Treatment of osteoporosis in the solid organ transplant recipient: an organ-based approach

Abstract

Bone and mineral disorders are highly prevalent in solid organ transplant recipients. These patients are at high risk for osteoporosis and fragility fractures due to several pre- and post-transplant factors, including end-stage organ disease leading to chronic malnutrition and osteomalacia, as well as chronic immunosuppressive therapy that has direct adverse effects on bone remodeling. Low pre-transplant bone mineral density is associated with an increased risk for fragility fracture post-transplant. Furthermore, there is a precipitous loss of bone density within 6-12 months post-transplant due to a myriad of causal factors. In this review, we will elaborate on the treatment options and challenges in management of osteoporosis in solid organ recipients using vitamin D, calcium, bisphosphonates, denosumab, and osteoanabolic agents. The greatest body of evidence discusses the use of bisphosphonates, with most patients benefiting from early treatment.

Keywords: bisphosphonates; bone loss; fragility fracture; glucocorticoid; heart transplant; kidney transplant; liver transplant; lung transplant; osteoanabolic agents; osteoporosis; osteoporotic fracture; solid organ transplant.

Graphical abstract

Figure 1.

Proposed algorithm for pre-lung transplant ZOL treatment for all postmenopausal female patients and men over the age of 50 years of age with T-score >−3. Although not included in this figure, the full protocol has a standardized calcium and vitamin D recommendation for all patients being evaluated for transplant. Pre-menopausal women and men <50 years of age with Z-score <−2 will require an urgent endocrinology referral. ZOL, zoledronic acid.