospital, 154 Anshan Road, Heping District, Tianjin, China
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Versele EB, Van Laecke S, Dhondt AW, Verbeke F, Vanholder R, Van Biesen W, Nagler EV. Bisphosphonates for preventing bone disease in kidney transplant recipients: a meta-analysis of randomized controlled trials. Transpl Int 2015; 29:153-64. [PMID: 26369899 DOI: 10.1111/tri.12691] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 07/21/2015] [Accepted: 09/07/2015] [Indexed: 11/29/2022]
Abstract
An estimated 60% of kidney transplant recipients have mineral bone disease and about 0.5% break their hip within the first year after transplantation. We conducted a systematic review of benefits and harms of bisphosphonates in kidney transplant recipients. We searched CENTRAL (Issue 5, 2015) for randomized controlled trials in all languages and screened the reference list of an earlier Cochrane review. One reviewer identified the trials, extracted all data, and assessed risk of bias. Meta-analysis used a random effects model, with results expressed as risk ratios (RR) or mean differences (MD) with 95% confidence intervals (CI). Bisphosphonates have uncertain effects on death (RR 0.45, CI 0.04-4.69) and vertebral fractures (RR 0.58, CI 0.24-1.43, I(2) 0%). Bisphosphonates moderately to importantly reduce the loss of vertebral bone mineral density (MD 5.98%, CI 3.77-8.18% change from baseline in g calcium/cm² at 12 months, I(2) 91%) and femoral bone mineral density (MD 5.57%, 3.12-8.01% change from baseline in g calcium/cm² at 12 months, I(2) 69%). At this stage, insufficient evidence exists to support routine use of bisphosphonates to reduce fracture risk after kidney transplantation. Data on important health outcomes are lacking, surrogate outcomes poorly reflect bone quality in kidney transplant recipients, and serious adverse events are not studied and reported systematically.
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Affiliation(s)
- Emmanuelle B Versele
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Ghent, Belgium
| | - Steven Van Laecke
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Ghent, Belgium
| | - Annemieke W Dhondt
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Ghent, Belgium
| | - Francis Verbeke
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Ghent, Belgium
| | - Raymond Vanholder
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Ghent, Belgium.,European Renal Best Practice (ERBP), guidance body of the European Renal Association - European Dialysis and Transplant Association (ERA-EDTA), Ghent, Belgium
| | - Wim Van Biesen
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Ghent, Belgium.,European Renal Best Practice (ERBP), guidance body of the European Renal Association - European Dialysis and Transplant Association (ERA-EDTA), Ghent, Belgium
| | - Evi V Nagler
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Ghent, Belgium.,European Renal Best Practice (ERBP), guidance body of the European Renal Association - European Dialysis and Transplant Association (ERA-EDTA), Ghent, Belgium
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9
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Tutal E, Uyar ME, Colak T, Bal Z, Demirci BG, Bozkurt T, Sezer S, Acar FNO. Low graft function and ongoing hyperparathyroidism are closely related to post-transplantation osteoporosis. Transplant Proc 2013; 45:1562-6. [PMID: 23726620 DOI: 10.1016/j.transproceed.2012.12.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Accepted: 12/31/2012] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Renal transplantation (RT) is the gold standard therapy for chronic renal failure. Immunosuppressive drug choice, malnutrition, adynamic bone disease and hyperparathyroidism are important factors impacting the development of posttransplant osteoporosis. Body composition analysis with bioimpedance devices (BIA) is a useful noninvasive tool to detect malnutrition among the RT population. We investigated the effects of graft function, immunosuppressive drug regimens and biochemical characteristics on bone mineral density of RT patients as well as the reliability of BIA measurements to diagnose osteoporosis. METHODS One hundred three recipients with a minimum of 12 months post-RT follow-up underwent body composition analysis using the Tanita Analyzer. The last 6 months of monthly biochemical parameters and glomerular filtration rates (GFR) as well as drug regimens were collected retrospectively from patient charts. Patients were divided into 2 groups, according to their femoral neck and lumbal T scores, as osteoporosis (n = 42) and control groups (n = 61). RESULTS The mean GFR of osteoporotic patients was significantly lower (P = .04) and parathyroid hormone (PTH) levels significantly higher (P = .002). According to BIA, osteoporotic patients showed lower bone mass, fat mass, visceral fat ratio, muscle mass, waist-hip ratios, and body mass index values (P < .05). Correlation analysis revealed GFR to negatively correlate with PTH (r = -0.231, P = .010) and positively with femur t scores (r = 0.389, P = .0001) as well as with BIA findings (P = .0001). In contrast, PTH levels in negatively correlated with lumbar and femoral neck t scores (r = -0.22, -0.4 and P = .026, .0001, respectively) but not with BIA findings including bone mass. CONCLUSION Changes in bone density after RT were affected by graft function. The rapid loss of bone mineral density emphasizes the need for prevention started in the early posttransplant period. BMD measurements provided a guide for treatment and for subsequent evaluation.
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Affiliation(s)
- E Tutal
- Department of Nephrology, Başkent University Medical School, Ankara, Turkey.
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Huang WH, Lee SY, Weng CH, Lai PC. Use of alendronate sodium (Fosamax) to ameliorate osteoporosis in renal transplant patients: a case-control study. PLoS One 2012. [PMID: 23185261 PMCID: PMC3502459 DOI: 10.1371/journal.pone.0048481] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background Renal transplant patients often have severe bone and mineral deficiencies. While the clinical effects of immunosuppressive agents like calcineurin inhibitors (CIs) and sirolimus on bone turnover are unclear, bisphosphonates are effective in bone recovery in these patients. Gender is significantly associated with osteoporosis and affects bone turnover, which is different in women and men. The effective gender-related site of action of bisphosphonates is unknown. Methods Initially, we enrolled 84 kidney recipients who had received their transplants at least 5 months ago; of these, 8 were excluded and 76 were finally included in the study. First bone mineral density (BMD) at the lumbar spine, hip, and femoral neck was determined using dual-energy X-ray absorptiometry (DXA) between September 2008 and March 2009. These 76 patients underwent a repeat procedure after a mean period 14 months. Immunosuppressive agents, bisphosphonates, patients' characteristics, and biochemical factors were analyzed on the basis of the BMD determined using DXA. Results After the 14-month period, the BMD of lumbar spine increased significantly (from 0.9 g/cm2 to 0.92 g/cm2, p<0.001), whereas that of the hip and femoral neck did not. Ordinal logistic regression analysis was used to show that Fosamax improved bone condition, as defined by WHO (p = 0.007). The use of immunosuppressive agents did not affect bone turnover (p>0.05). Moreover, in subgroup analysis, Fosamax increased the BMD at the lumbar spine and the hipbone in males (p = 0.028 and 0.03, respectively) but only at the lumbar spine in females (p = 0.022). Conclusion After a long periods after renal transplantation, the detrimental effects of steroid and immunosuppressive agents on bone condition diminished. Short-term Fosamax administration effectively improves BMD in these patients. The efficacy of Fosamax differed between male and female renal transplant patients.
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Affiliation(s)
- Wen-Hung Huang
- Department of Nephrology, Chang Gung Memorial Hospital, Linkou, Taiwan, Republic of China
- Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Shen-Yang Lee
- Department of Nephrology, Chang Gung Memorial Hospital, Linkou, Taiwan, Republic of China
- Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Cheng-Hao Weng
- Department of Nephrology, Chang Gung Memorial Hospital, Linkou, Taiwan, Republic of China
- Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
| | - Ping-Chin Lai
- Department of Nephrology, Chang Gung Memorial Hospital, Linkou, Taiwan, Republic of China
- Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China
- * E-mail:
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Coco M, Pullman J, Cohen HW, Lee S, Shapiro C, Solorzano C, Greenstein S, Glicklich D. Effect of risedronate on bone in renal transplant recipients. J Am Soc Nephrol 2012; 23:1426-37. [PMID: 22797188 DOI: 10.1681/asn.2011060623] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Bisphosphonates may prevent or treat the bone loss promoted by the immunosuppressive regimens used in renal transplantation. Risedronate is a commonly used third-generation amino-bisphosphonate, but little is known about its effects on the bone health of renal transplant recipients. We randomly assigned 42 new living-donor kidney recipients to either 35 mg of risedronate weekly or placebo for 12 months. We obtained bone biopsies at the time of renal transplant and after 12 months of protocol treatment. Treatment with risedronate did not affect bone mineral density (BMD) in the overall cohort. In subgroup analyses, it tended to preserve BMD in female participants but did not significantly affect the BMD of male participants. Risedronate did associate with increased osteoid volume and trabecular thickness in male participants, however. There was no evidence for the development of adynamic bone disease. In summary, further study is needed before the use of prophylactic bisphosphonates to attenuate bone loss can be recommended in renal transplant recipients.
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Affiliation(s)
- Maria Coco
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA.
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Abediazar S, Nakhjavani MR. Effect of alendronate on early bone loss of renal transplant recipients. Transplant Proc 2011; 43:565-7. [PMID: 21440762 DOI: 10.1016/j.transproceed.2011.01.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Renal transplant recipients (RTRs) are at risk of developing osteoporosis and osteopenia due to underlying renal osteodystrophy, hypophosphatemia, and immunosuppression. This process occurs more frequently in the first year after renal transplantation (RTX), resulting in eventual bone loss and fractures. The purpose of this study was to evaluate the effect of low-dose alendronate to prevent early bone loss after RTX. PATIENTS AND METHODS We prospectively studied 43 successful RTR including 22 men and 21-women with a mean overall age of 39.16±11.73 years, mean body mass index of 23.6±3.73, and mean dialysis duration of 25.73±17.67 months. We matched them based on age and sex: the alendronate-treated group received vitamin D (Vit D) during the study plus 30 mg alendronate weekly from 1 month after RTX. The control group only received Vit D. We measured serum calcium, phosphate, alkaline phosphatase, blood urea, creatinine, and intact parathyroid hormone (iPTH) at the pretransplant baseline and monthly thereafter as well as BMD of the lumbar spine, femur, and radius pretransplant baseline versus 3 and 6 months after RTX. RESULTS At 6 month after RTX, the lumbar BMD in the alendronate group increased significantly from 0.819±0.11 to 0.863±0.14 (P<.01), while it decreased in the control group from 0.897±0.17 to 0.817±0.16 (P<.001). There was also a significant increase in radius BMD (P<.001) and a nonsignificant increase in femoral BMD in the alendronate versus a significant decrease of femoral and radius BMD (P<.001) in the control group at 6 months. Upon multivariate analysis, there was a significant correlation between alendronate and spine BMD (r=.45, P<.001) but no linear regression between age, sex, BMI, dialysis duration of or iPTH with femoral, spine, or radius BMD changes at month 6. CONCLUSION Low-dose alendronate was significantly useful to mitigate fast bone loss and increase BMD immediately after RTX.
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Affiliation(s)
- S Abediazar
- Transplantation word, Iman Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
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Mainra R, Elder GJ. Individualized therapy to prevent bone mineral density loss after kidney and kidney-pancreas transplantation. Clin J Am Soc Nephrol 2009; 5:117-24. [PMID: 19965527 DOI: 10.2215/cjn.03770609] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Most patients who undergo kidney or kidney-pancreas transplantation have renal osteodystrophy, and immediately after transplantation bone mineral density (BMD) commonly falls. Together, these abnormalities predispose to an increased fracture incidence. Bisphosphonate or calcitriol therapy can preserve BMD after transplantation, but although bisphosphonates may be more effective, they pose potential risks for adynamic bone. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A total of 153 kidney (61%) and kidney-pancreas (39%) transplant recipients were allocated to bisphosphonate (62%) or calcitriol (38%) therapy using an algorithm that incorporated BMD, prevalent vertebral fracture, biomarkers of bone turnover, and risk factor assessment. Patients received cholecalciferol and calcium as appropriate and were followed for 12 mo. RESULTS Patients who were treated with bisphosphonates had lower BMD at the lumbar spine and femoral neck and longer time on dialysis. Age and gender were similar between the groups. At 12 mo, bisphosphonate-treated patients had significant BMD increases at the lumber spine and femoral neck and a negative trend at the wrist. Patients who were allocated to calcitriol, who were assessed to have lower baseline fracture risk, had no significant change in BMD at any site. At 1 yr, mean levels of bone turnover marker and intact parathyroid hormone normalized in both groups. Incident fracture rates did not differ significantly. CONCLUSIONS With targeted treatment, BMD levels were stable or improved and bone turnover markers normalized. This algorithm provides a guide to targeting therapy after transplantation that avoids BMD loss and may reduce suppression of bone turnover.
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Affiliation(s)
- Rahul Mainra
- Department of Renal Medicine, Westmead Hospital, Westmead, NSW 2145, Australia.
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MAINRA RAHUL, ELDER GRAHAME. Review article: Managing bone complications after kidney transplantation. Nephrology (Carlton) 2009; 14:437-42. [DOI: 10.1111/j.1440-1797.2009.01156.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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