Skeletal Integrity and Visceral Transplantation

Abstract

Despite continuous improvement in long-term survival, there is no knowledge about risk of bone health impairment and management strategies before and after intestinal transplantation. Therefore, 147 adults were retrospectively studied via chart review; 70 long-term survivors, 53 candidates and 24 recipients with longitudinal follow-up. Evaluation process included measurement of bone mineral density (BMD) and allied biochemical markers. Both long-term survivors and candidates showed low bone mass with lower (p < 0.05) z-scores at hip, femoral neck and spine. Vitamin D deficiency and secondary hyperparathyroidism were observed in both groups. Prevalence of osteoporosis was 44% among long-term survivors and 36% in candidates with age, BMD, duration of parenteral nutrition, type of immunosuppression and rejection being significant risk factors. Fragility fractures occurred at a higher (p = 0.02) rate among long-term survivors (20%) compared to candidates (6%). The longitudinal study documented acceleration (p = 0.025) of bone loss after transplantation with a decline of 13.4% (femoral neck), 12.7% (hip) and 2.1% (spine). Alendronate reduced (p < 0.05) but did not prevent bone loss. In conclusion, intestinal transplant recipients are at risk of osteoporosis secondary to bone loss before and after transplantation. Accordingly, current management includes comprehensive preventive measures with prompt therapeutic intervention utilizing intravenous bisphosphonates or subcutaneous human PTH 1–34.

Beyond 10 years, with or without an intestinal graft: Present and future?

“…Bone health was frequently impaired, due to long‐term therapy with corticosteroids and micronutrient deficiencies, and more than in children with intestinal failure who required PN 51 . However, the prevalence is higher in adults who underwent ITx 52 …”

“…51 However, the prevalence is higher in adults who underwent ITx. 52 Graft removal resulted in high mortality, partly due to complications related to retransplantation. The 5-year outcomes of retransplantation are variable; we believe that administering home PN following graft removal is preferable to immediate retransplantation.…”

Current Management of Short Bowel Syndrome

“…Metabolic bone disease (MBD) is increased in SBS patients requiring PN, including osteoporosis and osteomalacia. [136][137][138][139][140] A substantial prevalence of low bone mass has been described in these patients according to dual-energy X-ray absorptionmetry measurements of bone mineral density with the prevalence of osteoporosis in PN-treated patients (T-score Ͻ Ϫ2.5) being reported between 33% and 67%. MBD leads to a fracture rate of 10%.…”

“…139 The incidence of MBD is increased further after intestinal transplantation. 140 We screen the bone health at intake visit and perform close follow-up with dual-energy X-ray absorptionmetry scanning as indicated and based on published guidelines (National Osteoporosis Foundation [2008]. Clinician's guide to prevention and treatment of osteoporosis.…”

Nutrition and Small Bowel Transplantation

“…To quote from a review from the Pittsburgh group: “With a fully functioning graft, any nutrient deficiency can be repleted with oral supplementation.” 12 This statement appears to be largely true, with one possible exception being a deficiency of vitamin D. In an article by Resnick et al 21 that studied bone health after intestinal transplant, chronic deficiency of 25‐OH vitamin D was seen in almost two‐thirds of patients in a point prevalence study performed at a mean of almost 3 years after transplant. This number was very similar to that in candidates awaiting transplant.…”