Beth Israel Deaconess Medical Center
Transplant Manual
Title: Metabolic Bone Disease in Liver Transplant Recipients - Management
Purpose: To outline process for clinical management of liver transplant recipients
Policy Statement:
1. On average, there is a mild bone mineral density (BMD) deficit in patients with
chronic liver disease (CLD); however, there is considerable patient
heterogeneity.
2. Vertebral and non-vertebral fracture rates are increased in patients with CLD,
especially in postmenopausal women.
3. While there are some diseases (cholestatic liver disease) that display high risk
of metabolic bone disease, all patients with end-stage liver disease (ESLD) are
at high risk for osteoporosis/osteopenia.
4. Bone loss after liver transplantation (LT) follows a biphasic course, with the
greatest decrease during the first 3-6 months; then spontaneous stabilization
or even improvement can occur.
5. Most fractures develop in the first year and very few fractures occur after the
first 3 years.
6. Pre-transplant low bone mineral density (BMD) is a marker for high fracture risk
after liver transplantation.
7. All pre-transplant patients should be evaluated for presence of metabolic bone
disease.
Recommendations for assessment and management of metabolic bone disease
1. All patients should have serum calcium, phosphate, 1, 25 di (OH) vitamin D,
and free testosterone levels (in men) at transplant evaluation.
2. All patients should have a pre-transplant bone mineral density scan performed
(Dexa scan).
3. All patients require education regarding the importance of lifestyle changes to
prevent further bone loss (regular exercise and smoking cessation).
4. All patients should receive optimal calcium (1000-1200 mg orally per day) and
vitamin D (400-800 IU orally per day) supplementation.
5. Deficiencies of vitamin D (< 15 ng/ml) should be corrected (to >30 ng/ml) with
50,000 units orally of vitamin D per week for 8 weeks.
6. Hypogonadism in men (serum free testosterone <400 ng/ml) should be
corrected to levels between 600-800 ng/ml):
a. Testosterone enanthate (200-400 mg by IM injection every 2-4 weeks)
b. Androderm (apply two systems nightly to skin)
c. AndroGel (apply 5 g once daily)
7. Correction of hypogonadism in postmenopausal females is controversial, as
estrogen/progesterone therapy is no longer first-line therapy for treatment of
osteoporosis and because of risk of breast cancer, stroke, venous
thromboembolism and possibly coronary artery disease.
8. Due to the anticipation of further bone loss, any patient with a BMD of >-1.0 SD
1
as compared to control patients should initiate bisphosphonate therapy in
either of the following formats:
a. allendronate (Fosamax®) 35 mg orally once per week
b. risedronate (Actonel®) once 35 mg orally per week
c. ibandronate (Boniva®) 3 mg IV push over 1 minute every 3 months
(indicated in patients intolerant of oral form or those with high risk of
variceal bleed).
9. Patients should receive a dose of pamidronate 0.5 mg/Kg IV infusion prior to
discharge from transplant hospitalization.
10. Bone mineral density should be performed within 12 months after
transplantation and every 2 years thereafter.
11. Patients who demonstrate deterioration in BMD despite the above should be
referred to the Bone Unit (617-667-1765) for further follow-up.
Vice President Sponsor:
Approved by:
x Liver Selection Committee
Requestor Name:
Original Date Approved:
Next Review Date:
Revised:
Dianne Anderson, Sr. VP PCS
Douglas Hanto, MD, PhD and Michael Curry, MD
Co-Chairs
Michael Curry, MD
1/05
1/8
12/06
Eliminated:
2