Management of Bone Disease in Kidney Transplant Recipients

There are several types of bone disease that are commonly seen in kidney transplant recipients. These include pre-existing uremic osteodystrophy, osteopenia, osteoporosis, bone fracture, osteonecrosis and bone pain syndrome (Brandenburg et al., 2004; Cohen et al., 2004; Julian et al., 1991; Zisman and Sprague, 2006). Kidney transplant recipients are now living longer than ever, and thus, proper prevention and management of bone disease has become an increasingly important part of their long-term care. Complications from posttransplant bone disease not only cause significant morbidity, but also increase the cost of care, hospitalization, and mortality (Abbott et al., 2001; Duriex et al., 2002; Jeffrey et al., 2003; Vatour et al., 2004; Zhang et al., 2008). Bone disease after kidney transplant is a multifactorial process that includes continuing bone loss superimposed on pre-existing renal osteodystrophy (Brandenburg et al., 2004; Cohen et al., 2004; Zisman & Sprague, 2006; Zhang et al., 2008). There can be several different bone histologies and no single clinical biomarker can distinguish between the various bone disorders (Cruz et al., 2004; Cueto-Manzano et al., 2003; Monier-Faugere et al., 2000; Rolla et al., 2006). Bone biopsy, the gold standard for diagnosis and most accurate tool to guide clinical management is not commonly undertaken due to its invasive nature and difficulty with proper interpretation. The clinical disease spectrum includes four distinct phases: 1) pre-transplant osteodystrophy, 2) post-transplant bone loss exacerbated by a number of factors including immunosuppressive medications, 3) late stabilization with a functioning allograft, and 4) a return to uremic osteodystrophy when the renal allograft fails. This chapter will review the complex pathophysiology of the various types of bone diseases after kidney transplantation and explore the current evidence for their prevention and treatment.