The management of mineral and bone disease after kidney transplantation: A narrative overview.

Post-transplant mineral bone disease (PT-MBD) is associated with increased morbidity and mortality in kidney transplant recipients. Bone abnormalities can range from adynamic bone disease to severe persistent hyperparathyroidism with associated hypercalcemia and hypophosphataemia. In addition, these patients can develop other complications such as osteopenia and osteoporosis; further increasing the risk of fragility fractures. Appropriate management is challenging, given the lack of robust evidence. Bone turnover biomarkers and imaging studies are not entirely validated to differentiate between these pathological entities. Available interventions to control high turnover bone disease include calcimimetic drugs (Cinacalcet) and surgical parathyroidectomy. Cinacalcet has been shown to improve bone biochemistry and reduce the number of required parathyroidectomies. However, none of the meta-analyses identified a significant reduction in the overall mortality. Cinacalcet remains the treatment of choice for high turnover bone disease in the first year after transplantation, sometimes serving as a precursor to the surgery. In general, severe hyperparathyroidism does not respond adequately to cinacalcet alone, and many of these patients would eventually require parathyroidectomy. In our opinion, total parathyroidectomy should be avoided as this leads to undetectable PTH and subsequent adynamic bone disease. Anti-resorptive treatment, on the other hand, is indicated for proven osteoporosis if excretory graft function permits. In this narrative review, we provide an overview of the management of PT-MBD, based on the current best available evidence. [ABSTRACT FROM AUTHOR]