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  • Review Article
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Bone disease after renal transplantation

Nature Reviews Nephrology volume 6, pages 32–40 (2010)Cite this article

Abstract

In light of greatly improved long-term patient and graft survival after renal transplantation, improving other clinical outcomes such as risk of fracture and cardiovascular disease is of paramount importance. After renal transplantation, a large percentage of patients lose bone. This loss of bone results from a combination of factors that include pre-existing renal osteodystrophy, immunosuppressive therapy, and the effects of chronically reduced renal function after transplantation. In addition to low bone volume, histological abnormalities include decreased bone turnover and defective mineralization. Low bone volume and low bone turnover were recently shown to be associated with cardiovascular calcifications, highlighting specific challenges for medical therapy and the need to prevent low bone turnover in the pretransplant patient. This Review discusses changes in bone histology and mineral metabolism that are associated with renal transplantation and the effects of these changes on clinical outcomes such as fractures and cardiovascular calcifications. Therapeutic modalities are evaluated based on our understanding of bone histology.

Key Points

  • Metabolic abnormalities are common in patients after renal transplantation

  • Pathogenetic mechanisms associated with bone loss in renal transplant recipients are different to those involved in postmenopausal bone loss

  • Low bone turnover is common in patients with bone disease associated with renal transplantation

  • Focal or generalized osteomalacia may coexist with bone loss after renal transplantation

  • Cardiovascular calcifications may be associated with low bone volume and low bone turnover in recipients of renal transplants

  • Use of bisphosphonates for treatment of bone loss associated with renal transplantation may have deleterious effects because of reduced glomerular filtration rate and the presence of low bone turnover

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Figure 1: Glucocorticoids reduce bone turnover.
Figure 2: Low turnover bone disease (adynamic bone disease) in a 35-year-old white male renal transplant recipient.
Figure 3: Low turnover osteomalacia in a 49-year-old white female renal transplant recipient.
Figure 4: Administration of pamidronate reduces bone turnover after renal transplantation.113

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Acknowledgements

This project was supported by grants NIH RO1 DK51530 (H. H. Malluche), by the Kentucky Nephrology Research Trust (M.-C. Monier-Faugere), and by the Dean's Clinical Research Scholar Program, University of Kentucky, no 1012,112,710 (J. Herberth). The authors want to thank Dr Jessica McAbee, MD, Department of Internal Medicine, University of Kentucky, for her assistance with the literature review.

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  1. Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Room MN 564, UK Medical Center, 800 Rose Street, Lexington, 40508, KY, USA

    Hartmut H. Malluche, Marie-Claude Monier-Faugere & Johann Herberth

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Malluche, H., Monier-Faugere, MC. & Herberth, J. Bone disease after renal transplantation. Nat Rev Nephrol 6, 32–40 (2010). https://doi.org/10.1038/nrneph.2009.192

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