Avascular osteonecrosis in kidney transplant recipients: Risk factors in a recent cohort study and evaluation of the role of secondary hyperparathyroidism.

Renaud Felten,Rose-Marie Javier,Peggy Perrin,Bruno Moulin,Sophie Caillard,John Richard Lee

doi:10.1371/journal.pone.0212931

Renaud Felten, Rose-Marie Javier + Show 4 more

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https://doi.org/10.1371/journal.pone.0212931

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Journal: PloS one	Publication Date: Feb 22, 2019
Citations: 13	License type: CC BY 4.0

Affiliation: University of Strasbourg

Abstract

Avascular osteonecrosis (AVN) is a bone complication that indicates poor functional prognosis. Modern immunosuppressive and steroid-sparing drugs have significantly lowered the occurrence of AVN after kidney transplantation (KT). However, recent data on its incidence rates and risk factors are lacking. Using a large, recent cohort, we sought to investigate AVN incidence and risk factors, with a special focus on mineral and bone disorders. We conducted a cohort study in 805 patients who underwent KT between 2004 and 2014. AVN was identified in 32 patients (4%): before KT in 15 (1.8%) and after KT in 18 (2.2%) cases, including one patient with both. In the group with post-KT AVN, the median time intervals from KT to 1) first symptoms and 2) AVN diagnosis were 12 months [1–99] and 20 months [4–100], respectively. Being overweight/obese, having pre-transplant diabetes or hyperparathyroidism at transplantation, developing acute rejection, and receiving higher cumulative corticosteroid doses were associated with AVN occurrence. Multivariate analysis revealed that BMI ≥ 26 kg/m2 and higher cumulative corticosteroid doses were predictive of AVN. In conclusion, overweight/obesity is a strong risk factor for AVN. Despite a low maintenance dose, the use of corticosteroids—mostly for treatment of acute rejection—remains an independent risk factor.

Highlights

Avascular osteonecrosis (AVN) is a disabling bone complication that can occur after kidney transplantation (KT)
We focused on the role of secondary hyperparathyroidism and pretransplant bone mineral density (BMD) in AVN occurrence
We assessed AVN occurrence before transplantation and distinguished it from AVN occurring after transplantation, limiting bias in the analysis of factors associated with AVN after transplantation, and allowing better identification of AVN risk factors after KT

Summary

Introduction

Avascular osteonecrosis (AVN) is a disabling bone complication that can occur after kidney transplantation (KT). Corticosteroids play a central role in the genesis of AVN, and recent reports suggest that the use of steroid-sparing anti-calcineurin agents has reduced incidence rates to less than 5% [3,4,5]. There is a lack of recent data regarding incidence rates, clinical features, or AVN risk factors, as most studies evaluate few risk. Avascular osteonecrosis in kidney transplant recipients antibody-mediated rejection; AHR, adjusted hazard ratio; AVN, avascular osteonecrosis; BMD, bone mineral density; BMI, body mass index; CsA, cyclosporine A; eGFR, estimated glomerular filtration rate; HD, hemodialysis; HIV, human immunodeficiency virus; KT, kidney transplantation; M3, M12, M24, month 3, 12 or 24 post-transplantation; MDRD, modification of diet in renal disease; MMF, mycophenolate mofetil; MRI, magnetic resonance imaging; OR, odds ratio; PD, peritoneal dialysis; preT-AVN, pre-transplant AVN; NOAVN, new onset AVN; PTH, parathyroid hormone; SD, standard deviation; TCMR, T cellmediated rejection. Few studies concerning recipients with renal transplant performed after the year 2000 are available [6,7,8,9,10]

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