1
|
Leng Y, Yu X, Yang Y, Xia Y. Efficacy and safety of medications for osteoporosis in kidney transplant recipients or patients with chronic kidney disease: A meta-analysis. J Investig Med 2023; 71:760-772. [PMID: 37387531 DOI: 10.1177/10815589231184215] [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] [Indexed: 07/01/2023]
Abstract
This study conducted a meta-analysis to analyze the efficacy and safety of osteoporosis medications in kidney transplant recipients and patients with chronic kidney disease (CKD). PubMed, Embase, the Cochrane Central Register of Controlled Trials were searched from the date of their inception through October 21, 2022. We performed a meta-analysis of the efficacy and safety of osteoporosis medications in adult patients with stage 3-5 CKD or kidney transplant recipients enrolled in randomized clinical trials (RCTs). We calculated the standard mean deviations with 95% confidence intervals (CI) for bone mineral density (BMD) and T scores after 6 and 12 months treatment, pooled odds ratio and 95% CI for fracture risk, and summarized adverse events. The inclusion criteria were met by 27 studies. Out of this, 19 studies were included for the meta-analysis. In stage 3-4 CKD patients, alendronate increased lumbar spine BMD. In patients at stage 5 CKD and undergoing hemodialysis, alendronate and raloxifene increased lumbar spine BMD. After 6 months, the BMD of kidney transplant recipients was seen to be significantly increased; however, there was no difference after 12 months, and the risk of fracture did not reduce. Thus, there is no evidence that these medications reduce the risk of fracture, and their effect on BMD and fracture remains unproven. These medications may increase the incidence of adverse events and their safety needs to be further evaluated. Therefore, we cannot draw a definitive conclusion about the efficacy and safety of osteoporosis medications in the above group of patients.
Collapse
Affiliation(s)
- Yunji Leng
- Phase I Clinical Trial Center, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xian Yu
- Phase I Clinical Trial Center, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yi Yang
- Phase I Clinical Trial Center, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yifan Xia
- Department of Joint Surgery, Chongqing General Hospital, Chongqing, China
| |
Collapse
|
2
|
Chen CH, Lo WC, Hu P, Chan HC, Shen WC, Wu MS, Wu MY. Efficacy of Osteoporosis Medications for Patients With Chronic Kidney Disease: An Updated Systematic Review and Network Meta-Analysis. Front Pharmacol 2022; 13:822178. [PMID: 35222037 PMCID: PMC8873386 DOI: 10.3389/fphar.2022.822178] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 01/13/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Chronic kidney disease (CKD) is associated with bone and mineral metabolism. In this study we evaluated the comparative efficacies and safety of osteoporosis medications in patients with CKD or a history of kidney transplantation, and make recommendations for the best choice of osteoporosis treatment among patients with CKD or a history of kidney transplantation. Methods: We systemically searched for randomized controlled trials published in PubMed, Embase, and Cochrane databases up to June 2020. Network-meta analysis was used to compare the relative effectiveness of different treatments. A random-effects model was used when heterogeneity was expected. The safety of different treatments was also evaluated in terms of reported major adverse events. Results: A total of 17 studies with data from 10,214 patients who had stage 2–5 CKD, were receiving dialysis, or had a history of kidney transplantation were included in the network meta-analysis. Treatment with teriparatide, denosumab, alendronate, and raloxifene were all associated with a significantly reduced risk of fractures compared to treatment with placebos [teriparatide: odds ratio (OR) = 0.19, 95% confidence interval (CI): 0.10–0.35; denosumab: OR = 0.40, 95% CI: 0.27–0.58; alendronate: OR = 0.61, 95% CI: 0.40–0.92; raloxifene: OR = 0.52, 95% CI: 0.41–0.67]. The rank probability and the surface under the cumulative ranking (SUCRA) values suggested that teriparatide ranked the highest for improvement in vertebral bone mineral density (BMD) (SUCRA = 97.8%), whereas denosumab ranked the highest for improvement in femoral neck BMD (SUCRA = 88.3%). Conclusion: Teriparatide and denosumab seem to be the most effective treatments for preventing bone loss and reducing the risk of fracture in our network comparison. However, because of the limitations and potential biases in the reviewed studies, there is still some uncertainty about the best treatment options for osteoporosis in patients with CKD or a history of kidney transplantation. Systematic Review Registration: [PROSPERO], identifier [CRD42020209830].
Collapse
Affiliation(s)
- Chia-Hsien Chen
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Department of Orthopedic Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- School of Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, Taiwan
| | - Wei-Cheng Lo
- Master Program in Applied Epidemiology, College of Public Health, Taipei Medical University, Taipei, Taiwan
| | - Ping‐Jen Hu
- Division of Gastroenterology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Master’s Program in Biomedicine, College of Science and Engineering, National Taitung University, Taitung, Taiwan
| | - Hsiu-Chen Chan
- Department of Pharmacy, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Wan-Chen Shen
- Department of Pharmacy, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Mai-Szu Wu
- Division of Nephrology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Taipei Medical University Research Center of Urology and Kidney, Taipei Medical University, Taipei, Taiwan
| | - Mei-Yi Wu
- Division of Nephrology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Taipei Medical University Research Center of Urology and Kidney, Taipei Medical University, Taipei, Taiwan
- College of Public Health, Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan
- *Correspondence: Mei-Yi Wu,
| |
Collapse
|
3
|
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.
Collapse
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
| | | |
Collapse
|
4
|
Anastasilakis AD, Tsourdi E, Makras P, Polyzos SA, Meier C, McCloskey EV, Pepe J, Zillikens MC. Bone disease following solid organ transplantation: A narrative review and recommendations for management from The European Calcified Tissue Society. Bone 2019; 127:401-418. [PMID: 31299385 DOI: 10.1016/j.bone.2019.07.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 07/07/2019] [Accepted: 07/08/2019] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Solid organ transplantation is an established therapy for end-stage organ failure. Both pre-transplantation bone disease and immunosuppressive regimens result in rapid bone loss and increased fracture rates. METHODS The European Calcified Tissue Society (ECTS) formed a working group to perform a systematic review of existing literature on the consequences of end-stage kidney, liver, heart, and lung disease on bone health. Moreover, we assessed the characteristics of post-transplant bone disease and the skeletal effects of immunosuppressive agents and aimed to provide recommendations for the prevention and treatment of transplantation-related osteoporosis. RESULTS Characteristics of bone disease may differ depending on the organ that fails, but patients awaiting solid organ transplantation frequently depict a wide spectrum of bone and mineral abnormalities. Common features are a decreased bone mass and impaired bone strength with consequent high fracture risk, all of which are aggravated in the early post-transplantation period. CONCLUSION Both the underlying disease leading to end-stage organ failure and the immunosuppression regimens implemented after successful organ transplantation have detrimental effects on bone mass, quality and strength. Given existing ample data confirming the high frequency of bone disease in patients awaiting solid organ transplantation, we recommend that all transplant candidates should be assessed for osteoporosis and fracture risk and, if indicated, treated before and after transplantation. Since bone loss in the early post-transplantation period occurs in virtually all solid organ recipients and is associated with glucocorticoid administration, the goal should be to use the lowest possible dose and to taper and withdraw glucocorticoids as early as possible.
Collapse
Affiliation(s)
| | - Elena Tsourdi
- Department of Medicine III, Technische Universität Dresden Medical Center, Dresden, Germany; Center for Healthy Aging, Technische Universität Dresden Medical Center, Dresden, Germany
| | - Polyzois Makras
- Department of Endocrinology and Diabetes, 251 Hellenic Force & VA General Hospital, Athens, Greece
| | - Stergios A Polyzos
- First Department of Pharmacology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Christian Meier
- Division of Endocrinology, Diabetology and Metabolism, University Hospital and University of Basel, Switzerland
| | - Eugene V McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK; Centre for Integrated research in Musculoskeletal Ageing (CIMA), Mellanby Centre for Bone Research, University of Sheffield, Sheffield, UK
| | - Jessica Pepe
- Department of Internal Medicine and Medical Disciplines, "Sapienza" University, Rome, Italy
| | - M Carola Zillikens
- Bone Center, Department of Internal Medicine, Erasmus MC, Rotterdam, the Netherlands.
| |
Collapse
|
5
|
Lip A, Warias A, Shamseddin MK, Thomson B, Wijeratne DT. Effect of Bisphosphonates on Bone Health in Adult Renal Transplant Patients: Beyond the First Year Posttransplant-A Systematic Review and Meta-Analysis. Can J Kidney Health Dis 2019; 6:2054358119858014. [PMID: 31263566 PMCID: PMC6595663 DOI: 10.1177/2054358119858014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 04/22/2019] [Indexed: 12/24/2022] Open
Abstract
Background: Bone mineral density (BMD) decreases postrenal transplantation. Evidence
demonstrating the effects of bisphosphonates on BMD and fracture risk beyond
1-year posttransplant is sparse in existing literature, but remains
essential to enhance clinical outcomes in this population. Objective: Our study aimed to systematically review and meta-analyze the current
literature on the use of any bisphosphonate in the adult renal transplant
population beyond the first year of renal transplant to determine its effect
on BMD and fracture incidence. Design: We conducted a systematic review and meta-analysis of primary research
literature that included full-text, English-language, original randomized
clinical trials (RCTs) and observational studies. Setting: Patient data were primarily captured in an outpatient setting across various
studies. Patients: Our population of interest was patients older than 18 years who received
deceased/living donor kidney transplantation and any bisphosphonate with a
follow-up greater than 12 months posttransplantation. Measurements: The primary outcome was change in BMD from baseline. Secondary outcomes were
the incidence of fractures and effects of other confounders on bone
health. Methods: We included RCTs and observational studies that satisfied our inclusion
criteria. Each study was analyzed for risk of bias and data were
extrapolated to analyze for overall statistical significance accounting for
heterogeneity of studies. Results: Sixteen studies (N = 1762) were analyzed. The follow-up ranged from 12 to 98
months. There was a nonsignificant improvement in BMD with bisphosphonate
treatment persisting into the second and third years posttransplant at the
lumbar spine. The calculated standardized mean BMD difference was −0.29
(−0.75 to 0.17), P = .22. Only 5 studies reported a total
of 43 new fractures. Prednisone (P < .01), low body
weight (P < .001), low body mass index
(P < .01), and male gender (P <
.05) correlated with reduced lumbar and femoral BMD. Limitations: Limitations of this review include the use of BMD as a surrogate outcome, the
bias of the included studies, and the incomplete reporting data in numerous
analyzed studies. Conclusions: We demonstrate no statistically significant benefit of bisphosphonate
treatment on BMD beyond the first year postrenal transplantation. Despite
heterogeneity of treatment, a differential nonsignificant improvement in
lumbar spine BMD was consistent and may be clinically relevant. Trial Registration: PROSPERO CRD42019125593
Collapse
Affiliation(s)
- Alyssa Lip
- Division of General Internal Medicine, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Ashley Warias
- Division of General Internal Medicine, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - M Khaled Shamseddin
- Division of General Internal Medicine, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Benjamin Thomson
- Division of General Internal Medicine, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - D Thiwanka Wijeratne
- Division of General Internal Medicine, Department of Medicine, Queen's University, Kingston, ON, Canada
| |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|