Monitoring bone mineral density after kidney transplantation: Patients not taking osteoporosis pharmacotherapy

This algorithm summarizes our suggested approach to monitoring BMD in kidney transplant recipients over the first two years after transplantation. This approach to monitoring, which is based on our clinical experience, depends on the patient's risk of fracture. All patients should continue nonpharmacologic measures to prevent bone loss. This algorithm is intended for use with other UpToDate content. For additional details, including the evidence supporting this approach, refer to UpToDate topics on the prevention and treatment of bone disease after kidney transplantation.

BMD: bone mineral density; DXA: dual energy x-ray absorptiometry.

* If persistent hyperparathyroidism, vitamin D deficiency, and/or hypophosphatemia are present posttransplant, fracture risk assessment should be performed 6 to 12 months after these conditions have been adequately managed. In kidney transplant recipients, criteria for high fracture risk include:

History of low-trauma fracture (including radiologic evidence of vertebral fracture)
Osteoporosis by BMD criteria (T-score ≤–2.5 at hip, spine, or forearm)
Low bone mass (T-score between –1.0 and –2.5) and 1 or more clinical risk factors for fracture that cannot be mitigated.

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.

¶ 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.

Δ Decreased BMD is defined as a decline that exceeds the least significant change (LSC) for the specific instrument used.

◊ For patients with no interim fragility fracture and stable or increased BMD on repeat DXA, increasing the interval of subsequent BMD assessments to between 2 and 5 years is reasonable, depending on the clinical setting.

§ 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 choice of pharmacotherapy is based on the assessment of bone turnover and kidney allograft function. Refer to UpToDate content on the treatment of osteoporosis in kidney transplant recipients for more details.

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Monitoring bone mineral density after kidney transplantation: Patients not taking osteoporosis pharmacotherapy