Chapter 24 - Management: Established Osteoporosis in Organ Transplant Recipients

Abstract

This chapter focuses on the secondary prevention or treatment of “established” transplant-related bone loss in patients. A substantial number of patients with transplants are osteoporotic, whether defined in terms of bone density or the occurrence of fractures after minor trauma. Fracture risk can be assessed from the combination of clinical risk factors and bone density measurements. This chapter provides a list of conditions and drugs associated with bone loss, many of which are common in transplanted patients. Possibly the most powerful predictor of future fractures is the past history of fracture. There is a continuous, inverse relationship between fracture risk and bone density. Most sites of bone density measurement give a comparable prediction of global fracture risk. The most commonly assessed sites are the hip and spine. The chapter reviews evidence for treatments to reverse “established” bone loss. Supplementation of calcium, vitamin D, or calciferol can be helpful in treating post-transplantation osteoporosis. In individuals whose bone density is at the lower end of the young normal range, intervention with a single agent, usually a bisphosphonate is appropriate, though sex-hormone replacement is an option in those with demonstrable deficiency. In a patient with marked bone loss, these agents can be combined with each other or with other interventions such, as alfacalcidol. The widespread adoption of these strategies may result in fewer patients who have to accept the morbidity of multiple fractures.