Bone Disease Post-Renal Transplant at St. Joseph’s Healthcare Hamilton – A Retrospective Chart Review

Abstract

INTRODUCTION: Studies have demonstrated a rapid decrease in bone mineral density (BMD) in the first 6-12 months after renal transplantation. Bone loss after renal transplantation is primarily related to the use of glucocorticoids and persistent hyperparathyroidism. In the transplant recipient, clinical manifestations of persistent hyperparathyroidism include hypophosphatemia and hypercalcemia. KDIGO suggests treatment with vitamin D or vitamin D analogues to suppress parathyroid hormone and improve BMD. OBJECTIVES: The primary objective was to determine the effect of vitamin D and vitamin D analogues on BMD post renal transplant. Secondary objectives were to determine the effect of vitamin D and vitamin D analogues on calcium and phosphate levels, as well as, phosphate supplementation prescribed. In addition, we examined the rate of prescription of vitamin D and vitamin D analogues in patients that had a post-operative order set prompting healthcare review of vitamin D and vitamin D analogues versus patients that did not have this order set. METHODS: A retrospective chart review of inpatient and renal transplant clinic charts. RESULTS: BMD one year post-transplant appears to be similar across treatment groups. Overall, need for phosphate supplementation was reduced beyond 30 days post-transplant irrespective of vitamin D or vitamin D analogue supplementation. Treatment with vitamin D or vitamin D analogues did not appreciably raise serum calcium levels. Combination treatment with vitamin D and vitamin D analogues did not result in an observed added benefit with respect to phosphate levels, phosphate supplementation, or calcium levels. Therefore, there may be a potential cost savings with prescription of vitamin D alone. CONCLUSION: This review suggests there is no difference in median BMD one year post-transplant among patients prescribed vitamin D, vitamin D analogues or the combination of the two. There was good uptake of the vitamin D order on the renal transplant post-operative order set as an inpatient; however, there is variability in vitamin D analogue prescribing in the outpatient renal transplant clinic which does not utilize a predefined order set.