Fracture Risk in Kidney Transplant Recipients: A Systematic Review

Background. Fractures in men and women after kidney transplantation are associated with morbidity (including acute and chronic pain), mortality, and high economic costs. Methods. We systematically reviewed cohort studies that provided estimates on incidence and risk factors for fracture in kidney transplant recipients. We abstracted data in duplicate and assessed the methodological quality of each study on a 17-point scale (17 representing the highest quality). Results. We screened 2715 articles, reviewed 81, and included 10 studies totaling 262,678 recipients (study mean, 26,268 recipients; range, 61Y77,430). The average follow-up ranged from 1.7 to 5.3 years. The study quality scores ranged from 8 to 13. Fracture sites varied by study resulting in a highly variable incidence rate ranging from 3.3 to 99.6 fractures per 1000 person-years. Similarly, the 5-year cumulative incidence for fracture varied ranging from 0.85% to 27%. Common factors associated with an increased fracture risk were older age, female sex, the presence of diabetes, and receipt of dialysis before transplantation. Other less common but statistically significant risk factors were a previous history of fracture and receipt of a kidney from a deceased (vs. living) donor. Conclusions. There is poor consensus on the incidence and risk factors for fractures in kidney transplant recipients. Previous studies vary substantially in quality, fracture definitions, and the characteristics of recipients studied. Future research should clarify fracture incidence and risk, which will inform the design of future prevention trials and guide prognostication.