Version July 2025
BMD: bone mineral density; BSAP: bone-specific alkaline phosphatase; CTX: C-telopeptide; DXA: dual-energy x-ray absorptiometry; VFA: vertebral fracture assessment.
* No consensus exists on the optimal timing of these assessments. We typically assess clinical risk factors for fracture and perform initial laboratory assessments within 2 to 4 weeks after transplant, or when kidney allograft function stabilizes. We remeasure BTMs 3 months after initial measurement. We measure BMD and assess for radiographic vertebral fracture(s) either prior to transplant or within 3 months after transplant.
¶ Lifestyle measures include weight-bearing exercise, smoking cessation, good nutrition, limiting alcohol intake, early mobilization after transplantation, and fall prevention.
Δ In general, the authors of this topic do not use any pharmacotherapy to prevent bone loss in kidney transplant recipients, regardless of their fracture risk, until CKD-MBD, including persistent hyperparathyroidism, has been optimally managed for 6 to 12 months. This approach allows the remodeling bone sufficient time to reach a new steady state before an antiresorptive agent is administered.
◊ Some UpToDate contributors also use the Fracture Risk Assessment Tool (FRAX) to estimate fracture risk. Although not specifically validated in kidney transplant recipients, observational data support the utility of FRAX for predicting fracture risk in this population. Refer to UpToDate content on FRAX for more information.
§ Biochemical evidence of low bone turnover is defined as CTX and BSAP concentrations in the lower one-third of the assay-specific reference range for premenopausal females. Biochemical evidence of high bone turnover is defined as CTX and BSAP concentrations in the upper two-thirds of the assay-specific reference range or above the reference range for premenopausal females. When using serial assessment of these markers, we interpret a downward trend in CTX and BSAP levels or stable but low CTX and BSAP levels as evidence of low bone turnover.
¥ Accelerated bone loss and increased risk of vertebral fracture is evident after discontinuation of denosumab. If denosumab is discontinued, alternative therapy (typically a bisphosphonate) should begiven to prevent rapid bone loss.