1
|
Jaikaransingh V. Bone health and fracture prevention after kidney transplantation. J Clin Transl Endocrinol 2024; 36:100345. [PMID: 38737624 PMCID: PMC11081796 DOI: 10.1016/j.jcte.2024.100345] [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: 02/13/2024] [Revised: 04/21/2024] [Accepted: 04/24/2024] [Indexed: 05/14/2024] Open
Abstract
Changes in bone health and strength are common after kidney transplantation and can lead to an increased risk of fracture. This has implications for morbidity, mortality and renal allograft survival. This review will focus on the changes that occur in bone health and fracture risk after kidney transplantation and examine the evidence available to guide diagnostic and therapeutic decisions with the aim of fracture prevention.
Collapse
Affiliation(s)
- Vishal Jaikaransingh
- University of Florida College of Medicine – Jacksonville, Department of Medicine, Division of Nephrology, United States
| |
Collapse
|
2
|
Jørgensen HS, Lloret MJ, Lalayiannis AD, Shroff R, Evenepoel P. Ten tips on how to assess bone health in patients with chronic kidney disease. Clin Kidney J 2024; 17:sfae093. [PMID: 38817914 PMCID: PMC11137676 DOI: 10.1093/ckj/sfae093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Indexed: 06/01/2024] Open
Abstract
Patients with chronic kidney disease (CKD) experience a several-fold increased risk of fracture. Despite the high incidence and the associated excess morbidity and premature mortality, bone fragility in CKD, or CKD-associated osteoporosis, remains a blind spot in nephrology with an immense treatment gap. Defining the bone phenotype is a prerequisite for the appropriate therapy of CKD-associated osteoporosis at the patient level. In the present review, we suggest 10 practical 'tips and tricks' for the assessment of bone health in patients with CKD. We describe the clinical, biochemical, and radiological evaluation of bone health, alongside the benefits and limitations of the available diagnostics. A bone biopsy, the gold standard for diagnosing renal bone disease, is invasive and not widely available; although useful in complex cases, we do not consider it an essential component of bone assessment in patients with CKD-associated osteoporosis. Furthermore, we advocate for the deployment of multidisciplinary expert teams at local, national, and potentially international level. Finally, we address the knowledge gaps in the diagnosis, particularly early detection, appropriate "real-time" monitoring of bone health in this highly vulnerable population, and emerging diagnostic tools, currently primarily used in research, that may be on the horizon of clinical practice.
Collapse
Affiliation(s)
- Hanne Skou Jørgensen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Nephrology, Aalborg University Hospital, Aalborg, Denmark
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Maria Jesús Lloret
- Department of Nephrology, Hospital Fundació Puigvert, Barcelona, Spain
- Institut de Recerca Sant-Pau (IR-Sant Pau), Barcelona, Spain
| | - Alexander D Lalayiannis
- Department of Pediatric Nephrology, Birmingham Women's and Children's Hospitals, Birmingham, UK
| | - Rukshana Shroff
- Renal Unit, UCL Great Ormond Street Hospital and Institute of Child Health, London, UK
| | - Pieter Evenepoel
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, Katholieke Universiteit Leuven, Leuven, Belgium
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| |
Collapse
|
3
|
Jia L, Chao S, Yang Q, Chen Q, Yuan Z, Chen L, Zhang T, Zhu K, Niu Y. The comprehensive incidence and risk factors of fracture in kidney transplant recipients: A meta-analysis. Nephrology (Carlton) 2024. [PMID: 38689467 DOI: 10.1111/nep.14301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 03/08/2024] [Accepted: 03/26/2024] [Indexed: 05/02/2024]
Abstract
AIM Kidney transplant recipients are at high risk of fracture due to many factors such as nutritional status, hyperparathyroidism, acidosis and steroid administration. The current meta-analysis aimed to comprehensively analyse the incidence and risk factors of fracture in kidney transplant recipients. METHODS A systematic search on Embase, Web of Science, PubMed and Cochrane Library until November 2023 was performed. RStudio software was used to analyse data. RESULTS Twenty-eight eligible studies containing 310 530 kidney transplant recipients were included in the analysis. The pooled incidence of fracture was 10% (95% confidence interval [CI]: 7%-13%) generally. When divided by regions, it was further observed that the pooled incidence of fracture was 13% (95% CI: 9%-17%) in Europe, 11% (95% CI: 6%-16%) in North America, 7% (95% CI: 3%-11%) in Asia. Regarding the risk factors, pooled analysis revealed that age of recipient (hazard ratio [HR] = 1.50, 95% CI: 1.17-1.91), female sex (HR = 1.45, 95% CI: 1.36-1.53), pretransplantation diabetes (HR = 1.76, 95% CI: 1.58-1.97), pretransplantation fracture history (HR = 2.28, 95% CI: 1.86-2.78), dialysis duration (HR = 1.09, 95% CI: 1.01-1.17) and deceased donor (HR = 1.21, 95% CI: 1.05-1.39) related to higher risk of fracture. The general quality of included studies was acceptable, and no publication bias existed except for the analysis between age of recipient and fracture incidence; further trim and fill method indicated age of recipient showed a correlation trend with the fracture incidence without the statistical significance. CONCLUSION The pooled incidence of fracture reaches 10% in kidney transplant recipients, which relates to age of recipient, female sex, pretransplantation diabetes or fracture history, dialysis duration and decease donor.
Collapse
Affiliation(s)
- Lei Jia
- Organ Transplantation Department, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Sheng Chao
- Organ Transplantation Department, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Qizhen Yang
- Organ Transplantation Department, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Qian Chen
- Organ Transplantation Department, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Zhihui Yuan
- Organ Transplantation Department, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Luobei Chen
- Organ Transplantation Department, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Tao Zhang
- Organ Transplantation Department, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Kejing Zhu
- Organ Transplantation Department, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Yulin Niu
- Organ Transplantation Department, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| |
Collapse
|
4
|
Teh JW, Mac Gearailt C, Lappin DWP. Post-Transplant Bone Disease in Kidney Transplant Recipients: Diagnosis and Management. Int J Mol Sci 2024; 25:1859. [PMID: 38339137 PMCID: PMC10856017 DOI: 10.3390/ijms25031859] [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: 01/10/2024] [Revised: 01/24/2024] [Accepted: 02/01/2024] [Indexed: 02/12/2024] Open
Abstract
Kidney transplantation is the preferred gold standard modality of treatment for kidney failure. Bone disease after kidney transplantation is highly prevalent in patients living with a kidney transplant and is associated with high rates of hip fractures. Fractures are associated with increased healthcare costs, morbidity and mortality. Post-transplant bone disease (PTBD) includes renal osteodystrophy, osteoporosis, osteonecrosis and bone fractures. PTBD is complex as it encompasses pre-existing chronic kidney disease-mineral bone disease and compounding factors after transplantation, including the use of immunosuppression and the development of de novo bone disease. After transplantation, the persistence of secondary and tertiary hyperparathyroidism, renal osteodystrophy, relative vitamin D deficiency and high levels of fibroblast growth factor-23 contribute to post-transplant bone disease. Risk assessment includes identifying both general risk factors and kidney-specific risk factors. Diagnosis is complex as the gold standard bone biopsy with double-tetracycline labelling to diagnose the PTBD subtype is not always readily available. Therefore, alternative diagnostic tools may be used to aid its diagnosis. Both non-pharmacological and pharmacological therapy can be employed to treat PTBD. In this review, we will discuss pathophysiology, risk assessment, diagnosis and management strategies to manage PTBD after kidney transplantation.
Collapse
Affiliation(s)
- Jia Wei Teh
- Department of Nephrology, Galway University Hospital, H91 YR71 Galway, Ireland
| | - Conall Mac Gearailt
- Department of Rheumatology, Galway University Hospital, H91 YR71 Galway, Ireland
| | - David W. P. Lappin
- Department of Nephrology, Galway University Hospital, H91 YR71 Galway, Ireland
- School of Medicine, University of Galway, H91 TK33 Galway, Ireland
| |
Collapse
|
5
|
van den Born JC, Meziyerh S, Vart P, Bakker SJL, Berger SP, Florquin S, de Fijter JW, Gomes-Neto AW, Idu MM, Pol RA, Roelen DL, van Sandwijk MS, de Vries DK, de Vries APJ, Bemelman FJ, Sanders JSF. Comparison of 2 Immunosuppression Minimization Strategies in Kidney Transplantation: The ALLEGRO Trial. Transplantation 2024; 108:556-566. [PMID: 37650722 DOI: 10.1097/tp.0000000000004776] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
BACKGROUND Evidence on the optimal maintenance of immunosuppressive regimen in kidney transplantation recipients is limited. METHODS The Amsterdam, LEiden, GROningen trial is a randomized, multicenter, investigator-driven, noninferiority, open-label trial in de novo kidney transplant recipients, in which 2 immunosuppression minimization strategies were compared with standard immunosuppression with basiliximab, corticosteroids, tacrolimus, and mycophenolic acid. In the minimization groups, either steroids were withdrawn from day 3, or tacrolimus exposure was reduced from 6 mo after transplantation. The primary endpoint was kidney transplant function at 24 mo. RESULTS A total of 295 participants were included in the intention-to-treat analysis. Noninferiority was shown for the primary endpoint; estimated glomerular filtration rate at 24 mo was 45.3 mL/min/1.73 m 2 in the early steroid withdrawal group, 49.0 mL/min/1.73 m 2 in the standard immunosuppression group, and 44.7 mL/min/1.73 m 2 in the tacrolimus minimization group. Participants in the early steroid withdrawal group were significantly more often treated for rejection ( P = 0.04). However, in this group, the number of participants with diabetes mellitus during follow-up and total cholesterol at 24 mo were significantly lower. CONCLUSIONS Tacrolimus minimization can be considered in kidney transplant recipients who do not have an increased immunological risk. Before withdrawing steroids the risk of rejection should be weighed against the potential metabolic advantages.
Collapse
Affiliation(s)
- Joost C van den Born
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Soufian Meziyerh
- Department of Internal Medicine, Division of Nephrology, Leiden University Medical Center, Leiden, the Netherlands
- Transplant Center, Leiden University Medical Center, Leiden, the Netherlands
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Priya Vart
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Stephan J L Bakker
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Stefan P Berger
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Sandrine Florquin
- Department of Pathology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Johan W de Fijter
- Department of Internal Medicine, Division of Nephrology, Leiden University Medical Center, Leiden, the Netherlands
| | - António W Gomes-Neto
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Mirza M Idu
- Department of Surgery, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Robert A Pol
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Dave L Roelen
- Department of Immunology, Leiden University Medical Center, Leiden, the Netherlands
| | - Marit S van Sandwijk
- Renal Transplant Unit, Department of Internal Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Dorottya K de Vries
- Transplant Center, Leiden University Medical Center, Leiden, the Netherlands
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Aiko P J de Vries
- Department of Internal Medicine, Division of Nephrology, Leiden University Medical Center, Leiden, the Netherlands
- Transplant Center, Leiden University Medical Center, Leiden, the Netherlands
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Frederike J Bemelman
- Renal Transplant Unit, Department of Internal Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Jan Stephan F Sanders
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| |
Collapse
|
6
|
Tsai HL, Lin TC, Lin NC, Yang HH, Chang JW. Risk Factors for Fractures in Renal Transplantation: A Population-Based Cohort Study. Am J Nephrol 2023; 54:498-507. [PMID: 37783206 DOI: 10.1159/000533125] [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: 05/13/2023] [Accepted: 07/17/2023] [Indexed: 10/04/2023]
Abstract
INTRODUCTION Kidney transplant recipients are at an increased risk of fractures, and targeted preventive strategies are needed. Therefore, in this retrospective cohort study, we investigated a large population-based cohort to identify the transplant recipient-specific risk factors for fractures in Taiwanese kidney transplant recipients. METHODS We conducted a retrospective cohort study using the National Health Insurance Research Database. Patients who underwent renal transplantation between 2003 and 2015 were identified and followed until December 31, 2015, to observe the development of fractures. Variables associated with the development of post-transplant fractures were identified by calculating hazard ratios in a Cox regression model. RESULTS 5,309 renal transplant recipients were identified, of whom 553 (10.4%) were diagnosed with post-transplant fractures. Independent predictors of post-transplant fractures included an age at transplant ≥65 years (p < 0.001), female sex (p < 0.001), fractures within 3 years prior to transplantation (p < 0.001), and diabetes mellitus (p < 0.001). In addition, daily prednisolone doses >2.9–5.3 mg/day (p < 0.001), >5.3–8.7 mg/day (p < 0.001), and >8.7 mg/day (p < 0.001) were also independent predictors of post-transplant fractures. Conversely, the use of peritoneal dialysis before renal transplantation (p = 0.021), hypertension (p = 0.005), and the use of tacrolimus (p < 0.001), azathioprine (p = 0.006), mycophenolate mofetil/mycophenolic acid (p = 0.002), mTOR inhibitors (p = 0.004), and calcium supplements (p = 0.009) were inversely correlated with post-transplant fractures. CONCLUSION We recommend minimizing daily glucocorticoids as early and as far as possible in conjunction with immunosuppressive regimens such as tacrolimus, azathioprine, mycophenolate mofetil/mycophenolic acid, mTOR inhibitors, and calcium supplements, especially in older female recipients and in recipients with diabetes and a history of prior fractures.
Collapse
Affiliation(s)
- Hsin-Lin Tsai
- Division of Pediatric Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tzu-Ching Lin
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Niang-Cheng Lin
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Transplantation Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hui-Hsin Yang
- Division of Pediatric Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jei-Wen Chang
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| |
Collapse
|
7
|
Elder GJ. Current Status of Mineral and Bone Disorders in Transplant Recipients. Transplantation 2023; 107:2107-2119. [PMID: 36788445 DOI: 10.1097/tp.0000000000004538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Most patients with end-stage kidney disease undergoing kidney transplantation are affected by the chronic kidney disease-mineral and bone disorder. This entity encompasses laboratory abnormalities, calcification of soft tissues, and the bone abnormalities of renal osteodystrophy that together result in an increased risk of fracture, cardiovascular events, and mortality. Although many biochemical disturbances associated with end-stage kidney disease improve in the first year after transplantation, hyperparathyroidism commonly persists, and residual changes of renal osteodystrophy are slow to resolve. When superimposed on common, traditional risk factors, post-transplant glucocorticoid treatment, the possibility of tubular disturbances and post-transplant chronic kidney disease, rates of incident fracture remain high. This review examines hormonal and biochemical changes before and after kidney transplantation, fracture risk assessment tools and imaging modalities, a staged approach to management and concerns associated with antiresorptive and anabolic therapies. A multidisciplinary approach is proposed as the best means to improve patient-level outcomes.
Collapse
Affiliation(s)
- Grahame J Elder
- Department of Renal Medicine, Westmead Hospital, Sydney, Australia
- Skeletal Biology Program, Garvan Institute of Medical Research, Sydney, Australia
- School of Medicine, University of Notre Dame, Sydney, Australia
| |
Collapse
|
8
|
Time-Varying Risk Factors for Incident Fractures in Kidney Transplant Recipients: A Nationwide Cohort Study in South Korea. J Clin Med 2023; 12:jcm12062337. [PMID: 36983337 PMCID: PMC10058856 DOI: 10.3390/jcm12062337] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 03/12/2023] [Accepted: 03/14/2023] [Indexed: 03/19/2023] Open
Abstract
Little is known about the time-varying risk factors for fractures in kidney transplant recipients (KTRs). Using the Korea Organ Transplantation Registry, a nationwide cohort study of KTRs, the incidence, locations, and time-varying predictors of fractures were analyzed, including at baseline and post-transplant 6-month variables in KTRs who underwent KT between January 2014 and June 2019. Among 4134 KTRs, with a median follow-up of 2.94 years (12,441.04 person-years), 63 patients developed fractures. The cumulative 5-year incidence was 2.10%. The most frequent locations were leg (25.40%) and foot/ankle (22.22%). In multivariable analysis, older recipient age at baseline (hazard ratio [HR], 1.035; 95% confidence interval [CI], 1.007–1.064; p = 0.013) and higher tacrolimus trough level (HR, 1.112; 95% CI, 1.029–1.202; p = 0.029) were associated with higher risks for fractures. Pretransplant diabetes mellitus had a time-dependent impact on fractures, with increasing risk as time elapses (HR for diabetes mellitus 1.115; 95% CI, 0.439–2.832; HR for diabetes mellitus × time, 1.049; 95% CI, 1.007–1.094; p = 0.022). In conclusion, KTRs had a high risk of peripheral skeletal fractures in the first 5 years. At baseline recipient age, pretransplant diabetes mellitus and tacrolimus trough level after KT were responsible for the fractures in KTRs.
Collapse
|
9
|
Atagu N, Mihilli S, Nguyen HT, Wu A, Famure O, Li Y, Kim SJ. Risk Factors for First and Recurrent Fractures among Kidney Transplant Recipients. Prog Transplant 2023; 33:16-24. [PMID: 36514897 PMCID: PMC9975818 DOI: 10.1177/15269248221145034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction: Kidney transplantation is associated with increased risk of bone fracture. Current literature reports widely variable fracture burden and contains limited data on risk factors for recurrent fractures. Methods: The incidence of all and major osteoporotic fractures (hip, forearm, thoracolumbar, and proximal humerus) were assessed. The risk factors for first and recurrent fractures among 1285 Canadian kidney transplant recipients transplanted between January 1, 2004, and December 31, 2013 were also identified. Results: The 10-year cumulative incidence of all fractures and major osteoporotic fractures in this population was 27.1% (95% CI: 22.5, 32.4) and 17.8% (95% CI: 13.4, 23.5), respectively. On multivariable analysis, female sex (HR = 1.64 [95% CI: 1.20, 2.26]), history of fracture (HR = 1.54 [95% CI: 1.12, 2.11]), and pretransplant diabetes (HR = 1.85 [95% CI: 1.29, 2.65]) were recipient factors found to increase the risk for any first fracture posttransplant. These risk factors persist in analysis with the time origin 3-months posttransplant, where transplant age (HR = 1.01 [95% CI: 1.00, 1.03]) and increased time on pretransplant dialysis (HR = 1.06 [95% CI: 1.00, 1.12]) also emerge as risk factors for first fracture. On multivariable shared frailty model analysis, increased risk of recurrent fractures was associated with recipient female sex (HR = 1.74 [95% CI: 1.21, 2.51]) and history of diabetes (HR = 1.76 [95% CI: 1.17, 2.66]). Discussion: The results suggested that some risk factors for first fracture may not inform risk of recurrent fractures. As such, fracture risk should be assessed accordingly to optimize long-term care and implement preventive measures.
Collapse
Affiliation(s)
- Norman Atagu
- Russell H. Morgan Department of Radiology and Radiological Science, 1500Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Stefani Mihilli
- Ajmera Transplant Centre, Toronto General Hospital, 7989University Health Network, Toronto, Ontario, Canada
| | - Huong Thao Nguyen
- Ajmera Transplant Centre, Toronto General Hospital, 7989University Health Network, Toronto, Ontario, Canada
| | - Alicia Wu
- Ajmera Transplant Centre, Toronto General Hospital, 7989University Health Network, Toronto, Ontario, Canada
| | - Olusegun Famure
- Ajmera Transplant Centre, Toronto General Hospital, 7989University Health Network, Toronto, Ontario, Canada
| | - Yanhong Li
- Ajmera Transplant Centre, Toronto General Hospital, 7989University Health Network, Toronto, Ontario, Canada.,Department of Medicine (Nephrology), 12366University of Toronto, Medical, Toronto, Ontario, Canada
| | - S Joseph Kim
- Ajmera Transplant Centre, Toronto General Hospital, 7989University Health Network, Toronto, Ontario, Canada
| |
Collapse
|
10
|
Bone Disease in Chronic Kidney Disease and Kidney Transplant. Nutrients 2022; 15:nu15010167. [PMID: 36615824 PMCID: PMC9824497 DOI: 10.3390/nu15010167] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/19/2022] [Accepted: 12/19/2022] [Indexed: 12/31/2022] Open
Abstract
Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD) comprises alterations in calcium, phosphorus, parathyroid hormone (PTH), Vitamin D, and fibroblast growth factor-23 (FGF-23) metabolism, abnormalities in bone turnover, mineralization, volume, linear growth or strength, and vascular calcification leading to an increase in bone fractures and vascular disease, which ultimately result in high morbidity and mortality. The bone component of CKD-MBD, referred to as renal osteodystrophy, starts early during the course of CKD as a result of the effects of progressive reduction in kidney function which modify the tight interaction between mineral, hormonal, and other biochemical mediators of cell function that ultimately lead to bone disease. In addition, other factors, such as osteoporosis not apparently dependent on the typical pathophysiologic abnormalities resulting from altered kidney function, may accompany the different varieties of renal osteodystrophy leading to an increment in the risk of bone fracture. After kidney transplantation, these bone alterations and others directly associated or not with changes in kidney function may persist, progress or transform into a different entity due to new pathogenetic mechanisms. With time, these alterations may improve or worsen depending to a large extent on the restoration of kidney function and correction of the metabolic abnormalities developed during the course of CKD. In this paper, we review the bone lesions that occur during both CKD progression and after kidney transplant and analyze the factors involved in their pathogenesis as a means to raise awareness of their complexity and interrelationship.
Collapse
|
11
|
Batteux B, Nowak A, Séjourné A, Penet C, Masmoudi K, Brazier F, Laville SM, Bennis Y, Gras-Champel V, Choukroun G, Liabeuf S. Drugs associated with incident fragility fractures in kidney transplant recipients. Clin Kidney J 2022; 16:571-584. [PMID: 36865022 PMCID: PMC9972841 DOI: 10.1093/ckj/sfac265] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Indexed: 12/14/2022] Open
Abstract
Background The risk of fragility fractures is high in kidney transplant recipients, and steroids are reportedly a major cause. Other drugs known to induce fragility fractures have been studied in the general population but not in kidney transplant recipients. Here, we investigated the association between exposure over time to drugs that can injure bone (namely vitamin K antagonists, insulin, loop diuretics, proton pump inhibitors, opioids, selective serotonin reuptake inhibitors, antiepileptics and benzodiazepines) and incident fractures and changes over time in T-scores in this population. Methods A total of 613 consecutive kidney transplant recipients were included between 2006 and 2019. Drug exposures and incident fractures during the study period were comprehensively documented, and dual-energy X-ray absorptiometry was performed regularly. The data were analyzed using Cox proportional hazards models with time-dependent covariates and linear mixed models. Results Incident fractures occurred in 63 patients, giving a fracture incidence of 16.9 per 1000 person-years. Exposures to loop diuretics [hazard ratio (95% confidence interval) 2.11 (1.17-3.79)] and opioids [5.94 (2.14-16.52)] were associated with incident fractures. Exposure to loop diuretics was associated with a decrease over time in the T-score for the lumbar spine (P = .022) and for the wrist (P = .028). Conclusions This study suggests that the exposure to loop diuretics and opioids increases the risk of fracture in kidney transplant recipients.
Collapse
Affiliation(s)
| | - Alban Nowak
- Department of Clinical Pharmacology, Amiens University Medical Center, Amiens, France
| | - Alice Séjourné
- Department of Rheumatology, Saint-Quentin Medical Center, Saint-Quentin, France
| | - Clémence Penet
- Department of Rheumatology, Saint-Quentin Medical Center, Saint-Quentin, France
| | - Kamel Masmoudi
- Department of Clinical Pharmacology, Amiens University Medical Center, Amiens, France
| | - François Brazier
- MP3CV Laboratory, EA7517, Jules Verne University of Picardie, Amiens, France,Department of Nephrology Internal Medicine Dialysis Transplantation, Amiens University Medical Center, Amiens, France
| | - Solène M Laville
- Department of Clinical Pharmacology, Amiens University Medical Center, Amiens, France,MP3CV Laboratory, EA7517, Jules Verne University of Picardie, Amiens, France
| | - Youssef Bennis
- Department of Clinical Pharmacology, Amiens University Medical Center, Amiens, France,MP3CV Laboratory, EA7517, Jules Verne University of Picardie, Amiens, France
| | - Valérie Gras-Champel
- Department of Clinical Pharmacology, Amiens University Medical Center, Amiens, France,MP3CV Laboratory, EA7517, Jules Verne University of Picardie, Amiens, France
| | - Gabriel Choukroun
- MP3CV Laboratory, EA7517, Jules Verne University of Picardie, Amiens, France,Department of Nephrology Internal Medicine Dialysis Transplantation, Amiens University Medical Center, Amiens, France
| | - Sophie Liabeuf
- Department of Clinical Pharmacology, Amiens University Medical Center, Amiens, France,MP3CV Laboratory, EA7517, Jules Verne University of Picardie, Amiens, France
| |
Collapse
|
12
|
Haarhaus M, Aaltonen L, Cejka D, Cozzolino M, de Jong RT, D'Haese P, Evenepoel P, Lafage-Proust MH, Mazzaferro S, McCloskey E, Salam S, Skou Jørgensen H, Vervloet M. Management of fracture risk in CKD-traditional and novel approaches. Clin Kidney J 2022; 16:456-472. [PMID: 36865010 PMCID: PMC9972845 DOI: 10.1093/ckj/sfac230] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Indexed: 11/13/2022] Open
Abstract
The coexistence of osteoporosis and chronic kidney disease (CKD) is an evolving healthcare challenge in the face of increasingly aging populations. Globally, accelerating fracture incidence causes disability, impaired quality of life and increased mortality. Consequently, several novel diagnostic and therapeutic tools have been introduced for treatment and prevention of fragility fractures. Despite an especially high fracture risk in CKD, these patients are commonly excluded from interventional trials and clinical guidelines. While management of fracture risk in CKD has been discussed in recent opinion-based reviews and consensus papers in the nephrology literature, many patients with CKD stages 3-5D and osteoporosis are still underdiagnosed and untreated. The current review addresses this potential treatment nihilism by discussing established and novel approaches to diagnosis and prevention of fracture risk in patients with CKD stages 3-5D. Skeletal disorders are common in CKD. A wide variety of underlying pathophysiological processes have been identified, including premature aging, chronic wasting, and disturbances in vitamin D and mineral metabolism, which may impact bone fragility beyond established osteoporosis. We discuss current and emerging concepts of CKD-mineral and bone disorders (CKD-MBD) and integrate management of osteoporosis in CKD with current recommendations for management of CKD-MBD. While many diagnostic and therapeutic approaches to osteoporosis can be applied to patients with CKD, some limitations and caveats need to be considered. Consequently, clinical trials are needed that specifically study fracture prevention strategies in patients with CKD stages 3-5D.
Collapse
Affiliation(s)
| | - Louise Aaltonen
- Turku University Hospital, Kidney Center, Department of Medicine, Turku, Finland
| | - Daniel Cejka
- Department of Medicine III – Nephrology, Hypertension, Transplantation, Rheumatology, Geriatrics, Ordensklinikum Linz - Elisabethinen Hospital, Linz, Austria
| | - Mario Cozzolino
- Department of Health Sciences, Renal Division, University of Milan, ASST Santi Paolo e Carlo, Milan, Italy
| | - Renate T de Jong
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Internal Medicine and Endocrinology, Amsterdam, The Netherlands,Amsterdam Gastroenterology Endocrinology Metabolism Institute, Amsterdam, The Netherlands
| | - Patrick D'Haese
- Laboratory of Pathophysiology, Department of Biomedical Sciences, University of Antwerp, Antwerp, Belgium
| | - Pieter Evenepoel
- Department of Nephrology, University Hospitals Leuven, Leuven, Belgium,Department of Microbiology Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven-University of Leuven, Leuven, Belgium
| | | | - Sandro Mazzaferro
- Nephrology Unit at Policlinico Umberto I Hospital and Department of Translation and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Eugene McCloskey
- Academic Unit of Bone Metabolism, Centre for Integrated research in Musculoskeletal Ageing, Mellanby Centre for Musculoskeletal Research, Department of Oncology & Metabolism, University of Sheffield, Sheffield, UK
| | - Syazrah Salam
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK and Sheffield Kidney Institute, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Hanne Skou Jørgensen
- Department of Microbiology Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven-University of Leuven, Leuven, Belgium,Aarhus University Hospital, Department of Kidney Diseases, Aarhus,Denmark,Aarhus University, Department of Clinical Medicine, Aarhus,Denmark
| | - Marc Vervloet
- Department of Nephrology, Amsterdam University Medical Center, VU University Amsterdam, Amsterdam, The Netherlands,Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, Amsterdam, The Netherlands
| |
Collapse
|
13
|
Tang Z, Li T, Dai H, Feng C, Xie X, Peng F, Lan G, Yu S, Wang Y, Fang C, Nie M, Yuan X, Tang X, Jiang X, Zhu X, Fan Y, Peng J, Sun S, Zhong M, Zhang H, Peng L. Drug-induced Fanconi syndrome in patients with kidney allograft transplantation. Front Immunol 2022; 13:979983. [PMID: 36059468 PMCID: PMC9437944 DOI: 10.3389/fimmu.2022.979983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 08/01/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundPatients after kidney transplantation need to take long-term immunosuppressive and other drugs. Some of these drug side effects are easily confused with the symptoms of Fanconi syndrome, resulting in misdiagnosis and missed diagnosis, and causing serious consequences to patients. Therefore, improving awareness, early diagnosis and treatment of Fanconi syndrome after kidney transplantation is critical.MethodsThis retrospective study analyzed 1728 cases of allogeneic kidney transplant patients admitted to the Second Xiangya Hospital of Central South University from July 2016 to January 2021. Two patients with Fanconi syndrome secondary to drugs, adefovir dipivoxil (ADV) and tacrolimus, were screened. We summarized the diagnostic process, clinical data, and prognosis.ResultsThe onset of Fanconi syndrome secondary to ADV after renal transplantation was insidious, and the condition developed after long-term medication (>10 years). It mainly manifested as bone pain, osteomalacia, and scoliosis in the late stage and was accompanied by obvious proximal renal tubular damage (severe hypophosphatemia, hypokalemia, hypocalcemia, hypouricemia, glycosuria, protein urine, acidosis, etc.) and renal function damage (increased creatinine and azotemia). The pathological findings included mitochondrial swelling and deformity in renal tubular epithelial cells. The above symptoms and signs were relieved after drug withdrawal, but the scoliosis was difficult to rectify. Fanconi syndrome secondary to tacrolimus has a single manifestation, increased creatinine, which can be easily confused with tacrolimus nephrotoxicity. However, it is often ineffective to reduce the dose of tacrolomus, and proximal renal failure can be found in the later stage of disease development. There was no abnormality in the bone metabolism index and imageological examination findings. The creatinine level decreased rapidly, the proximal renal tubule function returned to normal, and no severe electrolyte imbalance or urinary component loss occurred when the immunosuppression was changed from tacrolimus to cyclosporine A.ConclusionsFor the first time, drug-induced Fanconi syndrome after kidney transplantation was reported. These results confirmed that the long-term use of ADV or tacrolimus after kidney transplantation may have serious consequences, some of which are irreversible. Greater understanding of Fanconi syndrome after kidney transplantation is necessary in order to avoid incorrect and missed diagnosis.
Collapse
Affiliation(s)
- Zhouqi Tang
- Department of Kidney Transplantation, The Second Xiangya Hospital of Central South University, Changsha, China
- Clinical Research Center for Organ Transplantation in Hunan Province, Central South University, Changsha, China
| | - Tengfang Li
- Department of Kidney Transplantation, The Second Xiangya Hospital of Central South University, Changsha, China
- Clinical Research Center for Organ Transplantation in Hunan Province, Central South University, Changsha, China
| | - Helong Dai
- Department of Kidney Transplantation, The Second Xiangya Hospital of Central South University, Changsha, China
- Clinical Research Center for Organ Transplantation in Hunan Province, Central South University, Changsha, China
- Clinical Immunology Center, Central South University, Changsha, China
- Department of Organ Transplantation, The Fifth Clinical Medical College of Henan University of Chinese Medicine (Zhengzhou Peole’s Hosital), Zhengzhou, China
| | - Chen Feng
- Department of Kidney Transplantation, The Second Xiangya Hospital of Central South University, Changsha, China
- Clinical Research Center for Organ Transplantation in Hunan Province, Central South University, Changsha, China
| | - Xubiao Xie
- Department of Kidney Transplantation, The Second Xiangya Hospital of Central South University, Changsha, China
- Clinical Research Center for Organ Transplantation in Hunan Province, Central South University, Changsha, China
| | - Fenghua Peng
- Department of Kidney Transplantation, The Second Xiangya Hospital of Central South University, Changsha, China
- Clinical Research Center for Organ Transplantation in Hunan Province, Central South University, Changsha, China
| | - Gongbin Lan
- Department of Kidney Transplantation, The Second Xiangya Hospital of Central South University, Changsha, China
- Clinical Research Center for Organ Transplantation in Hunan Province, Central South University, Changsha, China
| | - Shaojie Yu
- Department of Kidney Transplantation, The Second Xiangya Hospital of Central South University, Changsha, China
- Clinical Research Center for Organ Transplantation in Hunan Province, Central South University, Changsha, China
| | - Yu Wang
- Department of Kidney Transplantation, The Second Xiangya Hospital of Central South University, Changsha, China
- Clinical Research Center for Organ Transplantation in Hunan Province, Central South University, Changsha, China
| | - Chunhua Fang
- Department of Kidney Transplantation, The Second Xiangya Hospital of Central South University, Changsha, China
- Clinical Research Center for Organ Transplantation in Hunan Province, Central South University, Changsha, China
| | - Manhua Nie
- Department of Kidney Transplantation, The Second Xiangya Hospital of Central South University, Changsha, China
- Clinical Research Center for Organ Transplantation in Hunan Province, Central South University, Changsha, China
| | - Xiaoqiong Yuan
- Department of Kidney Transplantation, The Second Xiangya Hospital of Central South University, Changsha, China
- Clinical Research Center for Organ Transplantation in Hunan Province, Central South University, Changsha, China
| | - Xiaotian Tang
- Department of Kidney Transplantation, The Second Xiangya Hospital of Central South University, Changsha, China
- Clinical Research Center for Organ Transplantation in Hunan Province, Central South University, Changsha, China
| | - Xin Jiang
- Department of Organ Transplantation, The Fifth Clinical Medical College of Henan University of Chinese Medicine (Zhengzhou Peole’s Hosital), Zhengzhou, China
| | - Xuejing Zhu
- Department of Nephrology, Hunan Key Laboratory of Kidney Disease and Blood Purification, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Yuxi Fan
- Department of Kidney Transplantation, The Second Xiangya Hospital of Central South University, Changsha, China
- Clinical Research Center for Organ Transplantation in Hunan Province, Central South University, Changsha, China
| | - Jiawei Peng
- Department of Kidney Transplantation, The Second Xiangya Hospital of Central South University, Changsha, China
- Clinical Research Center for Organ Transplantation in Hunan Province, Central South University, Changsha, China
| | - Siyu Sun
- Department of Kidney Transplantation, The Second Xiangya Hospital of Central South University, Changsha, China
- Clinical Research Center for Organ Transplantation in Hunan Province, Central South University, Changsha, China
| | - Mingda Zhong
- Department of Kidney Transplantation, The Second Xiangya Hospital of Central South University, Changsha, China
- Clinical Research Center for Organ Transplantation in Hunan Province, Central South University, Changsha, China
| | - Hedong Zhang
- Department of Kidney Transplantation, The Second Xiangya Hospital of Central South University, Changsha, China
- Clinical Research Center for Organ Transplantation in Hunan Province, Central South University, Changsha, China
| | - Longkai Peng
- Department of Kidney Transplantation, The Second Xiangya Hospital of Central South University, Changsha, China
- Clinical Research Center for Organ Transplantation in Hunan Province, Central South University, Changsha, China
- *Correspondence: Longkai Peng,
| |
Collapse
|
14
|
Kuppachi S, Cheungpasitporn W, Li R, Caliskan Y, Schnitzler MA, McAdams-DeMarco M, Ahn JB, Bae S, Hess GP, Segev DL, Lentine KL, Axelrod DA. Kidney Transplantation, Immunosuppression, and Fracture Risk: Clinical and Economic Implications. Kidney Med 2022; 4:100474. [PMID: 35669410 PMCID: PMC9166366 DOI: 10.1016/j.xkme.2022.100474] [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] [Indexed: 11/18/2022] Open
Abstract
Rationale & Objective Disorders of bone and mineral metabolism frequently develop with advanced kidney disease, may be exacerbated by immunosuppression after kidney transplantation, and increase the risk of fractures. Study Design Retrospective database study. Setting & Participants Kidney-only transplant recipients aged ≥18 years from 2005 to 2016 in the United States captured in US Renal Data System records, which integrate Organ Procurement and Transplantation Network/United Network for Organ Sharing records with Medicare billing claims. Exposures Various immunosuppression regimens in the first 3 months after kidney transplantation. Outcomes The development of fractures, as ascertained using diagnostic codes on Medicare billing claims. Analytical Approach We used multivariable Cox regression with inverse propensity weighting to compare the incidence of fractures >3 months-to-3 years after kidney transplantation associated with various immunosuppression regimens compared to a reference regimen of antithymocyte globulin (TMG) or alemtuzumab (ALEM) with tacrolimus + mycophenolic acid + prednisone using inverse probability treatment weighting. Results Overall, fractures were identified in 7.5% of kidney transplant recipients (women, 8.8%; men, 6.7%; age < 55 years, 5.9%; age ≥ 55 years, 9.3%). In time-varying regression, experiencing a fracture was associated with a substantially increased risk of subsequent death within 3 months (adjusted hazard ratio [aHR], 3.06; 95% confidence interval [CI], 2.45-3.81). Fractures were also associated with increased Medicare spending (first year: $5,122; second year: $10,890; third year: $11,083; [P < 0.001]). Induction with TMG or ALEM and the avoidance or early withdrawal of steroids significantly reduced the risk of fractures in younger (aHR, 0.63; 95% CI, 0.54-0.73) and older (aHR, 0.83; 95% CI, 0.74-0.94) patients. The avoidance or early withdrawal of steroids with any induction was associated with a reduced risk of fractures in women. Limitations This was a retrospective study which lacked data on immunosuppression levels. Conclusions Fractures after kidney transplantation are associated with significantly increased mortality risk and costs. The early avoidance or early withdrawal of steroids after induction with TMG or ALEM reduces the risk of fractures after kidney transplantation and should be considered for patients at high-risk of this complication, including older adults and women.
Collapse
Affiliation(s)
- Sarat Kuppachi
- Organ Transplant Center, University of Iowa, Iowa City, IA
| | | | - Ruixin Li
- Saint Louis University Transplant Center, Saint Louis University, St. Louis, MO
| | - Yasar Caliskan
- Saint Louis University Transplant Center, Saint Louis University, St. Louis, MO
| | - Mark A. Schnitzler
- Saint Louis University Transplant Center, Saint Louis University, St. Louis, MO
| | | | - JiYoon B. Ahn
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Sunjae Bae
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Gregory P. Hess
- Jefferson College of Population Health, Thomas Jefferson University, Philadelphia, PA
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Krista L. Lentine
- Saint Louis University Transplant Center, Saint Louis University, St. Louis, MO
- Address for Correspondence: Krista L. Lentine, MD, PhD, Saint Louis University Transplant Center, 1201 S. Grand Blvd., St. Louis, MO 63104.
| | | |
Collapse
|
15
|
Keronen S, Martola L, Finne P, Burton IS, Tong XF, Kröger H, Honkanen E. Bone volume, mineral density, and fracture risk after kidney transplantation. PLoS One 2022; 17:e0261686. [PMID: 35349587 PMCID: PMC8963906 DOI: 10.1371/journal.pone.0261686] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 12/07/2021] [Indexed: 11/18/2022] Open
Abstract
Background
Disordered mineral metabolism reverses incompletely after kidney transplantation in numerous patients. Post-transplantation bone disease is a combination of pre-existing chronic kidney disease and mineral disorder and often evolving osteoporosis. These two frequently overlapping conditions increase the risk of post-transplantation fractures.
Material and methods
We studied the prevalence of low bone volume in bone biopsies obtained from kidney transplant recipients who were biopsied primarily due to the clinical suspicion of persistent hyperparathyroidism between 2000 and 2015 at the Hospital District of Helsinki and Uusimaa. Parameters of mineral metabolism, results of dual-energy x-ray absorptiometry scans, and the history of fractures were obtained concurrently.
One hundred nine bone biopsies taken at a median of 31 (interquartile range, IQR, 18–70) months after transplantation were included in statistical analysis. Bone turnover was classified as high in 78 (72%) and normal/low in 31 (28%) patients. The prevalence of low bone volume (n = 47, 43%) was higher among patients with low/normal turnover compared to patients with high turnover [18 (58%) vs. 29 (37%), P = 0.05]. Thirty-seven fragility fractures in 23 (21%) transplant recipients corresponding to fracture incidence 15 per 1000 person-years occurred during a median follow-up 9.1 (IQR, 6.3–12.1) years. Trabecular bone volume did not correlate with incident fractures. Accordingly, low bone mineral density at the lumbar spine correlated with low trabecular bone volume, but not with incident fractures. The cumulative corticosteroid dose was an important determinant of low bone volume, but not of incident fractures.
Conclusions
Despite the high prevalence of trabecular bone loss among kidney transplant recipients, the number of fractures was limited. The lack of association between trabecular bone volume and fractures suggests that the bone cortical compartment and quality are important determinants of bone strength and post-transplantation fracture.
Collapse
Affiliation(s)
- Satu Keronen
- Department of Nephrology, Abdominal Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- * E-mail:
| | - Leena Martola
- Department of Nephrology, Abdominal Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Patrik Finne
- Department of Nephrology, Abdominal Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Inari S. Burton
- Kuopio Musculoskeletal Research Unit (KMRU), University of Eastern Finland, Kuopio, Finland
| | - Xiaoyu F. Tong
- Kuopio Musculoskeletal Research Unit (KMRU), University of Eastern Finland, Kuopio, Finland
| | - Heikki Kröger
- Kuopio Musculoskeletal Research Unit (KMRU), University of Eastern Finland, Kuopio, Finland
- Department of Orthopedics, Traumatology and Hand Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Eero Honkanen
- Department of Nephrology, Abdominal Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| |
Collapse
|
16
|
Kizilbash SJ, Jensen CJ, Kouri AM, Balani SS, Chavers B. Steroid avoidance/withdrawal and maintenance immunosuppression in pediatric kidney transplantation. Pediatr Transplant 2022; 26:e14189. [PMID: 34786800 DOI: 10.1111/petr.14189] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/30/2021] [Accepted: 10/06/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Corticosteroids have been an integral part of maintenance immunosuppression for pediatric kidney transplantation. However, prolonged steroid therapy is associated with significant toxicities resulting in several SW/avoidance strategies in recent years. METHOD/OBJECTIVE This comprehensive review aims to discuss steroid-related toxicities and the safety, efficacy, and benefit of steroid avoidance/withdrawal immunosuppression in pediatric kidney transplant recipients. RESULTS Initial studies of SW/avoidance conducted in the setting of CSA and AZA showed an increased incidence of AR but no increase in graft loss or mortality with SW/avoidance maintenance immunosuppression. Studies performed under modern immunosuppression (induction therapy, Tac, and MMF) show no significant increase in AR or graft loss with SW/avoidance immunosuppression. Furthermore, SW/avoidance immunosuppression is associated with significant improvement in growth, BMI, BP control, and lipid profile in pediatric kidney transplant recipients. Despite these data, SW/avoidance remains controversial, and only 40% of pediatric kidney transplant recipients in the United States are currently on SW/avoidance maintenance immunosuppression. CONCLUSION SW/avoidance maintenance immunosuppression is safe and associated with fewer side effects compared with steroid-inclusive maintenance immunosuppression in pediatric kidney transplant recipients.
Collapse
Affiliation(s)
- Sarah J Kizilbash
- Pediatric Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Chelsey J Jensen
- Solid Organ Transplant, University of Minnesota, Minneapolis, Minnesota, USA
| | - Anne M Kouri
- Pediatric Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Shanthi S Balani
- Pediatric Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Blanche Chavers
- Pediatric Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
| |
Collapse
|
17
|
Panel-reactive Antibody and the Association of Early Steroid Withdrawal With Kidney Transplant Outcomes. Transplantation 2022; 106:648-656. [PMID: 33826598 PMCID: PMC8490476 DOI: 10.1097/tp.0000000000003777] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Early steroid withdrawal (ESW) is a viable maintenance immunosuppression strategy in low-risk kidney transplant recipients. A low panel-reactive antibody (PRA) may indicate low-risk condition amenable to ESW. We aimed to identify the threshold value of PRA above which ESW may pose additional risk and to compare the association of ESW with transplant outcomes across PRA strata. METHODS We studied 121 699 deceased-donor kidney-only recipients in 2002-2017 from Scientific Registry of Transplant Recipients. Using natural splines and ESW-PRA interaction terms, we explored how the associations of ESW with transplant outcomes change with increasing PRA values and identified a threshold value for PRA. Then, we assessed whether PRA exceeding the threshold modified the associations of ESW with 1-y acute rejection, death-censored graft failure, and death. RESULTS The association of ESW with acute rejection exacerbated rapidly when PRA exceeded 60. Among PRA ≤60 recipients, ESW was associated with a minor increase in rejection (adjusted odds ratio [aOR], 1.001.051.10) and with a tendency of decreased graft failure (adjusted hazard ratio [aHR], 0.910.971.03). However, among PRA >60 recipients, ESW was associated with a substantial increase in rejection (aOR, 1.191.271.36; interaction P < 0.001) and with a tendency of increased graft failure (aHR, 0.981.081.20; interaction P = 0.028). The association of ESW with death was similar between PRA strata (PRA ≤60, aHR, 0.910.961.01; and PRA >60, aHR, 0.900.991.09; interaction P = 0.5). CONCLUSIONS Our findings show that the association of ESW with transplant outcomes is less favorable in recipients with higher PRA, especially those with PRA >60, suggesting a possible role of PRA in the risk assessment for ESW.
Collapse
|
18
|
Jørgensen HS, Behets G, Bammens B, Claes K, Meijers B, Naesens M, Sprangers B, Kuypers DR, Cavalier E, D’Haese P, Evenepoel P. Natural History of Bone Disease following Kidney Transplantation. J Am Soc Nephrol 2022; 33:638-652. [PMID: 35046132 PMCID: PMC8975071 DOI: 10.1681/asn.2021081081] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 01/09/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Knowledge of the effect of kidney transplantation on bone is limited and fragmentary. The aim of this study was to characterize the evolution of bone disease in the first post-transplant year. METHODS We performed a prospective, observational cohort study in patients referred for kidney transplantation under a steroid-sparing immunosuppressive protocol. Bone phenotyping was done before, or at the time of, kidney transplantation, and repeated at 12 months post-transplant. The phenotyping included bone histomorphometry, bone densitometry by dual-energy x-ray absorptiometry, and biochemical parameters of bone and mineral metabolism. RESULTS Paired data were obtained for 97 patients (median age 55 years; 72% male; 21% of patients had diabetes). Bone turnover remained normal or improved in the majority of patients (65%). Bone histomorphometry revealed decreases in bone resorption (eroded perimeter, mean 4.6% pre- to 2.3% post-transplant; P<0.001) and disordered bone formation (fibrosis, 27% pre- versus 2% post-transplant; P<0.001). Whereas bone mineralization was normal in all but one patient pretransplant, delayed mineralization was seen in 15% of patients at 1 year post-transplant. Hypophosphatemia was associated with deterioration in histomorphometric parameters of bone mineralization. Changes in bone mineral density were highly variable, ranging from -18% to +17% per year. Cumulative steroid dose was related to bone loss at the hip, whereas resolution of hyperparathyroidism was related to bone gain at both spine and hip. CONCLUSIONS Changes in bone turnover, mineralization, and volume post-transplant are related both to steroid exposure and ongoing disturbances of mineral metabolism. Optimal control of mineral metabolism may be key to improving bone quality in kidney transplant recipients. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER Evolution of Bone Histomorphometry and Vascular Calcification Before and After Renal Transplantation, NCT01886950.
Collapse
Affiliation(s)
- Hanne Skou Jørgensen
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium,Department of Kidney Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Geert Behets
- Laboratory of Pathophysiology, University of Antwerp, Wilrijk, Belgium
| | - Bert Bammens
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Kathleen Claes
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Bjorn Meijers
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Ben Sprangers
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Dirk R.J. Kuypers
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Etienne Cavalier
- Department of Clinical Chemistry, University of Liège, Liège, Belgium
| | - Patrick D’Haese
- Laboratory of Pathophysiology, University of Antwerp, Wilrijk, Belgium
| | - Pieter Evenepoel
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium .,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| |
Collapse
|
19
|
Abstract
After kidney transplantation, mineral and bone disorders are associated with higher risk of fractures and consequent morbidity and mortality. Disorders of calcium and phosphorus, vitamin D deficiency, and hyperparathyroidism are also common. The epidemiology of bone disease has evolved over the past several decades due to changes in immunosuppressive regimens, mainly glucocorticoid minimization or avoidance. The assessment of bone disease in kidney transplant recipients relies on risk factor recognition and bone mineral density assessment. Several drugs have been trialed for the treatment of post-transplant mineral and bone disorders. This review will focus on the epidemiology, effect, and treatment of metabolic and skeletal derangements in the transplant recipient.
Collapse
Affiliation(s)
- Pascale Khairallah
- Section of Nephrology and Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, Texas
| | - Thomas L. Nickolas
- Division of Nephrology, Columbia University Irving Medical Center, New York, New York
| |
Collapse
|
20
|
Cianciolo G, Tondolo F, Barbuto S, Angelini A, Ferrara F, Iacovella F, Raimondi C, La Manna G, Serra C, De Molo C, Cavicchi O, Piccin O, D'Alessio P, De Pasquale L, Felisati G, Ciceri P, Galassi A, Cozzolino M. OUP accepted manuscript. Clin Kidney J 2022; 15:1459-1474. [PMID: 35892022 PMCID: PMC9308095 DOI: 10.1093/ckj/sfac050] [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: 12/09/2021] [Indexed: 11/25/2022] Open
Abstract
Chronic kidney disease mineral and bone disorder may persist after successful kidney transplantation. Persistent hyperparathyroidism has been identified in up to 80% of patients throughout the first year after kidney transplantation. International guidelines lack strict recommendations about the management of persistent hyperparathyroidism. However, it is associated with adverse graft and patient outcomes, including higher fracture risk and an increased risk of all-cause mortality and allograft loss. Secondary hyperparathyroidism may be treated medically (vitamin D, phosphate binders and calcimimetics) or surgically (parathyroidectomy). Guideline recommendations suggest medical therapy first but do not clarify optimal parathyroid hormone targets or indications and timing of parathyroidectomy. There are no clear guidelines or long-term studies about the impact of hyperparathyroidism therapy. Parathyroidectomy is more effective than medical treatment, although it is associated with increased short-term risks. Ideally parathyroidectomy should be performed before kidney transplantation to prevent persistent hyperparathyroidism and improve graft outcomes. We now propose a roadmap for the management of secondary hyperparathyroidism in patients eligible for kidney transplantation that includes the indications and timing (pre- or post-kidney transplantation) of parathyroidectomy, the evaluation of parathyroid gland size and the integration of parathyroid gland size in the decision-making process by a multidisciplinary team of nephrologists, radiologists and surgeons.
Collapse
Affiliation(s)
- Giuseppe Cianciolo
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Italy
| | - Francesco Tondolo
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Italy
| | - Simona Barbuto
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Italy
| | - Andrea Angelini
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Italy
| | - Francesca Ferrara
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Italy
| | - Francesca Iacovella
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Italy
| | - Concettina Raimondi
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Italy
| | - Gaetano La Manna
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Italy
| | - Carla Serra
- Interventional, Diagnostic and Therapeutic Ultrasound Unit, Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria Sant’Orsola Malpighi Hospital, Bologna, Italy
| | - Chiara De Molo
- Interventional, Diagnostic and Therapeutic Ultrasound Unit, Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria Sant’Orsola Malpighi Hospital, Bologna, Italy
| | - Ottavio Cavicchi
- Department of Otolaryngology Head and Neck Surgery, IRCSS Azienda Ospedaliero Universitaria di Bologna, Policlinico Sant'Orsola, Bologna, Italy
| | - Ottavio Piccin
- Department of Otolaryngology Head and Neck Surgery, IRCSS Azienda Ospedaliero Universitaria di Bologna, Policlinico Sant'Orsola, Bologna, Italy
| | - Pasquale D'Alessio
- Department of Otolaryngology Head and Neck Surgery, IRCSS Azienda Ospedaliero Universitaria di Bologna, Policlinico Sant'Orsola, Bologna, Italy
| | - Loredana De Pasquale
- Department of Otolaryngology, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Milan, Italy
| | - Giovanni Felisati
- Department of Otolaryngology, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Milan, Italy
| | - Paola Ciceri
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Milan, Italy
| | - Andrea Galassi
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Milan, Italy
| | | |
Collapse
|
21
|
AL-Otaibi NE, Alotaibi AS, Albekairy NA, Shawaqfeh MS, Alotaibi M, Alharbi S, Alkatheri A, Albekairy AM. Assessment of Risk Factors Associated with Bone and Mineral Disease Post-Renal Transplantation: “The Experiences of Two Centers”. TRANSPLANT RESEARCH AND RISK MANAGEMENT 2021. [DOI: 10.2147/trrm.s338844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
|
22
|
Ledford CK, VanWagner MJ, Spaulding AC, Spencer-Gardner LS, Wilke BK, Porter SB. Outcomes of Femoral Neck Fracture Treated With Hip Arthroplasty in Solid Organ Transplant Patients. Arthroplast Today 2021; 11:212-216. [PMID: 34660866 PMCID: PMC8503575 DOI: 10.1016/j.artd.2021.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 08/31/2021] [Accepted: 09/08/2021] [Indexed: 11/29/2022] Open
Abstract
Background Solid organ transplant (SOT) patients have increased risk of complications, infection, and mortality after elective total hip arthroplasty (THA). The study aims to compare SOT recipients' clinical outcomes to a matched group of nontransplant patients after nonelective THA and hemiarthroplasty for acute femoral neck fracture (FNF). Methods A retrospective review identified 31 SOT patients undergoing hip arthroplasty (24 hemiarthroplasty and 7 THA) for FNF and were matched 1:1 to non-SOT patients based on age, sex, body mass index, surgical procedure, and year of surgery. Patient survivorship, perioperative outcomes, complications, and reoperations were compared. The mean follow-up was 3 years. Results The estimated survivorship free from mortality for SOT and non-SOT patients at 1- year was not different (77% and 84%, respectively, P = .52). The 90-day readmission rate was significantly higher with 8 (26%) in the SOT cohort and none in the non-SOT group (P < .01). Major medical complications occurred in 16% of SOT patients compared to 5% in controls (P = .21). Three (10%) reoperations/revisions were required for SOT patients and none in non-SOT group (P = .24). Conclusion SOT recipients undergoing nonelective hip arthroplasty for FNF demonstrated increased readmission rates compared to matched controls. For this rare clinical scenario, diligent perioperative care by surgeons and multidisciplinary transplant specialists is necessary to mitigate increased risk of SOT patients.
Collapse
Affiliation(s)
- Cameron K Ledford
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | | | - Aaron C Spaulding
- Division of Health Delivery Research, Mayo Clinic, Jacksonville, FL, USA
| | | | - Benjamin K Wilke
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Steven B Porter
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
| |
Collapse
|
23
|
Jørgensen HS, Behets G, Bammens B, Claes K, Meijers B, Naesens M, Sprangers B, Kuypers DRJ, D'Haese P, Evenepoel P. Patterns of renal osteodystrophy one year after kidney transplantation. Nephrol Dial Transplant 2021; 36:2130-2139. [PMID: 34383929 DOI: 10.1093/ndt/gfab239] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Renal osteodystrophy is considered common, but is not well characterized, in contemporary kidney transplant recipients. This study reports extensively on bone phenotype by bone histomorphometry, bone densitometry, and novel bone biomarkers 1 year after kidney transplantation. METHODS A transiliac bone biopsy and dual energy x-ray absorptiometry were performed in 141 unselected kidney transplant recipients in this observational cohort study. Blood and 24 hr urine samples were collected simultaneously. RESULTS Median age was 57 ± 11 years, 71% were men, and all were of Caucasian ethnicity. Bone turnover was normal in 71% of patients, low in 26%, and high in just four cases (3%). Hyperparathyroidism with hypercalcemia was present in 13% of patients, of which one had high bone turnover. Delayed bone mineralization was detected in 16% of patients, who were characterized by hyperparathyroidism (137 vs. 53 ρg/mL), a higher fractional excretion of phosphate (40 vs. 32%), and lower levels of phosphate (2.68 vs 3.18 mg/dL) and calcidiol (29 vs. 37 ng/mL) compared to patients with normal bone mineralization. Osteoporosis was present in 15-46% of patients, with the highest prevalence at the distal skeleton. The proportion of osteoporotic patients was comparable across categories of bone turnover and mineralization. CONCLUSION The majority of kidney transplant recipients, including patients with osteoporosis, have a normal bone turnover at 1-year post-transplant. Low bone turnover is seen in a substantial subset, while high bone turnover is rare. Vitamin D deficiency and hypophosphatemia represent potential interventional targets to improve bone health post-transplant.
Collapse
Affiliation(s)
- Hanne Skou Jørgensen
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU, Leuven, Belgium.,Department of Kidney Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Geert Behets
- Laboratory of Pathophysiology, University of Antwerp, Wilrijk, Belgium
| | - Bert Bammens
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU, Leuven, Belgium.,Department of Medicine, Division of Nephrology, University Hospitals Leuven, Belgium
| | - Kathleen Claes
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU, Leuven, Belgium.,Department of Medicine, Division of Nephrology, University Hospitals Leuven, Belgium
| | - Bjorn Meijers
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU, Leuven, Belgium.,Department of Medicine, Division of Nephrology, University Hospitals Leuven, Belgium
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU, Leuven, Belgium.,Department of Medicine, Division of Nephrology, University Hospitals Leuven, Belgium
| | - Ben Sprangers
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU, Leuven, Belgium.,Department of Medicine, Division of Nephrology, University Hospitals Leuven, Belgium
| | - Dirk R J Kuypers
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU, Leuven, Belgium.,Department of Medicine, Division of Nephrology, University Hospitals Leuven, Belgium
| | - Patrick D'Haese
- Laboratory of Pathophysiology, University of Antwerp, Wilrijk, Belgium
| | - Pieter Evenepoel
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU, Leuven, Belgium.,Department of Medicine, Division of Nephrology, University Hospitals Leuven, Belgium
| |
Collapse
|
24
|
Marine n-3 Polyunsaturated Fatty Acids and Bone Mineral Density in Kidney Transplant Recipients: A Randomized, Placebo-Controlled Trial. Nutrients 2021; 13:nu13072361. [PMID: 34371870 PMCID: PMC8308635 DOI: 10.3390/nu13072361] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 06/27/2021] [Accepted: 07/08/2021] [Indexed: 11/17/2022] Open
Abstract
Kidney transplant recipients are at high risk of progressive bone loss and low-energy fractures in the years following transplantation. Marine n-3 polyunsaturated fatty acids (n-3 PUFA) supplementation may have beneficial effects on bone strength. The Omega-3 fatty acids in Renal Transplantation (ORENTRA) trial was an investigator initiated, randomized, placebo-controlled trial investigating the effects of marine n-3 PUFA supplementation after kidney transplantation. Effects of supplementation on bone mineral density (BMD) and calcium metabolism were pre-defined secondary endpoints. Adult kidney transplant recipients (n = 132) were randomized to 2.6 g marine n-3 PUFA supplement or olive oil (control) from 8 to 52 weeks post-transplant. Dual energy X-ray absorptiometry was performed to assess changes in bone mineral density of hip, spine, and forearm, as well as trabecular bone score (TBS) of the lumbar spine. Student's t test was used to assess between-group differences. There were no differences in ΔBMD between the two groups (intervention vs. control) at lumbar spine (-0.020 ± 0.08 vs. -0.007 ± 0.07 g/cm², p = 0.34), total hip (0.001 ± 0.03 vs. -0.005 ± 0.04, p = 0.38), or other skeletal sites in the intention-to-treat analyses. There was no difference in the change in TBS score (0.001 ± 0.096 vs. 0.009 ± 0.102, p = 0.62). Finally, no effect on biochemical parameters of mineral metabolism was seen. Results were similar when analyzed per protocol. In conclusion, we found no significant effect of 44 weeks of supplementation with 2.6 g of marine n-3 PUFA on BMD in kidney transplant recipients.
Collapse
|
25
|
Prevalence of Musculoskeletal Manifestations in Adult Kidney Transplant's Recipients: A Systematic Review. ACTA ACUST UNITED AC 2021; 57:medicina57060525. [PMID: 34071098 PMCID: PMC8224589 DOI: 10.3390/medicina57060525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 05/19/2021] [Accepted: 05/21/2021] [Indexed: 11/17/2022]
Abstract
Background and Objectives: The musculoskeletal (MSK) manifestations in the kidney transplant recipient (KTxR) could lead to decreased quality of life and increased morbidity and mortality. However, the prevalence of these MSK manifestations is still not well-recognized. This review aimed to investigate the prevalence and outcomes of MSK manifestations in KTxR in the last two decades. Materials and Methods: Research was performed in EBSCO, EMBASE, CINAHL, PubMed/MEDLINE, Cochrane, Google Scholar, PsycINFO, Scopus, Science Direct, and Web of Science electronic databases were searched during the years 2000–2020. Results: The PRISMA flow diagram revealed the search procedure and that 502 articles were retrieved from the initial search and a total of 26 articles were included for the final report in this review. Twelve studies reported bone loss, seven studies reported a bone pain syndrome (BPS) or cyclosporine-induced pain syndrome (CIPS), and seven studies reported hyperuricemia (HU) and gout. The prevalence of MSK manifestations in this review reported as follow: BPS/CIPS ranged from 0.82% to 20.7%, while bone loss ranged from 14% to 88%, and the prevalence of gout reported in three studies as 7.6%, 8.0%, and 22.37%, while HU ranged from 38% to 44.2%. Conclusions: The post-transplantation period is associated with profound MSK abnormalities of mineral metabolism and bone loss mainly caused by corticosteroid therapy, which confer an increased fracture risk. Cyclosporine (CyA) and tacrolimus were responsible for CIPS, while HU or gout was attributable to CyA. Late diagnosis or treatment of post-transplant bone disease is associated with lower quality of life among recipients
Collapse
|
26
|
Jørgensen HS, David K, Salam S, Evenepoel P. Traditional and Non-traditional Risk Factors for Osteoporosis in CKD. Calcif Tissue Int 2021; 108:496-511. [PMID: 33586002 DOI: 10.1007/s00223-020-00786-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 12/02/2020] [Indexed: 12/11/2022]
Abstract
Osteoporosis is a state of bone fragility with reduced skeletal resistance to trauma, and consequently increased risk of fracture. A wide range of conditions, including traditional risk factors, lifestyle choices, diseases and their treatments may contribute to bone fragility. It is therefore not surprising that the multi-morbid patient with chronic kidney disease (CKD) is at a particularly high risk. CKD is associated with reduced bone quantity, as well as impaired bone quality. Bone fragility in CKD is a composite of primary osteoporosis, accumulation of traditional and uremia-related risk factors, assaults brought on by systemic disease, and detrimental effects of drugs. Some risk factors are modifiable and represent potential targets for intervention. This review provides an overview of the heterogeneity of bone fragility in CKD.
Collapse
Affiliation(s)
- Hanne Skou Jørgensen
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Karel David
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Laboratory of Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Syazrah Salam
- Sheffield Kidney Institute, Sheffield Teaching Hospitals National Health Service Foundation Trust, Sheffield, UK
- Academic Unit of Bone Metabolism and 3 Mellanby Centre for Bone Research, Medical School, University of Sheffield, Sheffield, UK
| | - Pieter Evenepoel
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium.
| | | |
Collapse
|
27
|
Al Jurdi A, Da Silva Martins J, Riella LV. Mineral Bone Disorders in Kidney Transplantation. Semin Nephrol 2021; 41:168-179. [PMID: 34140095 DOI: 10.1016/j.semnephrol.2021.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Bone disease after kidney transplantation is associated with an increased risk of fractures, morbidity, and mortality. Its pathophysiology is complex, involving multiple contributors including pretransplant bone disease, immunosuppressive medications, and changes in the parathyroid-bone-kidney axis. Risk scores, bone turnover markers, and noninvasive imaging modalities are only able to partially predict the fracture risk in kidney transplant recipients. The optimal management of bone disease after kidney transplantation has not yet been established, with only a limited number of randomized clinical trials evaluating the efficacy of treatment regimens in kidney transplant recipients. This review focuses on the pathophysiology, evaluation, prevention, and treatment of post-kidney transplant mineral and bone disease as guided by recent evidence.
Collapse
Affiliation(s)
- Ayman Al Jurdi
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Leonardo V Riella
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| |
Collapse
|
28
|
Bae S, Garonzik-Wang JM, Massie AB, McAdams-DeMarco MA, Coresh J, Segev DL. Inconsistencies in the association of clinical factors with the choice of early steroid withdrawal across kidney transplant centers: A national registry study. Clin Transplant 2021; 35:e14176. [PMID: 33259086 PMCID: PMC8284554 DOI: 10.1111/ctr.14176] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 11/20/2020] [Accepted: 11/24/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Approximately 30% of kidney transplant recipients undergo early steroid withdrawal (ESW) for maintenance immunosuppression. However, there is no consensus on which patients are suitable for ESW, and transplant centers may disagree on how various clinical factors characterize individual recipients' suitability for ESW. METHODS To examine center-level variation in the association of clinical factors with the choice of ESW, we studied 206 544 kidney transplant recipients from 278 centers in 2002-2017 using SRTR data. We conducted multi-level logistic regressions to characterize the association of clinical factors with the choice of ESW at each transplant center. RESULTS The association of clinical factors with the choice of ESW varied substantially across centers. We found particularly greater inconsistency in recipient age, PRA, re-transplantation, living/deceased donor, post-transplant length of stay, and delayed graft function. For example, across the entire population, re-transplantation was associated with lower odds of ESW (population odds ratio = 0.35 0.400.46 ). When estimated at each center, this odds ratio was significantly lower than the population odds ratio at 48 (17.3%) centers and significantly higher at 28 (10.1%) centers. CONCLUSIONS We have observed apparent inconsistencies across transplant centers in the practice of tailoring ESW to the recipient's risk profile. Standardized guidelines for ESW tailoring are needed.
Collapse
Affiliation(s)
- Sunjae Bae
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Allan B Massie
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Mara A McAdams-DeMarco
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| |
Collapse
|
29
|
Factors Related to Bone Metabolism in Kidney Transplant Recipients. Mediators Inflamm 2021; 2021:6679095. [PMID: 33510582 PMCID: PMC7826208 DOI: 10.1155/2021/6679095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 01/08/2021] [Indexed: 02/06/2023] Open
Abstract
This study is aimed at establishing the prevalence of osteoporosis and osteopenia in kidney transplant recipients (KTRs) and determining the risk factors for bone mass loss. We invited KTRs who were under regular follow-up at Jiangxi Provincial People's Hospital Affiliated with Nanchang University to attend an assessment of osteoporotic risk assessed by questionnaire, biochemical profile, and dual-energy X-ray absorptiometry (DXA) scanning of the lumbar spine, total hip, and femoral neck. Binary logistic regression models were used to investigate the relationship between the different variables and bone mass density (BMD). A total of 216 patients satisfied the inclusion criteria. The group consisted of 156 men (72.22%) and 60 women (27.78%), and the mean age was 41.50 ± 9.98 years. There were 81 patients with normal bone mass (37.50%) and 135 patients with bone mass loss (62.50%). Logistic regression analysis showed that a higher phosphorus value and higher alkaline phosphatase concentration and a longer use of glucocorticoids were risk factors for bone mass loss in KTRs, and maintaining an appropriate weight and exercising an appropriate number of times per week helped to maintain bone mass.
Collapse
|
30
|
Iseri K, Carrero JJ, Evans M, Felländer-Tsai L, Berg HE, Runesson B, Stenvinkel P, Lindholm B, Qureshi AR. Incidence of Fractures Before and After Dialysis Initiation. J Bone Miner Res 2020; 35:2372-2380. [PMID: 32717115 PMCID: PMC7757394 DOI: 10.1002/jbmr.4141] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 07/13/2020] [Accepted: 07/19/2020] [Indexed: 12/22/2022]
Abstract
Fractures are common in dialysis patients, but little is known about the trajectory of incidence rates of different types of fractures before and after dialysis initiation. To address this, we investigated the incidence of major fractures before and after dialysis initiation. We performed a retrospective statistical analysis using the Swedish Renal Registry of 9041 incident dialysis patients (median age 67 years, 67% men) starting dialysis 2005 through 2015 to identify major fractures (hip, spine, humerus, and forearm) occurring during the dialysis transition period from 1 year before until 1 year after dialysis initiation. Using flexible parametric hazard models and the Fine-Gray model, we estimated adjusted fracture incidence rates and predictors of major fractures. We identified 361 cases with primary diagnosis of major fracture, of which 196 (54%) were hip fractures. The crude incidence rate of major fractures before dialysis initiation was 17 per 1000 patient-years (n = 157) and after dialysis initiation it was 24 per 1000 patient-years (n = 204). The adjusted incidence rate of major fractures began to increase 6 months before dialysis initiation, and then stabilized at a higher rate after 1 year. The adjusted incidence rate of hip fractures started to increase sharply 3 months before dialysis initiation, peaked at initiation, and declined thereafter. In contrast, the adjusted incidence rate of non-hip fractures was stable during the transition period and gradually increased over time. Higher age, female sex, and history of previous major fractures were associated with increased fracture incidence both before and after dialysis initiation. We conclude that the incidence of major fractures, especially hip fractures, start to rise 6 months before initiation of dialysis therapy, indicating that heightened surveillance with implementation of preventive measures to avoid fractures is warranted during the transition period to dialysis. © 2020 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
Collapse
Affiliation(s)
- Ken Iseri
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.,Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Juan Jesús Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Marie Evans
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Li Felländer-Tsai
- Division of Orthopaedics and Biotechnology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Hans E Berg
- Division of Orthopaedics and Biotechnology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Björn Runesson
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Peter Stenvinkel
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Bengt Lindholm
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Abdul Rashid Qureshi
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
31
|
Hauge SC, Frost M, Hansen D. Understanding Bone Disease in Patients with Diabetic Kidney Disease: a Narrative Review. Curr Osteoporos Rep 2020; 18:727-736. [PMID: 33048275 DOI: 10.1007/s11914-020-00630-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Both diabetes and kidney disease associate with the development of bone disease and an increased risk of fragility fractures. The etiologies of bone disease in patients with diabetic kidney disease (DKD) are multiple and complex. This review explores the association between DKD and bone disease and discusses how the presence of both diabetes and kidney disease may impair bone quality and increase fracture risk. Diagnostic tools as well as future research areas are also discussed. RECENT FINDINGS Patients with DKD have an increased risk of fragility fracture, most pronounced in patients with type 1 diabetes, and in DKD a high prevalence of adynamic bone disease is found. Recent studies have demonstrated disturbances in the interplay between bone regulating factors in DKD, such as relative hypoparathyroidism and alterations of bone-derived hormones including fibroblast growth factor-23 (FGF-23), sclerostin and klotho, which lead to bone disease. This review examines the current knowledge on bone disease in patients with DKD, clinical considerations for patient care, as well as subjects for future research.
Collapse
Affiliation(s)
- Sabina Chaudhary Hauge
- Department of Nephrology, Herlev Hospital, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark.
| | - Morten Frost
- Department of Endocrinology, Odense University Hospital, Kløvervænget 6, 5000, Odense C, Denmark
| | - Ditte Hansen
- Department of Nephrology, Herlev Hospital, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen N, Denmark
| |
Collapse
|
32
|
Batteux B, Gras-Champel V, Lando M, Brazier F, Mentaverri R, Desailly-Henry I, Rey A, Bennis Y, Masmoudi K, Choukroun G, Liabeuf S. Early steroid withdrawal has a positive effect on bone in kidney transplant recipients: a propensity score study with inverse probability-of-treatment weighting. Ther Adv Musculoskelet Dis 2020; 12:1759720X20953357. [PMID: 33193832 PMCID: PMC7604996 DOI: 10.1177/1759720x20953357] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 08/01/2020] [Indexed: 12/17/2022] Open
Abstract
Background: Long-term corticosteroid use after kidney transplantation is associated with a decrease in bone mineral density (BMD) and a high fracture risk. We hypothesized that patients with early steroid withdrawal (ESW) would display a gain in BMD in the year following kidney transplantation, when compared with patients on long-term corticosteroid therapy. Methods: In a cohort of kidney transplant recipients, 356 patients were included between 2012 and 2019. Dual-energy X-ray absorptiometry was performed 1 and 12 months after transplantation. The data were analyzed using linear regression with inverse probability-of-treatment weighting (based on a propensity score). Results: At 1 year after transplantation, the gain in BMD was significantly greater in recipients with ESW than in recipients on long-term corticosteroid therapy for the lumbar spine (+0.036 g/cm2, p < 0.001) and the femoral neck (+0.020 g/cm2, p = 0.035). Among patients with ESW, (i) none had osteoporosis, (ii) the percentage with normal BMD increased from 33.3% at month 1 to 54.4% at month 12, and (iii) the percentage with osteopenia fell from 56.2% to 45.6%. In patients undergoing long-term corticosteroid therapy, the fracture incidence was 13.5 per 1000 person-years. None of the patients in the ESW group experienced a fracture. Conclusion: ESW has a positive effect on bone in kidney transplant recipients.
Collapse
Affiliation(s)
- Benjamin Batteux
- Department of Clinical Pharmacology, Amiens University Medical Center, Rue du Professeur Christian Cabrol, Amiens, 80054, France
| | - Valérie Gras-Champel
- Regional Pharmacovigilance Centre, Department of Clinical Pharmacology, Amiens University Medical Center, Amiens, France
| | - Mathilde Lando
- Department of Nephrology Internal Medicine Dialysis Transplantation, Amiens University Medical Center, Amiens, France
| | - François Brazier
- Department of Nephrology Internal Medicine Dialysis Transplantation, Amiens University Medical Center, Amiens, France
| | - Romuald Mentaverri
- MP3CV Laboratory, EA7517, Jules Verne University of Picardie, Amiens, France
| | | | - Amayelle Rey
- Regional Pharmacovigilance Centre, Department of Clinical Pharmacology, Amiens University Medical Center, Amiens, France
| | - Youssef Bennis
- Regional Pharmacovigilance Centre, Department of Clinical Pharmacology, Amiens University Medical Center, Amiens, France
| | - Kamel Masmoudi
- Regional Pharmacovigilance Centre, Department of Clinical Pharmacology, Amiens University Medical Center, Amiens, France
| | - Gabriel Choukroun
- MP3CV Laboratory, EA7517, Jules Verne University of Picardie, Amiens, France
| | - Sophie Liabeuf
- Regional Pharmacovigilance Centre, Department of Clinical Pharmacology, Amiens University Medical Center, Amiens, France
| |
Collapse
|
33
|
Iseri K, Carrero JJ, Evans M, Felländer-Tsai L, Berg HE, Runesson B, Stenvinkel P, Lindholm B, Qureshi AR. Fractures after kidney transplantation: Incidence, predictors, and association with mortality. Bone 2020; 140:115554. [PMID: 32730931 DOI: 10.1016/j.bone.2020.115554] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 07/18/2020] [Accepted: 07/21/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Major fractures (MF) are associated with increased mortality in the general population and represent an even higher risk in patients with chronic kidney disease. We investigated incidence, predictors and clinical outcomes associated with first MF (MFfirst) following kidney transplantation (KT). METHODS We used the Swedish National Renal Registry of 3992 first KT recipients (2005-2016) (median age 53 years, 65% men) and identified all MFfirst in hip, spine, humerus and forearm following KT. We estimated incidence rates and predictors of MFfirst using flexible parametric hazard models and Fine-Gray analysis accounting for competing risk of death, and risk of all-cause mortality following MFfirst using Cox proportional hazards models with fracture as time-varying exposure. RESULTS During median follow-up of 4.8 years (IQR 2.2-7.9 years), there were 279 fractures of which 139 were forearm fractures. The crude incidence rate of MFfirst (n = 279) was 13.5/1000 patient-years and that of hip fractures (n = 69) 3.4/1000 patient-years. The multivariate-adjusted fracture incidence rates were highest during the first 6 months following KT, and 86% higher in women than in men. High age, female sex, previous history of MF, diabetes nephropathy, pretransplant dialysis therapy and acute rejection were associated with increased risk for MFfirst, whereas pre-emptive KT was associated with lower risk of MFfirst. Spline curves showed markedly higher impact of higher age on risk of MFfirst in women than in men. MFfirst (n = 279) independently predicted increased all-cause mortality risk (hazard ratio, HR, 1.78(95%CI 1.35-2.36)). Among MFfirst, with humerus fracture as reference, hip fracture (HR, 4.68(95%CI 1.56-14.06)) and spine fracture (HR, 4.02(95%CI 1.19-13.54)), but not forearm fracture (HR, 1.17 (95%CI 0.38-3.53)), were associated with increased all-cause mortality risk. CONCLUSIONS The initial 6 months following kidney transplantation is a high-risk period for MF. Among MF, hip fracture and spine fracture associate with substantially increased all-cause mortality risk.
Collapse
Affiliation(s)
- Ken Iseri
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan.
| | - Juan Jesús Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Marie Evans
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Li Felländer-Tsai
- Division of Orthopaedics and Biotechnology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Hans E Berg
- Division of Orthopaedics and Biotechnology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Björn Runesson
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Peter Stenvinkel
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Bengt Lindholm
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Abdul Rashid Qureshi
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
34
|
Foster JG, Foster KJ. Care of the Renal Transplant Patient. Prim Care 2020; 47:703-712. [PMID: 33121638 DOI: 10.1016/j.pop.2020.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Renal transplant has become a mainstay of treatment of patients with chronic renal failure. With improving survival outcomes, primary care physicians should be informed of the nuances that come with the ongoing care of this population and feel empowered to take part in the multidisciplinary care of these patients. This article provides an overview of the renal transplant process from initial evaluation through surgery and then focuses on long-term issues that renal transplant patients face in the primary care setting.
Collapse
Affiliation(s)
- Jennifer G Foster
- Charles E. Schmidt College of Medicine, Florida Atlantic University, 777 Glades Road, ME-104, Boca Raton, FL 33431, USA.
| | - Keith J Foster
- Broward Health North, 201 East Sample Road, Deerfield Beach, FL 33064, USA
| |
Collapse
|
35
|
Evenepoel P, Claes K, Meijers B, Laurent MR, Bammens B, Naesens M, Sprangers B, Cavalier E, Kuypers D. Natural history of mineral metabolism, bone turnover and bone mineral density in de novo renal transplant recipients treated with a steroid minimization immunosuppressive protocol. Nephrol Dial Transplant 2020; 35:697-705. [PMID: 30339234 DOI: 10.1093/ndt/gfy306] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 08/15/2018] [Indexed: 01/08/2023] Open
Abstract
The skeletal effects of renal transplantation are not completely understood, especially in patients managed with a steroid minimization immunosuppressive protocol and long term. We enrolled 69 adult transplant recipients (39 males; ages 51.1 ± 12.2 years), free of antiresorptive therapy and managed with a steroid minimization immunosuppressive protocol, into a 5-year prospective observational study to evaluate changes in areal bone mineral density (aBMD), mineral metabolism and bone remodelling. Dual energy X-ray absorptiometry, laboratory parameters of mineral metabolism (including parathyroid hormone, sclerostin and fibroblast growth factor 23) and non-renal cleared bone turnover markers (BTMs) (bone-specific alkaline phosphatase, trimeric N-terminal propeptide and tartrate-resistant acid phosphatase 5b) were assessed at baseline and 1 and 5 years post-transplantation. The mean cumulative methylprednisolone exposure at 1 and 5 years amounted to 2.5 ± 0.8 and 5.8 ± 3.3 g, respectively. Overall, bone remodelling activity decreased after transplantation. Post-transplant aBMD changes were minimal and were significant only in the ultradistal radius during the first post-operative year {median -2.2% [interquartile range (IQR) -5.9-1.2] decline, P = 0.01} and in the lumbar spine between Years 1 and 5 [median 1.6% (IQR -3.2-7.0) increase, P = 0.009]. BTMs, as opposed to mineral metabolism parameters and cumulative corticosteroid exposure, associated with aBMD changes, both in the early and late post-transplant period. Most notably, aBMD changes inversely associated with bone remodelling changes. In summary, in de novo renal transplant recipients treated with a steroid minimization immunosuppressive protocol, BMD changes are limited, highly variable and related to remodelling activity rather than corticosteroid exposure.
Collapse
Affiliation(s)
- Pieter Evenepoel
- Laboratory of Nephrology, KU Leuven Department of Microbiology and Immunology, University Hospitals Leuven, Leuven, Belgium.,Department of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Kathleen Claes
- Laboratory of Nephrology, KU Leuven Department of Microbiology and Immunology, University Hospitals Leuven, Leuven, Belgium.,Department of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Björn Meijers
- Laboratory of Nephrology, KU Leuven Department of Microbiology and Immunology, University Hospitals Leuven, Leuven, Belgium.,Department of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | | | - Bert Bammens
- Laboratory of Nephrology, KU Leuven Department of Microbiology and Immunology, University Hospitals Leuven, Leuven, Belgium.,Department of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Maarten Naesens
- Laboratory of Nephrology, KU Leuven Department of Microbiology and Immunology, University Hospitals Leuven, Leuven, Belgium.,Department of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Ben Sprangers
- Laboratory of Nephrology, KU Leuven Department of Microbiology and Immunology, University Hospitals Leuven, Leuven, Belgium.,Department of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | | | - Dirk Kuypers
- Laboratory of Nephrology, KU Leuven Department of Microbiology and Immunology, University Hospitals Leuven, Leuven, Belgium.,Department of Nephrology, University Hospitals Leuven, Leuven, Belgium
| |
Collapse
|
36
|
Risk Factors and Management of Osteoporosis Post-Transplant. ACTA ACUST UNITED AC 2020; 56:medicina56060302. [PMID: 32575603 PMCID: PMC7353876 DOI: 10.3390/medicina56060302] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 06/11/2020] [Accepted: 06/17/2020] [Indexed: 02/06/2023]
Abstract
Bone and mineral disorders are common after organ transplantation. Osteoporosis post transplantation is associated with increased morbidity and mortality. Pathogenesis of bone disorders in this particular sub set of the population is complicated by multiple co-existing factors like preexisting bone disease, Vitamin D deficiency and parathyroid dysfunction. Risk factors include post-transplant immobilization, steroid usage, diabetes mellitus, low body mass index, older age, female sex, smoking, alcohol consumption and a sedentary lifestyle. Immunosuppressive medications post-transplant have a negative impact on outcomes, and further aggravate osteoporotic risk. Management is complex and challenging due to the sub-optimal sensitivity and specificity of non-invasive diagnostic tests, and the underutilization of bone biopsy. In this review, we summarize the prevalence, pathophysiology, diagnostic tests and management of osteoporosis in solid organ and hematopoietic stem cell transplant recipients.
Collapse
|
37
|
Bae S, Garonzik Wang JM, Massie AB, Jackson KR, McAdams-DeMarco MA, Brennan DC, Lentine KL, Coresh J, Segev DL. Early Steroid Withdrawal in Deceased-Donor Kidney Transplant Recipients with Delayed Graft Function. J Am Soc Nephrol 2019; 31:175-185. [PMID: 31852720 DOI: 10.1681/asn.2019040416] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 09/10/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Early steroid withdrawal (ESW) is associated with acceptable outcomes in kidney transplant (KT) recipients. Recipients with delayed graft function (DGF), however, often have a suboptimal allograft milieu, which may alter the risk/benefit equation for ESW. This may contribute to varying practices across transplant centers. METHODS Using the Scientific Registry of Transplant Recipients, we studied 110,019 adult deceased-donor KT recipients between 2005 and 2017. We characterized the association of DGF with the use of ESW versus continued steroid maintenance across KT centers, and quantified the association of ESW with acute rejection, graft failure, and mortality using multivariable logistic and Cox regression with DGF-ESW interaction terms. RESULTS Overall 29.2% of KT recipients underwent ESW. Recipients with DGF had lower odds of ESW (aOR=0.600.670.75). The strength of this association varied across 261 KT centers, with center-specific aOR of <0.5 at 31 (11.9%) and >1.0 at 22 (8.4%) centers. ESW was associated with benefits and harms among recipients with immediate graft function (IGF), but only with harms among recipients with DGF. ESW was associated with increased acute rejection (aOR=1.091.161.23), slightly increased graft failure (aHR=1.011.061.12), but decreased mortality (aHR=0.860.890.93) among recipients with IGF. Among recipients with DGF, ESW was associated with a similar increase in rejection (aOR=1.12; 95% CI, 1.02 to 1.23), a more pronounced increase in graft failure (aHR=1.16; 95% CI, 1.08 to 1.26), and no improvement in mortality (aHR=1.00; 95% CI, 0.94 to 1.07). DGF-ESW interaction was statistically significant for graft failure (P=0.04) and mortality (P=0.003), but not for rejection (P=0.6). CONCLUSIONS KT centers in the United States use ESW inconsistently in recipients with DGF. Our findings suggest ESW may lead to worse KT outcomes in recipients with DGF.
Collapse
Affiliation(s)
- Sunjae Bae
- Departments of Epidemiology and.,Departments of Surgery and.,Biostatistics, Johns Hopkins School of Public Health, Baltimore, Maryland
| | | | - Allan B Massie
- Departments of Epidemiology and.,Departments of Surgery and
| | | | | | - Daniel C Brennan
- Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Krista L Lentine
- Center for Abdominal Transplantation, Saint Louis University, St. Louis, Missouri
| | - Josef Coresh
- Departments of Epidemiology and.,Biostatistics, Johns Hopkins School of Public Health, Baltimore, Maryland.,Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Dorry L Segev
- Departments of Epidemiology and .,Departments of Surgery and
| |
Collapse
|
38
|
Lee ES, Lim JH, Cho JH, Jung HY, Choi JY, Park SH, Kim YL, Ro H, Lee S, Han SY, Jung CW, Park JB, Kim MS, Yang J, Ahn C, Kim CD. Pretransplant Osteoporosis and Osteopenia are Risk Factors for Fractures After Kidney Transplantation. Transplant Proc 2019; 51:2704-2709. [DOI: 10.1016/j.transproceed.2019.03.071] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 03/12/2019] [Indexed: 11/16/2022]
|
39
|
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
|
40
|
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.
Collapse
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
| |
Collapse
|
41
|
Bone mineral density, bone turnover markers, and incident fractures in de novo kidney transplant recipients. Kidney Int 2019; 95:1461-1470. [DOI: 10.1016/j.kint.2018.12.024] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 11/12/2018] [Accepted: 12/13/2018] [Indexed: 11/20/2022]
|
42
|
Aleksova J, Ng KW, Jung C, Zeimer H, Dwyer KM, Milat F, MacIsaac RJ. Bone health in chronic kidney disease-mineral and bone disorder: a clinical case seminar and update. Intern Med J 2019; 48:1435-1446. [PMID: 30302919 DOI: 10.1111/imj.14129] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 08/15/2018] [Accepted: 08/25/2018] [Indexed: 12/14/2022]
Abstract
The metabolic abnormalities affecting bone in the setting of chronic kidney disease (CKD) are complex with overlapping and interacting aetiologies and have challenging diagnostic and management strategies. Disturbances in calcium, phosphate, fibroblast growth factor 23, parathyroid hormone concentrations and vitamin D deficiency are commonly encountered and contribute to the clinical syndromes of bone disorders in CKD, including hyperparathyroidism, osteomalacia, osteoporosis and adynamic bone disease. Mineral and bone abnormalities may also persist or arise de novo post-renal transplantation. The Kidney Disease Improving Global Outcomes organisation describes these mineral metabolism derangements and skeletal abnormalities as 'CKD Mineral and Bone Disorder'. Patients with this disorder have an increased risk of fracture, cardiovascular events and overall increased mortality. In light of the recently updated 2017 guidelines from the Kidney Disease Improving Global Outcomes, we present a clinical case-based discussion to highlight the complexities of investigating and managing the bone health of patients with CKD with a focus on these updates.
Collapse
Affiliation(s)
- Jasna Aleksova
- Hudson Institute for Medical Research, Melbourne, Victoria, Australia.,Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Kong W Ng
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Caroline Jung
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Howard Zeimer
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Karen M Dwyer
- School of Medicine, Faculty of Health, Deakin University, Melbourne, Victoria, Australia
| | - Frances Milat
- Hudson Institute for Medical Research, Melbourne, Victoria, Australia.,Department of Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Endocrinology, Monash Health, Melbourne, Victoria, Australia
| | - Richard J MacIsaac
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
43
|
Marques IDB, Araújo MJCLN, Graciolli FG, Dos Reis LM, Pereira RMR, Alvarenga JC, Custódio MR, Jorgetti V, Elias RM, Moysés RMA, David-Neto E. A Randomized Trial of Zoledronic Acid to Prevent Bone Loss in the First Year after Kidney Transplantation. J Am Soc Nephrol 2019; 30:355-365. [PMID: 30606784 DOI: 10.1681/asn.2018060656] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 11/25/2018] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Bone and mineral disorders commonly affect kidney transplant (KTx) recipients and have been associated with a high risk of fracture. Bisphosphonates may prevent or treat bone loss in such patients, but there is concern that these drugs might induce adynamic bone disease (ABD). METHODS In an open label, randomized trial to assess the safety and efficacy of zoledronate for preventing bone loss in the first year after kidney transplant, we randomized 34 patients before transplant to receive zoledronate or no treatment. We used dual-energy x-ray absorptiometry (DXA), high-resolution peripheral quantitative computed tomography (HR-pQCT), and bone biopsies to evaluate changes in bone in the 32 evaluable participants between the time of KTx and 12 months post-transplant. RESULTS Both groups of patients experienced decreased bone turnover after KTx, but zoledronate itself did not affect this outcome. Unlike previous studies, DXA showed no post-transplant bone loss in either group; we instead observed an increase of bone mineral density in both lumbar spine and total hip sites, with a significant positive effect of zoledronate. However, bone biopsies showed post-transplant impairment of trabecular connectivity (and no benefit from zoledronate); HR-pQCT detected trabecular bone loss at the peripheral skeleton, which zoledronate partially attenuated. CONCLUSIONS Current immunosuppressive regimens do not contribute to post-transplant central skeleton trabecular bone loss, and zoledronate does not induce ABD. Because fractures in transplant recipients are most commonly peripheral fractures, clinicians should consider bisphosphonate use in patients at high fracture risk who have evidence of significantly low bone mass at these sites at the time of KTx.
Collapse
Affiliation(s)
| | | | | | | | - Rosa Maria R Pereira
- Rheumatology Divisions, Hospital das Clínicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Jackeline C Alvarenga
- Rheumatology Divisions, Hospital das Clínicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | | | | | | | | |
Collapse
|
44
|
Sidibé A, Auguste D, Desbiens L, Fortier C, Wang YP, Jean S, Moore L, Mac‐Way F. Fracture Risk in Dialysis and Kidney Transplanted Patients: A Systematic Review. JBMR Plus 2019; 3:45-55. [PMID: 30680363 PMCID: PMC6339558 DOI: 10.1002/jbm4.10067] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 06/07/2018] [Accepted: 06/14/2018] [Indexed: 12/14/2022] Open
Abstract
Chronic kidney disease is associated with an increased risk of fracture and cardiovascular mortality. The risk of fracture in hemodialysis (HD), peritoneal dialysis (PD) and kidney transplant (KT) patients is higher when compared with the general population. However, there exists a knowledge gap concerning which group has the highest risk of fracture. We aimed to compare the risk of fracture in HD, PD, and KT populations. We conducted a systematic review of observational studies evaluating the risk of fracture in HD, PD, or KT patients. Eligible studies were searched using MEDLINE, Embase, Web of Science, and Cochrane Library from their inception to January 2016, and in grey literature. Incidences (cumulative and rate) of fracture were described together using the median, according to fracture sites, the data source (administrative database or cohort and clinical registry), and fracture diagnosis method. Prevalence estimates were described separately. We included 47 studies evaluating the risk of fracture in HD, PD, and KT populations. In administrative database studies, incidence of hip fracture in HD (median 11.45 per 1000 person-years [p-y]), range: 9.3 to 13.6 was higher than in KT (median 2.6 per 1000 p-y; range 1.5 to 3.8) or in PD (median 5.2 per 1000 p-y; range 4.1 to 6.3). In dialysis (HD+PD), three studies reported a higher incidence of hip fracture than in KT. Prevalent vertebral fracture (assessed by X-rays or questionnaire) reported in HD was in a similar range as that reported in KT. Incidence of overall fracture was similar in HD and KT, from administrative databases studies, but lower in HD compared with KT, from cohorts or clinical registry studies. This systematic review suggests an important difference in fracture risk between HD, PD, and KT population, which vary according to the diagnosis method for fracture identification. © 2018 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.
Collapse
Affiliation(s)
- Aboubacar Sidibé
- Centre de Recherche du CHU de QuébecHôpital Hôtel‐Dieu de QuébecDivision of Nephrology, Endocrinology, and Nephrology AxisFaculty of MedicineDepartment of Social and Preventive MedicineLaval UniversityQuebecCanada
| | - David Auguste
- Centre de Recherche du CHU de QuébecHôpital Saint‐SacrementFaculty of MedicineDepartment of Social and Preventive MedicineLaval UniversityQuebecCanada
| | - Louis‐Charles Desbiens
- Centre de Recherche du CHU de QuébecHôpital Hôtel‐Dieu de QuébecDivision of Nephrology, Endocrinology, and Nephrology AxisFaculty and Department of MedicineLaval UniversityQuebecCanada
| | - Catherine Fortier
- Centre de Recherche du CHU de QuébecHôpital Hôtel‐Dieu de QuébecDivision of Nephrology, Endocrinology, and Nephrology AxisFaculty and Department of MedicineLaval UniversityQuebecCanada
| | - Yue Pei Wang
- Centre de Recherche du CHU de QuébecHôpital Hôtel‐Dieu de QuébecDivision of Nephrology, Endocrinology, and Nephrology AxisFaculty and Department of MedicineLaval UniversityQuebecCanada
| | - Sonia Jean
- Institut National de Santé Publique du QuébecMedicine FacultyDepartment of Social and Preventive MedicineLaval UniversityQuebecCanada
| | - Lynne Moore
- Centre de Recherche du CHU de QuébecHôpital de l'Enfant‐JésusTraumatology AxisMedicine FacultyDepartment of Social and Preventive MedicineLaval UniversityQuebecCanada
| | - Fabrice Mac‐Way
- Centre de Recherche du CHU de QuébecHôpital Hôtel‐Dieu de QuébecDivision of Nephrology, Endocrinology, and Nephrology AxisFaculty and Department of MedicineLaval UniversityQuebecCanada
| |
Collapse
|
45
|
Abstract
PURPOSE OF REVIEW Despite metabolic improvements following kidney transplantation, transplant recipients still often suffer from complex mineral and bone disease after transplantation. RECENT FINDINGS The pathophysiology of post-transplant disease is unique, secondary to underlying pre-transplant mineral and bone disease, immunosuppression, and changing kidney function. Changes in modern immunosuppression regimens continue to alter the clinical picture. Modern management includes reducing cumulative steroid exposure and correcting the biochemical abnormalities in mineral metabolism. While bone mineral density screening appears to help predict fracture risk and anti-osteoporotic therapy appears to have a positive effect on bone mineral density, more data regarding specific treatment is necessary. Patients with mineral and bone disease after kidney transplantation require special care in order to properly manage and mitigate their mineral and bone disease. Recent changes in clinical management of transplant patients may also be changing the implications on patients' mineral and bone disease.
Collapse
Affiliation(s)
- Ariella M Altman
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Stuart M Sprague
- Division of Nephrology and Hypertension, NorthShore University HealthSystem, University of Chicago Medical School, 2650 Ridge Avenue, Evanston, IL, 60201, USA.
| |
Collapse
|
46
|
Pérez-Sáez MJ, Herrera S, Prieto-Alhambra D, Vilaplana L, Nogués X, Vera M, Redondo-Pachón D, Mir M, Güerri R, Crespo M, Díez-Pérez A, Pascual J. Maintenance low dose systemic glucocorticoids have limited impact on bone strength and mineral density among incident renal allograft recipients: A pilot prospective cohort study. Bone 2018; 116:290-294. [PMID: 30145341 DOI: 10.1016/j.bone.2018.08.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 08/06/2018] [Accepted: 08/20/2018] [Indexed: 01/14/2023]
Abstract
Soon after kidney transplant (KT), a decrease in parathormone and bone mineral density (BMD) occur, but little is known on the impact of KT on novel bone quality parameters including trabecular bone score (TBS) and bone material strength index (BMSi). We aimed to study BMD, TBS and BMSi in the first year after KT, in patients not treated with any bone therapy. A cohort including 36 patients underwent KT on a low-glucocorticoid-dose protocol (5 mg daily-prednisone from post-operative-day 42 onwards) and was observed for 12 months prospectively. At 3 months, phosphorus and parathormone decreased, while calcium increased. We also observed at 3 months a transient mild 2.9% bone loss at femoral neck (BMD change 0.752 ± 0.15 vs 0.730 ± 0.15; p = 0.004), but no change at either spine or total hip. Both TBS and BMSi remained stable. At 12 months, lumbar (but not total hip or femoral neck) BMD slightly decreased by 2.1% vs baseline (0.950 ± 0.15 vs 0.930 ± 0.5; p = 0.046), while TBS and BMSi remained unmodified. In KT patients on low-dose glucocorticoids and no bone therapy, there were small BMD decreases at femoral neck (at 3 months) and lumbar spine (at 12 months), but no change in either TBS or BMSi. Low-dose post-KT glucocorticoid treatment shows limited impact on bone, supporting steroid-restrictive protocols.
Collapse
Affiliation(s)
- María José Pérez-Sáez
- Department of Nephrology, Hospital del Mar, Autonomous University of Barcelona, Spain; Institut Mar d'Investigacions Mediques, Barcelona, Spain; REDINREN, Instituto Carlos III, Madrid, Spain
| | - Sabina Herrera
- Institut Mar d'Investigacions Mediques, Barcelona, Spain; Department of Internal Medicine, Hospital del Mar, Autonomous University of Barcelona, Spain; CIBERFES, Instituto Carlos III, Madrid, Spain
| | - Daniel Prieto-Alhambra
- Institut Mar d'Investigacions Mediques, Barcelona, Spain; Oxford NIHR Musculoskeletal Biomedical Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Oxford OX3 7HE, United Kingdom of Great Britain and Northern Ireland; CIBERFES, Instituto Carlos III, Madrid, Spain
| | - Laia Vilaplana
- Institut Mar d'Investigacions Mediques, Barcelona, Spain; Department of Internal Medicine, Hospital del Mar, Autonomous University of Barcelona, Spain; CIBERFES, Instituto Carlos III, Madrid, Spain
| | - Xavier Nogués
- Institut Mar d'Investigacions Mediques, Barcelona, Spain; Department of Internal Medicine, Hospital del Mar, Autonomous University of Barcelona, Spain; CIBERFES, Instituto Carlos III, Madrid, Spain
| | - María Vera
- Department of Nephrology, Hospital del Mar, Autonomous University of Barcelona, Spain; Institut Mar d'Investigacions Mediques, Barcelona, Spain
| | - Dolores Redondo-Pachón
- Department of Nephrology, Hospital del Mar, Autonomous University of Barcelona, Spain; Institut Mar d'Investigacions Mediques, Barcelona, Spain; REDINREN, Instituto Carlos III, Madrid, Spain
| | - Marisa Mir
- Department of Nephrology, Hospital del Mar, Autonomous University of Barcelona, Spain; Institut Mar d'Investigacions Mediques, Barcelona, Spain
| | - Roberto Güerri
- Institut Mar d'Investigacions Mediques, Barcelona, Spain; Department of Internal Medicine, Hospital del Mar, Autonomous University of Barcelona, Spain; CIBERFES, Instituto Carlos III, Madrid, Spain
| | - Marta Crespo
- Department of Nephrology, Hospital del Mar, Autonomous University of Barcelona, Spain; Institut Mar d'Investigacions Mediques, Barcelona, Spain; REDINREN, Instituto Carlos III, Madrid, Spain
| | - Adolfo Díez-Pérez
- Institut Mar d'Investigacions Mediques, Barcelona, Spain; Department of Internal Medicine, Hospital del Mar, Autonomous University of Barcelona, Spain; CIBERFES, Instituto Carlos III, Madrid, Spain
| | - Julio Pascual
- Department of Nephrology, Hospital del Mar, Autonomous University of Barcelona, Spain; Institut Mar d'Investigacions Mediques, Barcelona, Spain; REDINREN, Instituto Carlos III, Madrid, Spain.
| |
Collapse
|
47
|
De Lucena DD, Rangel ÉB. Glucocorticoids use in kidney transplant setting. Expert Opin Drug Metab Toxicol 2018; 14:1023-1041. [DOI: 10.1080/17425255.2018.1530214] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Débora Dias De Lucena
- Department of Medicine, Division of Nephrology, Federal University of São Paulo/Hospital do Rim e Hipertensão, São Paulo, Brazil
| | - Érika Bevilaqua Rangel
- Department of Medicine, Division of Nephrology, Federal University of São Paulo/Hospital do Rim e Hipertensão, São Paulo, Brazil
- Instituto Israelita de Ensino e Pesquisa, Hospital Israelita Albert Einstein, São Paulo, Brazil
| |
Collapse
|
48
|
Teenagers and young adults with nephropathic cystinosis display significant bone disease and cortical impairment. Pediatr Nephrol 2018; 33:1165-1172. [PMID: 29435659 DOI: 10.1007/s00467-018-3902-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 01/08/2018] [Accepted: 01/23/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND Bone impairment appears to be a novel complication of nephropathic cystinosis despite cysteamine therapy. Its exact underlying pathophysiology is nevertheless unclear. The objective of this study was to evaluate bone status among patients included in the French Crystobs study. METHODS In addition to clinical data, bone status was evaluated using biomarkers (ALP, PTH, 25-D, 1-25D, FGF23), DXA (spine and total body), and high-resolution peripheral quantitative computed tomography (HR-pQCT) at the tibia and radius. Results were compared to age- and gender-matched healthy controls (1:2 basis) from the local reference cohorts. RESULTS At a median age of 22.5 (10.2-34.6) years, 10 patients with nephropathic cystinosis were included (2 receiving conservative therapies, 2 undergoing hemodialysis, 6 with a past of renal transplantation); 7 out of 10 patients complained of a bone symptom (past of fracture, bone deformations, and/or bone pain). Biochemicals and spine DXA did not show any significant abnormalities. Using HR-pQCT, significant decreases in cortical parameters (e.g., cortical thickness 850 (520-1100) versus 1225 (480-1680) μm; p < 0.05) and total volumetric bone mineral density (290 (233-360) versus 323 (232-406) mg/cm3; p < 0.05) were observed in cystinotic patients in comparison to controls at the tibia. There were no differences for trabecular parameters. Similar results were observed at the radius. CONCLUSIONS In this pilot study, bone impairment (rather cortical than trabecular) is a significant clinical problem in nephropathic cystinosis; 70% of patients displayed significant bone symptoms, during teenage or young adulthood. This new complication should be known by physicians because of its potential dramatic impact on quality of life.
Collapse
|
49
|
Segaud N, Legroux I, Hazzan M, Noel C, Cortet B. Changes in bone mineral density after kidney transplantation: 2-year assessment of a French cohort. Osteoporos Int 2018; 29:1165-1175. [PMID: 29500526 DOI: 10.1007/s00198-018-4383-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 01/04/2018] [Indexed: 12/18/2022]
Abstract
INTRODUCTION In renal transplant patients, bone loss may be related to the drugs patients are taking but also to their past history of chronic kidney disease. The purpose of this study was to assess changes in BMD 2 years after an initial assessment (performed 9 months post transplantation) and the factors associated with these changes. METHODS This longitudinal study included patients who had undergone a renal transplantation between 2005 and 2011, and who were followed up at the Lille Regional University Hospital. Patients were included if they had a first bone evaluation (including bone densitometry, spine X-rays and biological assessment) and at least another BMD assessment. The first assessment was performed on average 9 months post transplantation. A second assessment was performed at 2 years. RESULTS Two hundred fifty-nine out of 366 patients satisfied the inclusion criteria. The population included 96 women. Mean age at transplantation was 49.7 ± 12.1 years. Mean duration of dialysis was 3.2 ± 3.3 years. For 75 patients (29.0%), corticosteroid treatment was discontinued 7 days after transplantation without subsequent resumption during follow-up. Vertebral fractures assessed by X-rays at baseline were found in 28 patients (10.8%). According to the WHO classification, 106 patients (40.9%) patients had osteoporosis and 111 patients (42.8%) had osteopenia at the first assessment. Oral bisphosphonates were prescribed for 95 patients. The decision to prescribe bisphosphonates was taken jointly by rheumatologists and nephrologists based on BMD assessment, past history of fracture and corticosteroid management. In all patients, BMD gains at the second evaluation (2.2 ± 0.79 years) compared with baseline were significant (3.9 ± 6.6, 2.6% ± 7.6, 3.0 ± 7.2% at the lumbar spine, femoral neck and total hip respectively; p < 0.0001). The difference in gain between bisphosphonate-treated and untreated patients was significant (+ 5.0 ± 0.8% (p < 0.0001), + 2.5 ± 1.0% (p = 0.01) and + 2.7 ± 0.9% (p < 0.01) at the lumbar spine, femoral neck and total hip respectively. The patients who benefited early corticosteroid discontinuation had higher gains in BMD at the lumbar spine (+ 2.1 ± 0.9%; p = 0.02) and total hip (+ 2.0 ± 1.0%; p = 0.04) compared to those for whom corticosteroid therapy was maintained. Stepwise regression analysis (patients without bisphosphonates) showed associations between change in BMD (femoral neck) and duration of corticosteroid therapy, bone alkaline phosphatase level at baseline, and absence of vertebral fracture. No correlation was found between change in BMD and duration of dialysis or renal function. CONCLUSION Kidney transplant recipients have an increased risk of bone fragility in the year following transplantation. Bisphosphonates and early corticosteroid discontinuation can improve BMD.
Collapse
Affiliation(s)
- N Segaud
- Service de médecine interne, CH Armentières, F-59280, Armentières, France.
- Service de Rhumatologie, CHU Lille, F-59000, Lille, France.
| | - I Legroux
- Service de Rhumatologie, CHU Lille, F-59000, Lille, France
- EA 4490 - PMOI - Physiopathologie des Maladies Osseuses Inflammatoires, Université de Lille, F-59000, Lille, France
| | - M Hazzan
- Service de Néphrologie, CHU Lille, F-59000, Lille, France
| | - C Noel
- Service de Néphrologie, CHU Lille, F-59000, Lille, France
| | - B Cortet
- Service de Rhumatologie, CHU Lille, F-59000, Lille, France
- EA 4490 - PMOI - Physiopathologie des Maladies Osseuses Inflammatoires, Université de Lille, F-59000, Lille, France
| |
Collapse
|
50
|
Underrecognition and Underestimation of Disturbances in Calcium-Phosphate Balance in Kidney Transplant Recipients. Transplant Proc 2018; 50:1790-1793. [PMID: 30056901 DOI: 10.1016/j.transproceed.2018.02.155] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Accepted: 02/19/2018] [Indexed: 12/13/2022]
Abstract
Disturbances in mineral metabolism, namely chronic kidney disease-metabolic bone disease, became more profound with impairment of renal function. The aim of the study was to assess how often calcium, phosphate, alkaline phosphatase, and parathyroid hormone (PTH) were measured in kidney transplant recipients relative to hemodialyzed patients. In addition, prevalence of hypercalcemia defined as calcium concentration over 10.5 mg/dL was assessed. PATIENTS AND METHODS We studied 200 kidney allograft recipients and 100 hemodialyzed patients. Calcium, phosphate, alkaline phosphatase, 25-hydroxy vitamin D, and PTH were obtained from outpatient charts. RESULTS All the studied parameters were available in 100% of the hemodialyzed patients. In kidney allograft recipients, calcium and phosphate levels were available in 80%, alkaline phosphatase activity was available in 40%, PTH was available in less than 10%, and vitamin D was available in 1%. Hypercalcemia was present in 10% of hemodialyzed patients and in 5% of kidney allograft recipients. Vitamin D analogue was administered to 98% of hemodialyzed patients, whereas vitamin D was administered to 28% of kidney allograft recipients, particularly those with impaired kidney function. In conclusion, calcium and phosphate are seldom assessed on an outpatient basis in kidney allograft recipients, making the diagnosis and treatment of secondary hyperparathyroidism in this population difficult. Care of kidney transplant recipients could be substantially improved, particularly in regard to chronic kidney disease-metabolic bone disease, when regular check-ups for calcium-phosphate balance are implemented and proper treatment could be introduced to prevent further chronic kidney disease-metabolic bone disease.
Collapse
|