Version July 2025
BMD: bone mineral density; BSAP: bone-specific alkaline phosphatase; CTX: C-telopeptide; DXA: dual-energy x-ray absorptiometry.
* Nonpharmacologic measures include lifestyle measures (eg, weight-bearing exercise, smoking cessation), glucocorticoid dose minimization, calcium and vitamin D in normocalcemic patients, and treatment of persistent hyperparathyroidism. Refer to UpToDate content on general measures to prevent bone loss in kidney transplant recipients.
¶ Decreased BMD is defined as a decline that exceeds the least significant change (LSC) for the specific instrument used.
Δ Secondary causes of bone loss include severe hyperparathyroidism, celiac disease, and hyperthyroidism. Refer to other UpToDate content on the evaluation for secondary causes of bone loss.
◊ The decision to discontinue osteoporosis pharmacotherapy should be individualized based on estimated fracture risk, including non-BMD risk factors for fracture. In patients with major non-BMD risk factors for fracture (eg, continued glucocorticoid therapy >5 mg/day of prednisone or equivalent), continued pharmacotherapy may be warranted.
§ Discontinuation of denosumab has been associated with rebound increases in bone resorption and an associated increased risk of multiple vertebral fractures. Thus, if denosumab is discontinued, an alternative therapy (typically a bisphosphonate) should be given to prevent rapid bone loss and increased risk of vertebral fractures.
¥ There are no data in kidney transplant recipients on the optimal time to discontinue osteoporosis pharmacotherapy. Our practice is to continue therapy until the T-score is >–2.5 at all skeletal sites. For patients with severe osteoporosis, it may take several years to reach an adequate T-score.