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Effects of denosumab on bone metabolism and bone mineral density in kidney transplant patients: a systematic review and meta-analysis

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Abstract

Objective

The use of immunosuppressive agents, especially glucocorticoids, are associated with increased risks of bone loss in kidney transplant patients. Denosumab, a potent antiresorptive agent, has been shown to increase bone mineral density (BMD) in patients with CKD. However, its effects on bone metabolism and BMD in kidney transplant patients remain unclear.

Methods

A literature search was conducted using MEDLINE, EMBASE, and Cochrane Database from inception through April 2018 to identify studies evaluating denosumab’s effect on changes in bone metabolism and BMD from baseline to post-treatment course in kidney transplant patients. Study results were pooled and analyzed utilizing random-effects model. The protocol for this systematic review is registered with PROSPERO (International Prospective Register of Systematic Reviews; no. CRD42018095055).

Results

Five studies (a clinical trial and four cohort studies) with a total of 162 kidney transplant patients were identified. The majority of patients had a baseline eGFR ≥ 30 mL/min/1.73 m2. After treatment (≥ 6 to 12 months), there were significant increases in BMD with standardized mean differences (SMDs) of 3.26 (95% CI 0.88–5.64) and 1.83 (95% CI 0.43 to 3.22) for lumbar spine and femoral neck, respectively. There were also significant increases in T scores with SMDs of 0.92 (95% CI 0.58 to 1.25) and 1.14 (95% CI 0.17 to 2.10) for lumbar spine and femoral neck, respectively. After treatment, there were no significant changes in serum calcium (Ca) or parathyroid hormone (PTH) from baseline to post-treatment course (≥ 6 months) with mean differences (MDs) of 0.52 (95% CI, − 0.13 to 1.16) mmol/L and − 13.24 (95% CI, − 43.85 to 17.37) ng/L, respectively. The clinical trial data demonstrated more asymptomatic hypocalcemia in the denosumab (12 episodes in 39 patients) than in the control (1 episode in 42 patients) group. From the cohort studies, the pooled incidence of hypocalcemia following denosumab treatment was 1.7% (95% CI 0.4 to 6.6%). All reported hypocalcemic episodes were mild and asymptomatic, but the majority of patients required Ca and vitamin D supplements.

Conclusion

Among kidney transplant patients with good allograft function, denosumab effectively increases BMD and T scores in the lumbar spine and femur neck. From baseline to post-treatment, there are no differences in serum Ca and PTH. However, mild hypocalcemia can occur following denosumab treatment, requiring monitoring and titration of Ca and vitamin D supplements.

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Authors and Affiliations

  1. Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA

    Charat Thongprayoon & Michael A. Mao

  2. Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, 2500 N. State St, Jackson, MS, 39216, USA

    Prakrati Acharya, Aldo Torres-Ortiz, Maria Lourdes Gonzalez Suarez, Sohail Abdul Salim & Wisit Cheungpasitporn

  3. Division of Nephrology, Department of Medicine, Indiana University School of Medicine and Deaconess Health System, Evansville, IN, USA

    Narothama Reddy Aeddula

  4. Department of Internal Medicine, University of Arizona, Tucson, AZ, USA

    Tarun Bathini

  5. Department of Internal Medicine, Bassett Medical Center, Cooperstown, NY, USA

    Konika Sharma & Kanramon Watthanasuntorn

  6. Clinical Epidemiology Unit, Department of Research and Development, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand

    Patompong Ungprasert

  7. Department of Military and Community Medicine, Phramongkutklao College of Medicine, Bangkok, Thailand

    Wisit Kaewput

  8. Department of Internal Medicine, Metrowest Medical Center, Framingham, MA, USA

    Jirat Chenbhanich

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Thongprayoon, C., Acharya, P., Aeddula, N.R. et al. Effects of denosumab on bone metabolism and bone mineral density in kidney transplant patients: a systematic review and meta-analysis. Arch Osteoporos 14, 35 (2019). https://doi.org/10.1007/s11657-019-0587-0

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