Original article
Bone mineral density in lung-transplant recipients before and after graft: prevention of lumbar spine post-transplantation-accelerated bone loss by pamidronate

https://doi.org/10.1016/S1053-2498(00)00132-7Get rights and content

Abstract

Background: Lung-transplant recipients are at risk of osteoporosis. They may have low bone mass even before posttransplantation immunosuppressive therapy. We studied bone mineral density (BMD) before and after lung transplantation and compared the efficacy of antiresorptive therapies to calcium and vitamin D supplementation.

Methods

Areal BMD was assessed in 42 patients awaiting lung transplantation and measured again after surgery at 6 (n = 29), and at 12 months (n = 20). Nineteen patients received antiresorptive therapy (30 mg pamidronate IV every 3 months (n = 14), or hormonal replacement therapy (n = 5)), and 10 patients received only calcium and vitamin D supplements.

Results

Mean age- and gender-adjusted lumbar spine (LS) and femoral neck (FN) BMD was significantly decreased prior to transplantation (− 0.6 ± 0.2, p< 0.01, and − 1.5 ± 0.2 standard deviation, p < 0.001, respectively). At that time, 29% were osteoporotic (T-score < − 2.5 below the peak bone mass), while 55% were below − 1.0 T-score. Antiresorptive therapy decreased the rate of LS bone loss during the first 6 months and led to a significant increase of BMD at 1 year, with LS changes of + 0.2 ± 0.1 vs − 0.4 ± 0.1 Z-score in the calcium-vitamin D group (p< 0.002), and + 0.2 ± 0.1 vs − 0.04 ± 0.1 for FN (NS). One out of 20 patients experienced clinically evident fractures during antiresorptive therapy, and 3 out of 12 in the calcium-vitamin D group.

Conclusion

A significant proportion of patients awaiting lung transplantation was osteoporotic or osteopenic. Antiresorptive therapy (pamidronate or hormone-replacement therapy (HRT)) prevented accelerated LS bone loss after graft.

Section snippets

Patients

Between January 1993 and January 1999, we prospectively studied 42 adults awaiting lung transplantation ranging in age from 17 to 64 years (average age 46.0 ± 1.8 years of age). There were 22 men, 12 postmenopausal women, and 8 premenopausal women. The majority of patients suffered from either chronic obstructive pulmonary disease (COPD) or CF. Nineteen patients were receiving antiosteoporosis therapy either with calcium alone (n = 1); calcium and vitamin D (n = 9); estroprogestagens (n = 8),

Laboratory measurements

Plasma and urinary calcium, phosphate, and creatinine were measured. Plasma calcium was adjusted for protein levels (adjusted Ca = Ca/[(protein/160) + 0.55]). Urinary calcium/creatinine was taken as a reflection of net bone resorption. Osteocalcin, which is a marker of bone formation and turnover, was determined with an immunoradiometric assay (CIS-Bio, Gif-sur-Yvette, France). Urinary deoxypyridinoline, which is a specific marker of bone resorption, was measured by fluorescence emission after

Statistical analysis

All data are expressed as mean ± SEM. The statistical significance of the differences was assessed by a two-tailed Student’s t-test and an analysis of variance (ANOVA) for intergroup comparison. A paired Student’s t-test and a Mann Whitney test were used for intragroup comparison. A p value of less than 0.05 was considered significant.

Before transplantation

Recorded risk factors for osteoporosis before lung transplantation were menopause, history of glucocorticoid therapy, or tobacco use (Table I). Forty-three percent of the patients were receiving calcium and vitamin D, and/or hormone replacement. In patients awaiting lung transplantation, mean age- and gender-adjusted LS and FN BMD (Z-scores) was significantly decreased (LS: − 0.6 ± 0.2 SD, P< 0.01; FN: − 1.5 ± 0.2 SD, P< 0.001) (Table II). Twenty-nine percent were osteoporotic with a value at

Discussion

Lung-transplant recipients have typically low bone mass and an increased risk of osteoporotic fractures that could impair their quality of life and graft function.3, 10, 13, 14, 15 Since their low bone mass results from the amount present before transplantation and lost thereafter, we compared age- and gender-adjusted BMD at time of transplant and postoperatively.

The population studied was similar to that as previously reported by Shane et al. with 40% of patients suffering from COPD and 16%

Acknowledgements

The authors thank the teams of the Transplantation Unit and of the Division of Nuclear Medicine for patient care. This work was supported by a grant from the Swiss National Science Foundation (Grant No. 32-49757.96). The authors appreciate the contribution of Dr S. Ferrari, MD, in the initial part of this study.

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