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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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Dabbaghmanesh A, Bakhshayeshkaram M, Roshanzamir S, Naseri A, Dabbaghmanesh MM, Heydari ST, Talehzadeh P, Dabbaghmanesh MH, Jahromi SE. The effect of zoledronic acid on hip geometry in renal transplant recipients: a double-blind placebo-controlled randomized study. BMC Nephrol 2023; 24:331. [PMID: 37940839 PMCID: PMC10634030 DOI: 10.1186/s12882-023-03376-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 10/23/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND In renal transplant patients, bisphosphonates may prevent bone loss, but little is known about their effects on bone microarchitecture and geometrical hip parameters, as the key factors of bone stability. This study aimed to analyze the effect of zoledronic acid on the mentioned parameters in kidney transplant patients. METHODS In this double-blind, randomized trial, 33 patients were followed for six months after administering either 4mg of zoledronic acid or a placebo. Bone mineral density (BMD) measurement of the spine, hip, radius, and whole body was obtained, and trabecular bone score (TBS) was evaluated using the software. Geometric assessment at the proximal femur was performed by the HSA program. RESULTS Eighteen patients in the intervention group and 15 in the control group completed the study. The mean percentages of the changes in the BMD at the lumbar spine and whole body were significantly different between the placebo and intervention groups (-0.23% vs. 4.91% and -2.03% vs. 1.23%) (P < 0.05). Zoledronic acid appeared to enhance the subperiosteal diameter, endocortical diameter, and cross-sectional moment of inertia (CSMI) at the narrow neck in comparison with placebo (P < 0.05); however, no difference in TBS was observed between both groups (P > 0.05). CONCLUSIONS We concluded that a single administration of zoledronic acid might ameliorate bone loss at the lumbar spine and the whole body and maintain the subperiosteal diameter, endocortical diameter, and CSMI as parameters of bone strength at the narrow neck of the proximal femur after six months in renal-transplant recipients. TRIAL REGISTRATION This study was registered in IRCT (ID: IRCT20181202041821N1) on 04-05-2019.
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Affiliation(s)
- Alireza Dabbaghmanesh
- Endocrinology and Metabolism Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Marzieh Bakhshayeshkaram
- Endocrinology and Metabolism Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sharareh Roshanzamir
- Department of Physical Medicine and Rehabilitation, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Arzhang Naseri
- Endocrinology and Metabolism Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Seyed Taghi Heydari
- Health Policy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Pedram Talehzadeh
- Endocrinology and Metabolism Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Prognostic value of preoperative serum alkaline phosphatase for predicting 3-year mortality in patients undergoing kidney transplantation: A retrospective study. PLoS One 2022; 17:e0273662. [PMID: 36037177 PMCID: PMC9423622 DOI: 10.1371/journal.pone.0273662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 08/14/2022] [Indexed: 11/19/2022] Open
Abstract
Serum alkaline phosphatase (ALP) levels are related to high-turnover bone disease and reflect vascular calcification and inflammation. ALP has been reported to have a prognostic impact in various cohorts including chronic kidney disease. This study investigated whether preoperative serum ALP level could be used for predicting mortality in patients undergoing kidney transplantation. We retrospectively reviewed 1,718 patients who underwent kidney transplantation between November 2005 and June 2017. Finally, 1,533 patients who met the inclusion criteria were classified into tertiles based on preoperative serum ALP level (< 51, 51–72, > 72 IU/L). The incidence of mortality was compared among the three tertiles, and a stepwise logistic regression analysis was performed to evaluate the predictors for mortality. The incidence of 3-year mortality was the highest in the third tertile (1.0% vs. 2.5% vs. 4.4% in the first, second, and third tertile, respectively, p = 0.003). The third tertile of ALP level (odds ratio [OR] 1.855, 95% CI 1.192–2.886, p = 0.006), age (OR 1.052, 95% CI 1.022–1.082, p = 0.011), and history of hypertension (OR 0.401, 95% CI 0.210–0.765, p = 0.006) remained as independent predictors of mortality. Preoperative serum ALP level was significantly higher in the non-survivor group than in the survivor group (58.00 [44.00–76.00] vs. 75.00 [56.25–113.00], p = 0.003). The optimal cut-off value of serum ALP to predict 3-year mortality was 71 IU/L (area under the curve 0.636, 95% CI 0.554–0.719, p = 0.003). Therefore, preoperative serum ALP level was an independent predictor of 3-year mortality in patients undergoing kidney transplantation.
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The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Secondary and Tertiary Renal Hyperparathyroidism. Ann Surg 2022; 276:e141-e176. [PMID: 35848728 DOI: 10.1097/sla.0000000000005522] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To develop evidence-based recommendations for safe, effective, and appropriate treatment of secondary (SHPT) and tertiary (THPT) renal hyperparathyroidism. BACKGROUND Hyperparathyroidism is common among patients with chronic kidney disease, end-stage kidney disease, and kidney transplant. The surgical management of SHPT and THPT is nuanced and requires a multidisciplinary approach. There are currently no clinical practice guidelines that address the surgical treatment of SHPT and THPT. METHODS Medical literature was reviewed from January 1, 1985 to present January 1, 2021 by a panel of 10 experts in SHPT and THPT. Recommendations using the best available evidence was constructed. The American College of Physicians grading system was used to determine levels of evidence. Recommendations were discussed to consensus. The American Association of Endocrine Surgeons membership reviewed and commented on preliminary drafts of the content. RESULTS These clinical guidelines present the epidemiology and pathophysiology of SHPT and THPT and provide recommendations for work-up and management of SHPT and THPT for all involved clinicians. It outlines the preoperative, intraoperative, and postoperative management of SHPT and THPT, as well as related definitions, operative techniques, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Preoperative and Perioperative Care, Surgical Planning and Parathyroidectomy, Adjuncts and Approaches, Outcomes, and Reoperation. CONCLUSIONS Evidence-based guidelines were created to assist clinicians in the optimal management of secondary and tertiary renal hyperparathyroidism.
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Kusumi K, Shaikhkhalil A, Patel HP, Mahan JD. Promoting bone health in children and adolescents following solid organ transplantation. Pediatr Transplant 2021; 25:e13940. [PMID: 33341105 DOI: 10.1111/petr.13940] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 09/02/2020] [Accepted: 09/03/2020] [Indexed: 02/06/2023]
Abstract
Solid organ transplantation in children and adolescents provides many benefits through improving critical organ function, including better growth, development, cardiovascular status, and quality of life. Unfortunately, bone status may be adversely affected even when overall status is improving, due to issues with pre-existing bone disease as well as medications and nutritional challenges inherent post-transplantation. For all children and adolescents, bone status entering adulthood is a critical determinant of bone health through adulthood. The overall health and bone status of transplant recipients benefits from attention to regular physical activity, good nutrition, adequate calcium, phosphorous, magnesium and vitamin D intake and avoidance/minimization of soda, extra sodium, and obesity. Many immunosuppressive agents, especially glucocorticoids, can adversely affect bone function and development. Minimizing exposure to "bone-toxic" medications is an important part of promoting bone health in children post-transplantation. Existing guidelines detail how regular monitoring of bone status and biochemical markers can help detect bone abnormalities early and facilitate valuable bone-directed interventions. Attention to calcium and vitamin D supplementation, as well as tapering and withdrawing glucocorticoids as early as possible after transplant, can provide best bone outcomes for these children. Dual-energy X-ray absorptiometry can be useful to detect abnormal bone mass and fracture risk in this population and newer bone assessment methods are being evaluated in children at risk for poor bone outcomes. Newer bone therapies being explored in adults with transplants, particularly bisphosphonates and the RANKL inhibitor denosumab, may offer promise for children with low bone mass post-transplantation.
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Affiliation(s)
| | - Ala Shaikhkhalil
- Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Hiren P Patel
- Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - John D Mahan
- Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
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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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Salter ML, Liu X, Bae S, Chu NM, Miller Dunham A, Humbyrd C, Segev DL, McAdams-DeMarco MA. Fractures and Subsequent Graft Loss and Mortality among Older Kidney Transplant Recipients. J Am Geriatr Soc 2019; 67:1680-1688. [PMID: 31059126 PMCID: PMC6684377 DOI: 10.1111/jgs.15962] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 03/26/2019] [Accepted: 04/03/2019] [Indexed: 12/28/2022]
Abstract
OBJECTIVES Older adults who undergo kidney transplantation (KT) are living longer with a functioning graft and are at risk for age-related adverse events including fractures. Understanding recipient, transplant, and donor factors and the outcomes associated with fractures may help identify older KT recipients at increased risk. We determined incidence of hip, vertebral, and extremity fractures; assessed factors associated with incident fractures; and estimated associations between fractures and subsequent death-censored graft loss (DCGL) and mortality. DESIGN This was a prospective cohort study of patients who underwent their first KT between January 1, 1999, and December 31, 2014. SETTING We linked data from the Scientific Registry of Transplant Recipients to Medicare claims through the US Renal Data System. PARTICIPANTS The analytic population included 47 815 KT recipients aged 55 years or older. MEASUREMENTS We assessed the cumulative incidence of and factors associated with post-KT fractures (hip, vertebral, or extremity) using competing risks models. We estimated risk of DCGL and mortality after fracture using adjusted Cox proportional hazards models. RESULTS The 5-year incidence of post-KT hip, vertebral, and extremity fracture for those aged 65 to 69 years was 2.2%, 1.0%, and 1.7%, respectively. Increasing age was associated with higher hip (adjusted hazard ratio [aHR] = 1.37 per 5-y increase; 95% confidence interval [CI] = 1.30-1.45) and vertebral (aHR = 1.31; 95% CI = 1.20-1.42) but not extremity (aHR = .97; 95% CI = .91-1.04) fracture risk. DCGL risk was higher after hip (aHR = 1.34; 95% CI = 1.12-1.60) and extremity (aHR = 1.30; 95% CI = 1.08-1.57) fracture. Mortality risk was higher after hip (aHR = 2.31; 95% CI = 2.11-2.52), vertebral (aHR = 2.80; 95% CI = 2.44-3.21), and extremity (aHR = 1.85; 95% CI = 1.64-2.10) fracture. CONCLUSION Our findings suggest that older KT recipients are at higher risk for hip and vertebral fracture but not extremity fracture; and those with hip, vertebral, or extremity fracture are more likely to experience subsequent graft loss or mortality. These findings underscore that different fracture types may have different underlying etiologies and risks, and they should be approached accordingly. J Am Geriatr Soc 67:1680-1688, 2019.
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Affiliation(s)
- Megan L Salter
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Xinran Liu
- Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore, Maryland
| | - Sunjae Bae
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore, Maryland
| | - Nadia M Chu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore, Maryland
| | - Alexandra Miller Dunham
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Casey Humbyrd
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore, Maryland
| | - Mara A McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore, Maryland
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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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Hsu BG, Chen YC, Ho GJ, Shih MH, Chou KC, Lin TY, Lee MC. Inverse Association Between Serum Osteoprotegerin and Bone Mineral Density in Renal Transplant Recipients. Transplant Proc 2016; 48:864-9. [PMID: 27234754 DOI: 10.1016/j.transproceed.2015.12.069] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 12/07/2015] [Indexed: 01/06/2023]
Abstract
BACKGROUND Osteoprotegerin (OPG) has pleiotropic effects on bone metabolism as well as endocrine function. Our aim was to evaluate the relationship between bone mineral density (BMD) and serum OPG concentration in renal transplant recipients. METHODS Fasting blood samples were obtained from 69 renal transplant recipients. BMD was measured in lumbar vertebrae (L2-L4) by dual-energy X-ray absorptiometry. Eight patients (11.6%) had BMD values indicative of osteoporosis, 28 patients (40.6%) had BMD values indicative of osteopenia, and 33 patients had normal BMD values. Increased serum OPG levels (P < .001), decreased body mass index (BMI) (P = .033), and decreased body weight (P = .010) were significantly correlated with low lumbar T-score cut-off points between groups (normal, osteopenia, and osteoporosis). RESULTS Women had significantly lower lumbar BMD values than men (P = .013). Menopause (P = .005), use of tacrolimus (P = .020), and use of cyclosporine (P = .046) were associated with lower lumbar BMD in renal transplant recipients. Univariate linear regression analysis revealed that lumbar BMD was positively correlated with height (P = .016), body weight (P = .001), and BMI (P = .015) and negatively correlated with age (P = .039) and log-OPG (P = .001). Multivariate linear regression analysis revealed that log-OPG (β: -0.275, R(2) change = 0.154, P = .014), body weight (β: 0.334, R(2) change = 0.073, P = .004), and age (β: -0.285, R(2) change = 0.079, P = .008) were independent predictors of lumbar BMD values in renal transplant recipients. CONCLUSIONS Serum OPG concentration correlated negatively with lumbar BMD values in renal transplant recipients.
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Affiliation(s)
- B-G Hsu
- Division of Nephrology, Buddhist Tzu Chi General Hospital, Hualien, Taiwan; School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Y-C Chen
- Department of Surgery, Buddhist Tzu Chi General Hospital, Hualien, Taiwan; School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - G-J Ho
- Department of Surgery, Buddhist Tzu Chi General Hospital, Hualien, Taiwan; School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - M-H Shih
- Department of Nursing, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
| | - K-C Chou
- Department of Nursing, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
| | - T-Y Lin
- Department of Laboratory Medicine, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
| | - M-C Lee
- Department of Surgery, Buddhist Tzu Chi General Hospital, Hualien, Taiwan; School of Medicine, Tzu Chi University, Hualien, Taiwan.
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10
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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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11
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Gioviale MC, Damiano G, Lombardo C, Maione C, Buscemi G, Lo Monte AI. Bone resorption in kidney transplant recipients. Transplant Proc 2015; 41:1170-4. [PMID: 19460508 DOI: 10.1016/j.transproceed.2009.03.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Early diagnosis of persistent hyperparathyroidism (HP) following kidney transplantation may prevent worsening of osteodystrophy and potential damage to the graft. We evaluated the utility of collagen pyridinoline (PYD) and deoxypyridinoline (DPD) urinary cross-links beyond the common HP markers to evaluate 70 selected stable recipients between 1997 and 2006 who were divided into 2 group depending on the immunosuppressive protocol. All patients showed elevated levels of urinary cross-links even though calcemia and phosphoremia values were normal. Their mean creatinine level was slightly increased. Data were assessed as mean values +/- SD. All variables underwent a correlation matrix analysis and a stepwise regression, with posttransplant intact parathyroid hormone (iPTH) as the dependent variable and other variables as regressors. A statistically significant correlation was observed between PYD and alkaline phosphatase (ALP; P = .0026, r = .41); PYD and DPD (P = .015, r = .34); pre- and posttransplant iPTH (P = .024, r = .31); and creatinine and ALP (P = .024, r = .31). Taking the groups separately, there were significant correlations between PYD and ALP (P = .0076, r = .42); PYD and DPD (P = .017, r = .38); ALP and posttransplant iPTH (P = .038, r = .33); osteocalcin (OC) and posttransplant iPTH (P = .048, r = .32); and pre- and posttransplant iPTH (P = .019, r = .37) among subjects in the first group, whereas subjects in the second group showed a correlation between posttransplant iPTH and age at transplantation (P = .032, r = .61). In conclusion, we showed that urinary cross-links may be helpful to reveal bone resorption in kidney recipients when usual bone metabolism parameters do not demonstrate hyperparathyroidism.
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Affiliation(s)
- M C Gioviale
- Department of General Surgery, Urgency, and Organ Transplantation, University of Palermo, School of Medicine, Palermo, Italy
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12
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Kazama JJ, Matsuo K, Iwasaki Y, Fukagawa M. Chronic kidney disease and bone metabolism. J Bone Miner Metab 2015; 33:245-52. [PMID: 25653092 DOI: 10.1007/s00774-014-0639-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Accepted: 10/07/2014] [Indexed: 12/14/2022]
Abstract
Chronic kidney disease-related mineral and bone disease (CKD-MBD) is a syndrome defined as a systemic mineral metabolic disorder associated with CKD, and the term renal osteodystrophy indicates a pathomorphological concept of bone lesions associated with CKD-MBD. Cortical bone thinning, abnormalities in bone turnover and primary/secondary mineralization, elevated levels of circulating sclerostin, increased apoptosis in osteoblasts and osteocytes, disturbance of the coupling phenomenon, iatrogenic factors, accumulated micro-crackles, crystal/collagen disorientation, and chemical modification of collagen crosslinks are all possible candidates found in CKD that could promote osteopenia and/or bone fragility. Some of above factors are the consequences of abnormal systemic mineral metabolism but for others it seem unlikely. We have used the term uremic osteoporosis to describe the uremia-induced bone fragility which is not derived from abnormal systemic mineral metabolism. Interestingly, the disease aspect of uremic osteoporosis appears to be similar to that of senile osteoporosis.
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Affiliation(s)
- Junichiro James Kazama
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan,
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13
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Torregrosa JV, Morales E, Díaz JM, Crespo J, Bravo J, Gómez G, Gentil MÁ, Rodríguez Benot A, García MR, Jiménez VL, Gutiérrez Dalmau A, Jimeno L, Sáez MJP, Romero R, Gómez Alamillo C. Cinacalcet for hypercalcaemic secondary hyperparathyroidism after renal transplantation: a multicentre, retrospective, 3-year study. Nephrology (Carlton) 2014; 19:84-93. [PMID: 24428216 DOI: 10.1111/nep.12186] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2013] [Indexed: 01/05/2023]
Abstract
AIMS Our aim was to evaluate the long-term effect of cinacalcet in patients with hypercalcaemic secondary hyperparathyroidism (SHPT) after renal transplantation (RT) in order to expand real-world data in this population. METHODS We performed a multicentre, observational, retrospective study in 17 renal transplant units from Spain. We collected data from renal recipients with hypercalcaemic (calcium >10.2 mg/dL) SHPT (intact parathyroid hormone (iPTH) > 120 pg/mL) who initiated cinacalcet in the clinical practice. RESULTS We included 193 patients with a mean (standard deviation (SD)) age of 52 (12) years, 58% men. Cinacalcet treatment was initiated at a median of 20 months after RT (median dose 30 mg/day). Mean calcium levels decreased from a mean (SD) of 11.1 (0.6) at baseline to 10.1 (0.8) at 6 months (9.0% reduction, P < 0.0001). Median iPTH was reduced by 23.0% at 6 months (P = 0.0005) and mean phosphorus levels increased by 11.1% (P < 0.0001). The effects were maintained up to 3-years. No changes were observed in renal function or anticalcineurin drug levels. Only 4.1% of patients discontinued cinacalcet due to intolerance and 1.0% due to lack of efficacy. CONCLUSIONS In renal transplant patients with hypercalcaemic SHPT, cinacalcet controlled serum calcium, iPTH and phosphorus levels up to 3 years. Tolerability was good.
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Affiliation(s)
- Jose-Vicente Torregrosa
- Nephrology Service and Renal Transplant Unit, Hospital Clínic de Barcelona, Barcelona, Spain
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Deregulation of bone forming cells in bone diseases and anabolic effects of strontium-containing agents and biomaterials. BIOMED RESEARCH INTERNATIONAL 2014; 2014:814057. [PMID: 24800251 PMCID: PMC3988913 DOI: 10.1155/2014/814057] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Revised: 02/20/2014] [Accepted: 03/03/2014] [Indexed: 11/30/2022]
Abstract
Age-related bone loss and osteoporosis are associated with bone remodeling changes that are featured with decreased trabecular and periosteal bone formation relative to bone resorption. Current anticatabolic therapies focusing on the inhibition of bone resorption may not be sufficient in the prevention or reversal of age-related bone deterioration and there is a big need in promoting osteoblastogenesis and bone formation. Enhanced understanding of the network formed by key signaling pathways and molecules regulating bone forming cells in health and diseases has therefore become highly significant. The successful development of agonist/antagonist of the PTH and Wnt signaling pathways are profits of the understanding of these key pathways. As the core component of an approved antiosteoporosis agent, strontium takes its effect on osteoblasts at multilevel through multiple pathways, representing a good example in revealing and exploring anabolic mechanisms. The recognition of strontium effects on bone has led to its expected application in a variety of biomaterial scaffolds used in tissue engineering strategies aiming at bone repairing and regeneration. While summarizing the recent progress in these respects, this review also proposes the new approaches such as systems biology in order to reveal new insights in the pathology of osteoporosis as well as possible discovery of new therapies.
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Abstract
BACKGROUND Fractures in men and women after kidney transplantation are associated with morbidity (including acute and chronic pain), mortality, and high economic costs. METHODS We systematically reviewed cohort studies that provided estimates on incidence and risk factors for fracture in kidney transplant recipients. We abstracted data in duplicate and assessed the methodological quality of each study on a 17-point scale (17 representing the highest quality). RESULTS We screened 2715 articles, reviewed 81, and included 10 studies totaling 262,678 recipients (study mean, 26,268 recipients; range, 61-77,430). The average follow-up ranged from 1.7 to 5.3 years. The study quality scores ranged from 8 to 13. Fracture sites varied by study resulting in a highly variable incidence rate ranging from 3.3 to 99.6 fractures per 1000 person-years. Similarly, the 5-year cumulative incidence for fracture varied ranging from 0.85% to 27%. Common factors associated with an increased fracture risk were older age, female sex, the presence of diabetes, and receipt of dialysis before transplantation. Other less common but statistically significant risk factors were a previous history of fracture and receipt of a kidney from a deceased (vs. living) donor. CONCLUSIONS There is poor consensus on the incidence and risk factors for fractures in kidney transplant recipients. Previous studies vary substantially in quality, fracture definitions, and the characteristics of recipients studied. Future research should clarify fracture incidence and risk, which will inform the design of future prevention trials and guide prognostication.
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16
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Magnetic bead-based proteomic technology to study paricalcitol effect in kidney transplant recipients. Eur J Pharmacol 2013; 709:72-9. [DOI: 10.1016/j.ejphar.2013.03.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Revised: 03/19/2013] [Accepted: 03/24/2013] [Indexed: 12/15/2022]
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Abstract
BACKGROUND Immunosuppressive regimen is associated with several metabolic adverse effects. Bone loss and fractures are frequent after transplantation and involve multifactorial mechanisms. METHODS A retrospective analysis of 130 patients submitted to simultaneous pancreas-kidney transplantation (SPKT) and an identification of risk factors involved in de novo Charcot neuroarthropathy by multivariate analysis were used; P<0.05 was considered significant. RESULTS Charcot neuroarthropathy was diagnosed in 4.6% of SPKT recipients during the first year. Cumulative glucocorticoid doses (daily dose plus methylprednisolone pulse) during the first 6 months both adjusted to body weight (>78 mg/kg) and not adjusted to body weight were associated with Charcot neuroarthropathy (P=0.001 and P<0.0001, respectively). Age, gender, race, time on dialysis, time of diabetes history, and posttransplantation hyperparathyroidism were not related to Charcot neuroarthropathy after SPKT. CONCLUSIONS Glucocorticoids are the main risk factors for de novo Charcot neuroarthropathy after SPKT. Protocols including glucocorticoid avoidance or minimization should be considered.
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18
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Saidak Z, Marie PJ. Strontium signaling: Molecular mechanisms and therapeutic implications in osteoporosis. Pharmacol Ther 2012; 136:216-26. [DOI: 10.1016/j.pharmthera.2012.07.009] [Citation(s) in RCA: 202] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2012] [Accepted: 07/06/2012] [Indexed: 12/15/2022]
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Alshayeb HM, Josephson MA, Sprague SM. CKD-mineral and bone disorder management in kidney transplant recipients. Am J Kidney Dis 2012; 61:310-25. [PMID: 23102732 DOI: 10.1053/j.ajkd.2012.07.022] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 07/09/2012] [Indexed: 12/11/2022]
Abstract
Kidney transplantation, the most effective treatment for the metabolic abnormalities of chronic kidney disease (CKD), only partially corrects CKD-mineral and bone disorders. Posttransplantation bone disease, one of the major complications of kidney transplantation, is characterized by accelerated loss of bone mineral density and increased risk of fractures and osteonecrosis. The pathogenesis of posttransplantation bone disease is multifactorial and includes the persistent manifestations of pretransplantation CKD-mineral and bone disorder, peritransplantation changes in the fibroblast growth factor 23-parathyroid hormone-vitamin D axis, metabolic perturbations such as persistent hypophosphatemia and hypercalcemia, and the effects of immunosuppressive therapies. Posttransplantation fractures occur more commonly at peripheral than central sites. Although there is significant loss of bone density after transplantation, the evidence linking posttransplantation bone loss and subsequent fracture risk is circumstantial. Presently, there are no prospective clinical trials that define the optimal therapy for posttransplantation bone disease. Combined pharmacologic therapy that targets multiple components of the disordered pathways has been used. Although bisphosphonate or calcitriol therapy can preserve bone mineral density after transplantation, there is no evidence that these agents decrease fracture risk. Moreover, bisphosphonates pose potential risks for adynamic bone disease.
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Affiliation(s)
- Hala M Alshayeb
- Department of Medicine, Section of Nephrology, University of Chicago, Chicago, IL, USA
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20
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Chauhan V, Ranganna KM, Chauhan N, Vaid M, Kelepouris E. Bone disease in organ transplant patients: pathogenesis and management. Postgrad Med 2012; 124:80-90. [PMID: 22691902 DOI: 10.3810/pgm.2012.05.2551] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Bone disease is common in recipients of kidney, heart, lung, liver, and bone marrow transplants, and causes debilitating complications, such as osteoporosis, osteonecrosis, bone pain, and fractures. The frequency of fractures ranges from 6% to 45% for kidney transplant recipients to 22% to 42% for heart, lung, and liver transplant recipients. Bone disease in transplant patients is the sum of complex mechanisms that involve both preexisting bone disease before transplant and post-transplant bone loss due to the effects of immunosuppressive medications. Evaluation of bone disease should preferably start before the transplant or in the early post-transplant period and include assessment of bone mineral density and other metabolic factors that influence bone health. This requires close coordination between the primary care physician and transplant team. Patients should be stratified based on their fracture risk. Prevention and treatment include risk factor reduction, antiresorptive medications, such as bisphosphonates and calcitonin, calcitriol, and/or gonadal hormone replacement. A steroid-avoidance protocol may be considered.
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Affiliation(s)
- Veeraish Chauhan
- Division of Nephrology, Department of Medicine, Drexel University College of Medicine and Hahnemann University Hospital, Philadelphia, PA 19102, USA.
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Hsu BG, Ho GJ, Lee CJ, Yang YC, Chen YC, Shih MH, Lee MC. Inverse association of serum long-acting natriuretic peptide and bone mineral density in renal transplant recipients. Clin Transplant 2011; 26:E105-10. [DOI: 10.1111/j.1399-0012.2011.01575.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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22
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van der Mei SF, Kuiper D, Groothoff JW, van den Heuvel WJA, van Son WJ, Brouwer S. Long-term health and work outcomes of renal transplantation and patterns of work status during the end-stage renal disease trajectory. JOURNAL OF OCCUPATIONAL REHABILITATION 2011; 21:325-334. [PMID: 21656250 PMCID: PMC3173627 DOI: 10.1007/s10926-011-9317-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
INTRODUCTION The aim of this study was to examine the health- and work outcomes of renal transplant recipients long-term after transplantation as well as the pattern of work status, work ability and disability benefits during the end-stage renal disease (ESRD) trajectory that precedes transplantation. METHODS 34 transplant recipients completed interviews 3, 13 months and >6 years posttransplantation. Health status (SF-36), work ability (WAI), and fatigue (CIS) were assessed by questionnaires, clinical data were derived from medical charts, and data on functional limitations were extracted from the social security system database. The work status trajectory preceding transplantation was examined retrospectively. RESULTS Of the 34 third wave transplant recipients, 29% were severely fatigued. Compared with the general working population, recipients experienced worse general health and less vitality. Non-working recipients had worse renal function and general health, and more limitations in physical functioning compared to working recipients. The WAI score indicated moderate work ability for 60% of the employed recipients. Although 67% were employed (45% parttime), 30% of those working still received some disability benefits. Social insurance physicians found variable levels of functional limitations. The mean work status trajectory showed more sickness absence and less work ability during dialysis, but after transplantation, both work status and work ability generally improved. CONCLUSIONS Transplant recipients have a compromised health status which leads to functional limitations and disability. Although work status improved after transplantation, a substantial number of the transplant recipients received disability benefits. The negative health consequences of anti-rejection medications may play an important role in long-term work ability. These results indicate that a 'new' kidney has advantages over dialysis with respect to work, but does not necessarily leads to 'normal' work outcomes.
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Affiliation(s)
- Sijrike F van der Mei
- Department of Health Sciences, University Medical Center Groningen, University of Groningen, P.O. Box 196, 9700 AD Groningen, The Netherlands.
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Association of mismatches for HLA-DR with incidence of posttransplant hip fracture in kidney transplant recipients. Transplantation 2011; 91:65-9. [PMID: 21452411 DOI: 10.1097/tp.0b013e3181fa94d6] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Bone fractures are a frequent complication after kidney transplantation, for which various predisposing factors have been identified. It has been suggested that human leukocyte antigen (HLA) mismatch increases the risk. METHODS Data on hip fractures occurring in the first 5 years posttransplant were analyzed among kidney transplants from deceased donors performed between 1995 and 2008 and reported to the Collaborative Transplant Study. RESULTS In the 20,509 patients analyzed, the cumulative rate of hip fracture by year 5 posttransplant was 0.85%. Cox regression analysis identified the following risk factors: female recipients aged 40 to 59 years (hazard ratio [HR] 2.26, P=0.029), female recipients 60 years or older (HR 5.14, P<0.001), male recipients 60 years or older (HR 2.39, P=0.028), and donor age more than or equal to 60 years (HR 1.75, P=0.009). Using the rate of fractures in recipients with zero HLA-DR mismatch as the reference, the risk of hip fracture increased for grafts with one HLA-DR mismatch to HR 1.85 (95% confidence interval [CI] 1.18-2.89, P=0.007) and with two HLA-DR mismatches to HR 2.24 (CI 1.25-4.02, P=0.007). There was a significant association between the number of HLA-DR mismatches and the diagnosis of osteoporosis 5 years after transplantation: one HLA-DR mismatch risk ratio 1.26 (CI 1.12-1.43, P<0.001) and two HLA-DR mismatches risk ratio 1.45 (CI 1.20-1.74, P<0.001). CONCLUSION The risk of hip fracture after kidney transplantation seems to be markedly exacerbated by HLA-DR mismatching. These findings add to the growing base of evidence that HLA-DR matching influences morbidity after kidney transplantation.
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Sakhaee K. Osteoporosis following organ transplantation: pathogenesis, diagnosis and management. Expert Rev Endocrinol Metab 2011; 6:157-176. [PMID: 30290452 DOI: 10.1586/eem.10.86] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Organ transplantation has become popular for the management of various chronic illnesses. With the advent of modern immunosuppressive treatments, the longevity of transplant recipients has increased. Consequently, morbid complications such as osteoporosis and bone fractures are seen at an increasing frequency in this population. In most transplant recipients, bone mineral density (BMD) falls shortly after transplantation. However, bone fracture rate plateaus in all except for post-renal transplant patients. Although the underlying pathophysiologic mechanism for this difference is not fully understood, potential mechanisms for sustained bone loss in renal transplant recipients may be persistent phosphorus wasting and defective bone mineralization. Current treatment regimens are based on studies in a small numbers of subjects with BMD as the primary outcome. Although BMD is recognized as a gold standard in the assessment of bone fracture risk, to date, its association with bone fracture risk in the general post-transplant population is not robust. Therefore, randomized controlled trials with bone fracture as the primary end point are crucial. The development of noninvasive bone markers in distinguishing bone turnover and bone mineralization status is also pivotal since skeletal lesions are heterogeneous in various organ transplantations. The elucidation of these underlying skeletal lesions is necessary for the consideration of selective treatment in this population.
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Affiliation(s)
- Khashayar Sakhaee
- a UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8885, USA.
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Edwards BJ, Desai A, Tsai J, Du H, Edwards GR, Bunta AD, Hahr A, Abecassis M, Sprague S. Elevated incidence of fractures in solid-organ transplant recipients on glucocorticoid-sparing immunosuppressive regimens. J Osteoporos 2011; 2011:591793. [PMID: 21922049 PMCID: PMC3172972 DOI: 10.4061/2011/591793] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2011] [Revised: 05/26/2011] [Accepted: 06/14/2011] [Indexed: 11/20/2022] Open
Abstract
This study was conducted to assess the occurrence of fractures in solid-organ transplant recipients. Methods. Medical record review and surveys were performed. Patients received less than 6 months of glucocorticoids. Results. Of 351 transplant patients, 175 patients provided fracture information, with 48 (27.4%) having fractured since transplant (2-6 years). Transplants included 19 kidney/liver (50% male), 47 kidney/pancreas (53% male), 92 liver (65% male), and 17 pancreas transplants (41% male). Age at transplant was 50.8 ± 10.3 years. Fractures were equally seen across both genders and transplant types. Calcium supplementation (n = 94) and bisphosphonate therapy (n = 52) were observed, and an association with a lower risk of fractures was noted for bisphosphonate users (OR = 0.45 95% C.I. 0.24, 0.85). Fracture location included 8 (16.7%) foot, 12 (25.0%) vertebral, 3 (6.3%) hand, 2 (4.2%) humerus, 5 (10.4%) wrist, 10 (20.8%) fractures at other sites, and 7 (14.6%) multiple fractures. The estimated relative risk of fracture was nearly seventeen-times higher in male liver transplant recipients ages 45-64 years compared with the general male population, and comparable to fracture rates on conventional immunosuppressant regimens. Conclusion. We identify a high frequency of fractures in transplant recipients despite limited glucocorticoid use.
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Affiliation(s)
- B. J. Edwards
- Bone Health and Osteoporosis Center, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA,*B. J. Edwards:
| | - A. Desai
- NorthShore University HealthSystem, Evanston, IL 60201, USA
| | - J. Tsai
- Bone Health and Osteoporosis Center, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - H. Du
- NorthShore University HealthSystem, Evanston, IL 60201, USA
| | - G. R. Edwards
- Bone Health and Osteoporosis Center, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - A. D. Bunta
- Bone Health and Osteoporosis Center, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - A. Hahr
- Bone Health and Osteoporosis Center, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - M. Abecassis
- Kovler Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - S. Sprague
- NorthShore University HealthSystem, Evanston, IL 60201, USA
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Morales E, Gutierrez E, Andres A. Treatment with calcimimetics in kidney transplantation. Transplant Rev (Orlando) 2010; 24:79-88. [DOI: 10.1016/j.trre.2010.01.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2009] [Accepted: 01/18/2010] [Indexed: 11/26/2022]
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Abstract
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.
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Affiliation(s)
- Peter R Ebeling
- Department of Medicine (Royal Melbourne Hospital/Western Hospital) and Endocrinology, The University of Melbourne, Western Hospital, Gordon Street, Footscray 3011, Victoria, Australia.
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Evaluation and management of bone disease and fractures post transplant. Transplant Rev (Orlando) 2008; 22:52-61. [PMID: 18631858 DOI: 10.1016/j.trre.2007.09.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Bone disease is common in recipients of kidney, liver, heart, and lung transplants and results in fractures in 20-40% of patients, a rate much higher than expected for age. Fractures occur because of the presence of bone disease as well as other factors such as neuropathy, poor balance, inactivity, and low body or muscle mass. Major contributors to bone disease include both preexisting bone disease and bone loss post transplant, which is greatest in the first 6-12 months when steroid doses are highest. Bone disease in kidney transplant recipients should be considered different from that which occurs in other solid organ transplant recipients for several reasons including the presence of renal osteodystrophy, which contributes to low bone mineral density in these patients; the location of fractures (more common in the legs and feet in these patients than in spine and hips as in other solid organ recipients); and the potential danger in using bisphosphonate therapy, which may cause more harm than good in kidney transplant recipients with low bone turnover. Evaluation in all patients should preferably occur in the pretransplant period or early post transplant and should include assessment of fracture risk as well as metabolic factors that can contribute to bone disease. Bone mineral density measurement is recommended in all patients even if its predictive value for fracture risk in the transplant population is unproven. Management of bone disease should be directed toward decreasing fracture risk as well as improving bone density. Pharmacologic and nonpharmacologic treatment strategies are discussed in this review. Although there have been many studies describing a beneficial effect of bisphosphonates and vitamin D analogues on bone density, none have been powered to detect a decrease in fracture rate.
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Kamar N, Gennero I, Spataru L, Esposito L, Guitard J, Lavayssière L, Cointault O, Gandia P, Durand D, Rostaing L. Pharmacodynamic effects of cinacalcet after kidney transplantation: once- versus twice-daily dose. Nephrol Dial Transplant 2008; 23:3720-6. [PMID: 18558623 DOI: 10.1093/ndt/gfn345] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND In the setting of kidney transplantation, cinacalcet has been given, mainly, once daily, but also twice daily. The aims of this prospective study were to assess the acute pharmacodynamic effect of cinacalcet administrated once or twice daily to kidney transplant patients with normal renal function and persisting hypercalcaemia due to hyperparathyroidism and to evaluate 1-year efficacy and tolerance of cinacalcet given at a dose of 30 mg b.i.d. METHODS Eleven patients, who received a transplant 6 (6-59) months previously, were included in the study. A first kinetic was done after administration of 60 mg of cinacalcet at 8 a.m. After a washout period of 1 week, the second kinetic was performed with cinacalcet given at 30 mg b.i.d within a 12-h period. RESULTS During both kinetics, serum calcium (sCa), ionized calcium (sCa(2+)), albumin-corrected Ca and parathyroid hormone (PTH) levels decreased significantly. At 24 h after the second kinetic, sCa(2+) was significantly lower. After 1 year of cinacalcet treatment, given at the dose of 30 mg b.i.d., there was a significant decrease in sCa, sCa(2+), PTH levels and calcium x phosphorus (Ph) product. In contrast, Ph levels increased significantly. There was no significant change in renal function. CONCLUSION Once- or twice-daily acute administration of cinacalcet to kidney-transplant patients has similar efficacy. One-year administration of cinacalcet, given as two daily doses, is safe and efficient.
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Affiliation(s)
- Nassim Kamar
- Department of Nephrology, Dialysis and Multi-Organ Transplantation, Toulouse University Hospital, Toulouse, France.
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Josephson MA. Vitamin D deficiency in African American kidney transplant recipients: bringing a common problem to light. Transplantation 2008; 85:670-2. [PMID: 18337657 DOI: 10.1097/tp.0b013e3181614055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Michelle A Josephson
- Department of Medicine, Section of Nephrology, University of Chicago, Chicago, Illinois 60637, USA.
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Hamdy NAT. Calcium and bone metabolism pre- and post-kidney transplantation. Endocrinol Metab Clin North Am 2007; 36:923-35; viii. [PMID: 17983929 DOI: 10.1016/j.ecl.2007.07.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Chronic kidney disease (CKD) is associated with significant disturbances in bone and mineral metabolism, the manifestations of which are heterogeneous in their expression and clinical impact. Over the last 2 decades, advances in the management of CKD and improved outcomes of kidney transplantation have led to the emergence of post-transplantation bone disease as a serious cause of morbidity in long-term survivors. The management of post-kidney transplantation bone disease represents a difficult challenge because of its complex pathophysiology and the paucity of clinical data on effective therapies. The optimal management of disturbances of bone and mineral metabolism before kidney transplantation forms the cornerstone of their successful management after transplantation. Therapeutic strategies to effectively and safely decrease skeletal morbidity after kidney transplantation are not yet clearly established.
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Affiliation(s)
- Neveen A T Hamdy
- Department of Endocrinology and Metabolic Diseases, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands.
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Related disorders of bone. Clin Rev Bone Miner Metab 2007. [DOI: 10.1007/bf02736670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Palmer SC, McGregor DO, Strippoli GF. Interventions for preventing bone disease in kidney transplant recipients. Cochrane Database Syst Rev 2007:CD005015. [PMID: 17636784 DOI: 10.1002/14651858.cd005015.pub3] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Patients with chronic kidney disease have significant abnormalities of bone remodeling and mineral homeostasis and are at increased risk of fracture. The fracture risk for a kidney transplant recipient is four times that of the general population and higher than for a patient on dialysis. Randomised controlled trials (RCTs) report the use of bisphosphonates, vitamin D sterols, calcitonin, and hormone replacement therapy to treat bone disease following transplantation. OBJECTIVES To evaluate the use of interventions for treating bone disease following kidney transplantation. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL in The Cochrane Library), Cochrane Renal Group's specialised register, MEDLINE, EMBASE, reference lists, and conference proceedings abstracts without language restriction. Date of last search: May 2006 SELECTION CRITERIA RCTs and quasi-RCTs comparing different treatments for kidney transplant recipients of any age were selected. We excluded all other transplant recipients, including kidney-pancreas transplant recipients. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data. Statistical analyses were performed using the random effects model and the results expressed as relative risk (RR) with 95% confidence intervals (CI) for dichotomous variables and mean difference (MD) for continuous outcomes. MAIN RESULTS Twenty-four trials (1,299 patients) were included. No individual intervention (bisphosphonates, vitamin D sterol or calcitonin) was associated with a reduction in fracture risk compared with placebo. Combining results for all active interventions against placebo demonstrated any treatment of bone disease was associated with a reduction in the RR of fracture (RR 0.51, 95% CI 0.27 to 0.99). Bisphosphonates (any route), vitamin D sterol, and calcitonin all had a beneficial effect on the bone mineral density at the lumbar spine. Bisphosphonates and vitamin D sterol also had a beneficial effect on the bone mineral density at the femoral neck. Bisphosphonates had greater efficacy for preventing bone mineral density loss when compared head-to-head with vitamin D sterols. Few or no data were available for combined hormone replacement, testosterone, selective oestrogen receptor modulators, fluoride or anabolic steroids. Other outcomes including all-cause mortality and drug-related toxicity were reported infrequently. AUTHORS' CONCLUSIONS Treatment with a bisphosphonate, vitamin D sterol or calcitonin after kidney transplantation may protect against immunosuppression-induced reductions in bone mineral density and prevent fracture. Adequately powered trials are required to determine whether bisphosphonates are better than vitamin D sterols for fracture prevention in this population. The optimal route, timing, and duration of administration of these interventions remains unknown.
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Affiliation(s)
- S C Palmer
- University of Otago, Department of Medicine, Christchurch School of Medicine and Health Sciences, PO Box 4345, Christchurch, New Zealand.
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Egbuna OI, Taylor JG, Bushinsky DA, Zand MS. Elevated calcium phosphate product after renal transplantation is a risk factor for graft failure. Clin Transplant 2007; 21:558-66. [PMID: 17645720 DOI: 10.1111/j.1399-0012.2007.00690.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Abnormal mineral metabolism is not uncommon after renal transplant (TXP). In dialysis patients, elevated serum phosphorous (P), calcium (Ca), CaP product, and parathyroid hormone (PTH) are associated with increased morbidity and mortality. The effect of these abnormalities on recipient and graft survival after renal transplantation is unknown. METHODS We retrospectively analyzed 422 kidney-only transplants performed between June 1996 and June 2003. Cases with graft or recipient survival less than three months, pre-TXP parathyroidectomy (PTX), cinacalcet therapy and incomplete records were excluded, leaving 303 cases for analysis using Cox models that included post-TXP PTX, levels of albumin-adjusted Ca(Ca(adj)), P, Ca(adj)P product and PTH. RESULTS There was an 11-25% prevalence of abnormal serum Ca(adj), P or Ca(adj)P product within the first year post-TXP. At least 24% of recipients not undergoing PTX with an equation estimated GFR of 40-60 mL/min had PTH levels >130 pg/mL at one yr post-TXP. This is above levels recommended by the U.S National Kidney Foundation kidney disease quality initiative for patients with stages I-IV chronic kidney disease. Adjusted Ca > 10.5 mg/dL at three months post-TXP was an independent risk for recipient death (OR 3.0; 95% CI: 1.2-7.4). A Ca(adj)P product >35 mg(2)/dL(2) at six months (OR 4.0; 95% CI: 1.2-13.1), and Ca >10.5 mg/dL at 12 months post-TXP (OR 4.0; 95% CI: 1.2-14) were independent risks for death-censored graft loss. Twenty-two recipients underwent PTX for severe hyperparathyroidism. CONCLUSION Abnormalities of mineral metabolism are common early after renal TXP. An elevated serum Ca(adj) at three months post-TXP increases the risk for recipient death, while an elevated Ca(adj)P and Ca(adj) later in the first post-TXP year increases the risk of long-term death-censored graft loss.
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Affiliation(s)
- Ogo I Egbuna
- Division of Nephrology, Beth Israel Deaconess Medical Center, and Division of Endocrinology and Hypertension - Calcium and Parathyroid Physiology Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Abbud-Filho M, Adams PL, Alberú J, Cardella C, Chapman J, Cochat P, Cosio F, Danovitch G, Davis C, Gaston RS, Humar A, Hunsicker LG, Josephson MA, Kasiske B, Kirste G, Leichtman A, Munn S, Obrador GT, Tibell A, Wadström J, Zeier M, Delmonico FL. A Report of the Lisbon Conference on the Care of the Kidney Transplant Recipient. Transplantation 2007; 83:S1-22. [PMID: 17452912 DOI: 10.1097/01.tp.0000260765.41275.e2] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Mario Abbud-Filho
- Instituto de Urologia e Nefrologia & Medical School - FAMERP, São José do Rio Preto-SP, Brazil
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El-Amm JM, Doshi MD, Singh A, Migdal S, Morawski K, Sternbauer D, Cincotta E, West MS, Losanoff JE, Gruber SA. Preliminary experience with cinacalcet use in persistent secondary hyperparathyroidism after kidney transplantation. Transplantation 2007; 83:546-9. [PMID: 17353771 DOI: 10.1097/01.tp.0000253429.33198.2f] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND There is limited experience with the use of cinacalcet in the treatment of persistent secondary hyperparathyroidism after kidney transplantation. METHODS We retrospectively analyzed our experience in 18 renal allograft recipients who initiated cinacalcet therapy from 1 month to 23 years (median 3 years) posttransplantation and were maintained on the drug for 6 months. The daily dose was titrated from 30 mg up to a maximum of 180 mg to achieve a reduction in serum intact parathyroid hormone (PTH) levels. RESULTS Sustainable, significant decreases in mean calcium and alkaline phosphatase were noted at 1 month and intact PTH by 3 months, with 50% of patients achieving at least a 30% drop in PTH levels at 6 months. Serum phosphorous increased at 6 months, whereas urine N-telopeptides decreased. There were no significant changes in serum osteocalcin, albumin, and hemoglobin levels. We did not observe a tachyphylaxis phenomenon. Two patients reported occasional nausea, but did not require medication discontinuation. Estimated glomerular filtration rate did decrease progressively over the 6-month period. CONCLUSION Cinacalcet appears to be an effective drug for the treatment of posttransplant hypercalcemia due to persistent secondary hyperparathyroidism. Further studies with more patients and longer follow-up will be needed to better elucidate the efficacy/safety profile for this agent, particularly with regard to long-term bone histology and renal outcomes.
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Affiliation(s)
- Jose-Marie El-Amm
- Division of Nephrology, Department of Medicine, Wayne State University School of Medicine, Harper Professional Building, Detroit, MI 48201, USA.
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Leca N, Laftavi M, Gundroo A, Kohli R, Min I, Karam J, Sridhar N, Blessios G, Venuto R, Pankewycz O. Early and severe hyperparathyroidism associated with hypercalcemia after renal transplant treated with cinacalcet. Am J Transplant 2006; 6:2391-5. [PMID: 16869807 DOI: 10.1111/j.1600-6143.2006.01475.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Bone disease is a common clinical problem following renal transplantation. In renal transplant recipients, multiple underlying factors determine the extent of bone loss and the subsequent risk of fractures. In addition to the well-recognized risk to bone disease posed by steroids, calcineurin inhibitors and pre-existing bone disease, persistent hyperparathyroidism (HPT) contributes to post-transplant bone loss. HPT is usually treated with vitamin D supplements combined with calcium. Patients whose HPT is associated with hypercalcemia pose a difficult therapeutic dilemma which often requires parathyroidectomy. Cinacalcet, a calcium mimetic agent, offers a unique pharmacologic approach to the treatment of patients with post-transplant hypercalcemia and HPT. In this paper, we describe the clinical course and biochemical changes in 10 renal transplant recipients with hypercalcemia and severe HPT early after renal transplantation treated with cinacalcet. Cinacalcet therapy corrected hypercalcemia and decreased parathyroid hormone (PTH) levels in all cases. A transient rise in the level of alkaline phosphatase was noted following initiation of cinacalcet therapy. In this patient population, correction of HPT was not permanent as discontinuing cinacalcet therapy led to a rapid rise in PTH level.
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Affiliation(s)
- N Leca
- Department of Medicine, SUNY University at Buffalo, NY, USA
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Freundlich M. Bone mineral content and mineral metabolism during cyclosporine treatment of nephrotic Syndrome. J Pediatr 2006; 149:383-9. [PMID: 16939753 DOI: 10.1016/j.jpeds.2006.04.060] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2005] [Revised: 03/23/2006] [Accepted: 04/27/2006] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Although cyclosporine (Cy) has been associated with bone loss following transplantation, its effects on bone in growing children are largely unknown. STUDY DESIGN Thirty-seven patients (2-16 years of age) with remitting nephrotic syndrome (NS), n = 16 receiving Cy for 39 +/- 27 months and n = 21 without Cy, underwent mineral metabolism and bone turnover assessment. In 28 of 37 patients, bone mineral density (BMD) was obtained while off corticosteroid therapy (Rx). RESULTS Urinary calcium (Ca), phosphate (PO(4)), and magnesium (Mg) excretion was normal, but serum Mg was lower in patients receiving Cy (1.8 +/- 0.1 v 1.95 +/- 0.2 mg/dL, P < .05). BMD Z scores were similar at the spine (-0.45 +/- 0.74 v 0.04 +/- 0.9) and femur (-0.17 +/- 0.52 v 0.38 +/- 1.28) with no Z score <-2. Serum bone-specific alkaline phosphatase was normal, and N-telopeptide of type I collagen also normal, was higher on Cy (P < .05). Cumulative prednisone exposure was similar and had no significant effect on height and BMD Z scores. Length of Cy-Rx and time elapsed from onset of NS did not correlate with BMD, height Z score, or markers of bone turnover. CONCLUSIONS In growing children with NS, during long-term Cy-Rx urinary wasting of Ca and Mg was absent and bone density was preserved.
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Weisinger JR, Carlini RG, Rojas E, Bellorin-Font E. Bone disease after renal transplantation. Clin J Am Soc Nephrol 2006; 1:1300-13. [PMID: 17699362 DOI: 10.2215/cjn.01510506] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
It has been well established that a rapid decrease in bone mineral density (BMD) occurs in the first 6 to 12 mo after a successful renal transplantation and persists, albeit at a lower rate, for many years. This rapid BMD loss significantly increases the fracture risk of these patients to levels that are even higher than those of patients who have chronic kidney disease stage 5 and are on dialysis. The presence of low BMD in renal transplant patients as a predictor of risk fracture is controversial. Indeed, as has been suggested also for patients with postmenopausal osteoporosis, there is not a compelling correlation between the decline in BMD and skeletal fractures. However, bone disease after renal transplantation probably represents a unique bone disorder that must encompass underlying renal osteodystrophy. In fact, this syndrome results from multiple factors that include pretransplantation bone status, use of glucocorticoids and other immunosuppressive drugs, hypophosphatemia, and alterations of the calcium-vitamin D axis. Recent studies have demonstrated decreased osteoblast number, reduced bone formation rate, delayed mineralization, and increased osteoblast and osteocyte apoptosis. Bisphosphonates and vitamin D metabolites may be valuable in preventing or diminishing early bone loss. However, clinicians should be careful with the use of bisphosphonates and oversuppression of bone, especially in patients with low bone turnover. New prospective, controlled trials are required to confirm the real efficacy of these drugs, particularly in long-term renal transplant patients.
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Affiliation(s)
- José R Weisinger
- Division of Nephrology, Hospital Universitario de Caracas, Universidad Central de Venezuela, Caracas, Venezuela.
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Winslow MM, Pan M, Starbuck M, Gallo EM, Deng L, Karsenty G, Crabtree GR. Calcineurin/NFAT signaling in osteoblasts regulates bone mass. Dev Cell 2006; 10:771-82. [PMID: 16740479 DOI: 10.1016/j.devcel.2006.04.006] [Citation(s) in RCA: 260] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2005] [Revised: 02/28/2006] [Accepted: 04/04/2006] [Indexed: 01/13/2023]
Abstract
Development and repair of the vertebrate skeleton requires the precise coordination of bone-forming osteoblasts and bone-resorbing osteoclasts. In diseases such as osteoporosis, bone resorption dominates over bone formation, suggesting a failure to harmonize osteoclast and osteoblast function. Here, we show that mice expressing a constitutively nuclear NFATc1 variant (NFATc1(nuc)) in osteoblasts develop high bone mass. NFATc1(nuc) mice have massive osteoblast overgrowth, enhanced osteoblast proliferation, and coordinated changes in the expression of Wnt signaling components. In contrast, viable NFATc1-deficient mice have defects in skull bone formation in addition to impaired osteoclast development. NFATc1(nuc) mice have increased osteoclastogenesis despite normal levels of RANKL and OPG, indicating that an additional NFAT-regulated mechanism influences osteoclastogenesis in vivo. Calcineurin/NFATc signaling in osteoblasts controls the expression of chemoattractants that attract monocytic osteoclast precursors, thereby coupling bone formation and bone resorption. Our results indicate that NFATc1 regulates bone mass by functioning in both osteoblasts and osteoclasts.
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Affiliation(s)
- Monte M Winslow
- Program in Immunology, Stanford University, Stanford, California 94305, USA
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Khan AA, Hanley DA, Bilezikian JP, Binkley N, Brown JP, Hodsman AB, Josse RG, Kendler DL, Lewiecki EM, Miller PD, Olszynski WP, Petak SM, Syed ZA, Theriault D, Watts NB. Standards for performing DXA in individuals with secondary causes of osteoporosis. J Clin Densitom 2006; 9:47-57. [PMID: 16731431 DOI: 10.1016/j.jocd.2006.01.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2006] [Accepted: 01/09/2006] [Indexed: 01/24/2023]
Abstract
This document addresses skeletal health assessment in individuals with secondary causes of osteoporosis. Recommendations are based on consensus of the Canadian Panel of the International Society for Clinical Densitometry and invited international experts. Bone mineral density (BMD) testing in these populations is performed in conjunction with careful evaluation of the disease state contributing to bone loss and increased fragility fracture risk, as well as assessment of other contributing risk factors for fracture. The presence of secondary causes of bone loss may further increase the risk of fracture independently of BMD and may necessitate earlier pharmacologic intervention. Dual-energy X-ray absorptiometry is indicated in the initial workup of secondary causes of osteoporosis. The BMD fracture risk relationship is not known for individuals with chronic renal failure (CRF). The BMD testing in this population may be normal in the presence of skeletal fragility, and quantitative bone histomorphometry is better at evaluating skeletal status than BMD in CRF. Dual-energy X-ray absorptiometry is a valuable tool in assessing skeletal health in individuals with secondary causes of osteoporosis.
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Affiliation(s)
- Aliya A Khan
- Division of Endocrinology, McMaster University, Hamilton, Ontario, Canada, and Hanover General Hospital, PA, USA.
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Pezzotta A, Mister M, Cravedi P, Azzollini N, Cassis L, Ruggiero V, DeSantis R, Carminati P, Remuzzi G, Noris M. Effect of a Novel Immunosuppressant, ST1959, on the Immune System and Renal Allograft Survival in Rats. Transplantation 2005; 80:231-6. [PMID: 16041268 DOI: 10.1097/01.tp.0000165434.89700.a7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND ST1959 is a 3,5-diaryl-s-triazole belonging to a novel class of contragestional agents with immunosuppressant activity. The aim of the present study was to investigate the effects of this drug on allogeneic immune response and on renal allograft survival in rats. METHODS One group of naive and one group of allosensitized Lewis rats received ST1959 (0.5 mg/kg/day for 6 days administered subcutaneously). The respective control groups received vehicle alone. At the end of treatment, all rats were killed and thymus, spleen, lymph nodes, bone marrow, and blood were harvested. Cell number, leukocyte subpopulations, and lymphocyte alloreactivity were evaluated. Three additional groups of Lewis rats received an allogeneic (Brown Norway [BN]) kidney transplant: two groups received ST1959 (0.5 mg/kg daily until death or for 6 days and then twice weekly), and the last one received vehicle. RESULTS In naive rats, ST1959 reduced the percentage of CD4CD8 (74.2+/-2.7%; vehicle, 89.1+/-1.1%; P<0.05) and increased the percentage of CD4CD8 thymocytes (5.7+/-0.8% vs. 2.8+/-0.4%; P<0.05). Infusion of allogeneic (BN) splenocytes caused a twofold increase of activated CD4 T cells (CD4CD25) that was prevented by ST1959 treatment. Consistently, the alloreactivity of lymphocytes from naive and allosensitized animals treated with ST1959 was significantly lower than that of control rats. ST1959 (in both tested regimens) significantly prolonged renal allograft survival in comparison with vehicle (12.4+/-0.5 vs. 7.7+/-0.5 days; P<0.001). CONCLUSIONS ST1959 possesses immunomodulatory effects and significantly prolongs survival of renal allografts in rats.
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Affiliation(s)
- Anna Pezzotta
- Transplant Research Center Chiara Cucchi de Alessandri e Gilberto Crespi, Mario Negri Institute for Pharmacological Research, Villa Camozzi, Ranica, Bergamo, Italy
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Palmer S, McGregor DO, Strippoli GFM. Interventions for preventing bone disease in kidney transplant recipients. Cochrane Database Syst Rev 2005:CD005015. [PMID: 15846740 DOI: 10.1002/14651858.cd005015.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Patients with chronic kidney disease have significant abnormalities of bone remodelling and calcium homeostasis and are at increased risk of fracture. The fracture risk for a kidney transplant recipient is four times that of the general population and higher than that for a patient on dialysis. Trials reporting the use of bisphosphonates, vitamin D analogues, calcitonin, and hormone replacement therapy to treat bone disease following engraftment exist. OBJECTIVES To evaluate the use of interventions for the treatment of bone disease following kidney transplantation. SEARCH STRATEGY The Cochrane CENTRAL Register of Controlled Trials (The Cochrane Library - Issue 3 2004), MEDLINE (1966 to August 2004), EMBASE (1980- August 2004) and reference lists were searched without language restriction. SELECTION CRITERIA Randomised trials of treatment of bone disease following kidney transplantation were included. Trials of recipients of any transplant other than a kidney transplant including trials of kidney-pancreas transplants were excluded. DATA COLLECTION AND ANALYSIS Two authors assessed independently trial quality and extracted data. Statistical analyses were performed using the random effects model and the results expressed as relative risk (RR) with 95% confidence intervals (CI) for dichotomous variables. For continuous variables the weighted mean difference (WMD) and its 95% CI was used. MAIN RESULTS Twenty-three eligible trials (1,209 patients) were identified. Seven trials compared more than two interventions. Nineteen trials compared active treatment with placebo, five vitamin D analogue and calcium, six vitamin D analogue alone, twelve bisphosphonates, and four nasal calcitonin. Eight trials compared two active treatments, one 17-beta oestradiol and medroxyprogesterone versus vitamin D analogue, five bisphosphonate versus vitamin D analogue, two vitamin D analogue and calcium versus calcium and one bisphosphonate versus calcitonin. Methodological quality was suboptimal. There were no significant differences between any treatment group for risk of fracture. Bisphosphonate, administered by any route, vitamin D analogue and calcitonin all had a beneficial effect on the bone mineral density at the lumbar spine. Bisphosphonates and vitamin D analogue had a beneficial effect on the bone mineral density at the femoral neck. Few or no data were available for combined hormone replacement, testosterone, selective oestrogen receptor modulators, fluoride or anabolic steroids. All-cause mortality and drug-related toxicity were reported infrequently and there was no statistical difference between treatment groups. AUTHORS' CONCLUSIONS No benefit from any intervention known to reduce risk of fracture from bone disease could be demonstrated to reduce fracture incidence in kidney transplant recipients.
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Affiliation(s)
- S Palmer
- Department of Nephrology, Christchurch Hospital, Private Bag 4710, Christchurch, New Zealand, 8001.
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Palmer SC, Strippoli GFM, McGregor DO. Interventions for preventing bone disease in kidney transplant recipients: A systematic review of randomized controlled trials. Am J Kidney Dis 2005; 45:638-49. [PMID: 15806466 DOI: 10.1053/j.ajkd.2004.12.007] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Before renal transplantation complex abnormalities of bone metabolism exist and lead to increased risk for fracture after transplantation. This study was conducted to assess the evidence available to guide targeted treatment to reduce bone disease in transplant recipients. METHODS The Cochrane CENTRAL Registry, MEDLINE, and EMBASE were searched for randomized trials of interventions for bone disease after renal transplantation. Data were extracted on fracture, bone mineral density (BMD) by means of dual-energy X-ray absorptiometry, acute graft rejection, and adverse events. Analysis was performed with a random-effects model, and all results are expressed as relative risk with 95% confidence intervals (CIs). RESULTS Twenty-three eligible trials (1,209 patients) were identified. No trial found a reduction in risk for fracture. Bisphosphonates (7 trials; 268 patients; weighted mean difference [WMD], 7.66; 95% CI, 4.82 to 10.50), vitamin D analogues (2 trials; 51 patients; WMD, 6.13; 95% CI, 4.97 to 7.29), and calcitonin (1 trial; 31 patients; WMD, 5.00; 95% CI, 0.88 to 9.12) favorably affected the percentage of change in BMD at the lumbar spine compared with no treatment. Bisphosphonates (4 trials; 149 patients; WMD, 7.18; 95% CI, 6.22 to 8.13) and vitamin D analogues (2 trials; 51 patients; WMD, 3.73; 95% CI, 2.71 to 4.75), but not calcitonin (1 trial; 31 patients; WMD, -0.30; 95% CI, -5.00 to 4.40), had a favorable effect on BMD measured at the femoral neck compared with no treatment. The incidence of reported toxicity was low. CONCLUSION The trials were inadequately powered to show a reduction in risk for fracture. Bisphosphonates and vitamin D have a beneficial effect on BMD at the lumbar spine and femoral neck. With increasing survival after renal transplantation, this study stresses the importance of randomized controlled trial evidence of interventions of bone disease after renal transplantation.
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Affiliation(s)
- Suetonia C Palmer
- Department of Nephrology, Christchurch Hospital, Christchurch, New Zealand.
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Dhanireddy KK, Xu H, Mannon RB, Hale DA, Kirk AD. The clinical application of monoclonal antibody therapies in renal transplantation. Expert Opin Emerg Drugs 2005. [DOI: 10.1517/14728214.9.1.23] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Elster EA, Hale DA, Mannon RB, Cendales LC, Swanson SJ, Kirk AD. The road to tolerance: renal transplant tolerance induction in nonhuman primate studies and clinical trials. Transpl Immunol 2004; 13:87-99. [PMID: 15380539 DOI: 10.1016/j.trim.2004.05.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2004] [Indexed: 02/06/2023]
Abstract
Organ transplantation has become a standard life-saving therapy for many causes of end stage organ failure. Although valuable, it remains hampered by the requirement for, and complications of, immunosuppression to prevent immune rejection of the transplanted organ. It is now clear that rejection can be avoided in some experimental systems without a requirement of immunosuppressive medication, and these experimental concepts are now making their way into the clinic in the form of early transplantation tolerance trials. This manuscript will discuss the most promising techniques for tolerance induction, namely, costimulation blockade, lymphocyte depletion, and mixed chimerism. Seminal preclinical studies will be cited and the results of initial clinical trials will be reviewed. The data to date indicate that while tolerance remains elusive, immunosuppression minimization is a feasible near-term alternative.
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Affiliation(s)
- Eric A Elster
- Department of Health and Human Services, Transplantation Branch, National Institutes of Diabetes, Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892, USA
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