Bone complications of lung transplantation

Factors that contribute to bone disease in patients with heart or lung disease

Lung transplantation is a new procedure and there are few studies of bone problems in these patients. The skeletal complications reported are serious. This figure shows an xray of a man who developed 7 vertebral compression fractures the first year after his lung transplant; before surgery he had normal bone density and no fractures.

Bone density is markedly reduced in lung transplant recipients; on average they are 2 standard deviations below age-matched reference ranges. Prospective studies showed loss of 4 to 4.8% in the first 6 months.

Fracture rate is high; in three prospective studies 10%,18% and 37% developed fractures in the first year. Patients continue to fracture for several years, and observational studies show 26, 35, and 42% incidence of vertebral compression fractures (the latter study included 60% of the transplant population, which were referred for evaluation, so the incidence could have been as low as 25%). The patients who fracture tend to have lower bone density values at the time of transplant.

Even when patients have received antiresorptive medications, the fracture rate and bone loss continue at high levels.

Osteocalcin is elevated. Parathyroid is high in some patients, and the vitamin D levels vary.

Literature review:

Author Date Design yrs N BMD Fxs Markers Comments
Trinbetti 00 trial 1 42 spine z-score
-.4 control
+.2 Rx 		25% in control, 5% Rx . 14 given pamidronate 30 q 6mo
Aris 00 trial 2 30 spine
+2.6% control
+8% pamidronate 		38%, same both groups high resorption, better with pam. pamidronate 30 q 6 mo
Spira 00 pros 0.5 22 spine -4.8%
hip - 4.7% 		18% symptomatic
by 1 yr 		. .
Shane 99 pros 1 30 half of patients lost
8% 		37% Increased Patients on antiresorptive Rx
Aringer 98 xs 1-4
post tx 		33 z below -2 in 67% of pts
median
spine -2.3
hip -2 		42%, timing throughout 3 yrs hi ocalcin, hi PTH, low D, low test 60% of tx patients were in study
Haden 97a xs 1 post tx 17 T -2.5 (age 42) 35% PTH hi .
Ferrari 96 pros 1 21 6 mo spine -4% 10% first yr . .
Aris 96 xs .3-3
post tx 		45 spine and hip z -2.3 26% . rx'd with ketoconazole

References

Aris, R. M.(2000). Efficacy of pamidronate for osteoporosis in patients with cystic fibrosis following lung transplantation. Am J Respir Crit Care Med 162: 941-6.

Trombetti, A.(2000). Bone mineral density in lung-transplant recipients before and after graft: prevention of lumbar spine post-transplantation-accelerated bone loss by pamidronate. J Heart Lung Transplant 19: 736-43.

Spira, A.(2000). Osteoporosis and lung transplantation: a prospective study. Chest 117(2): 476-81.

Shane, E.(1999). Bone loss and fracture after lung transplantation. Transplantation 68(2): 220-7.

Aringer, M.(1998). High turnover bone disease following lung transplantation. Bone 23(5): 485-8.

Aris, R. M.(1996). Severe osteoporosis before and after lung transplantation. Chest 109(5): 1176-83.

Ferrari, S. L.(1996). Osteoporosis in patients undergoing lung transplantation. Eur Respir J 9(11): 2378-82.

Schulman, L. L.(1997). Insufficiency fractures of the sacrum: a cause of low back pain after lung transplantation. J Heart Lung Transplant 16(10): 1081-5.

Shane, E.(1996). Osteoporosis in lung transplantation candidates with end-stage pulmonary disease. American Journal of Medicine 101(3): 262-269.

Updated 1/10/01

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