Joseph Kahwaji

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Key Points: Bisphosponate use may decrease the risk of fracture in patients receiving kidney transplant. Identifying those at risk of fracture after kidney transplant is critical. Background: Kidney transplant recipients are at higher risk of fractures compared with the general population. The use of bisphosphonates has been shown to increase bone mineral density after transplantation but has not been shown to lower fracture rates. In this study, we aim to determine whether exposure to bisphosphonates is associated with lower incidence of nonvertebral fractures after kidney transplantation. Methods: We conducted a retrospective review for all Southern California Kaiser Permanente kidney transplant recipients with osteoporosis transplanted between 2000 and 2019. Baseline variables were collected. Those prescribed an oral bisphosphonate were compared with those who were not. The primary outcome was nonvertebral fracture. Chi-square test was used to evaluate categorical variables and Wilcoxon rank-sum test for continuous variables. Propensity scores were generated to balance covariates in the bisphosphonate and nonbisphosphonate groups. Cause-specific hazard and subdistribution (Fine–Gray) methods were performed for competing risk analysis. Death-censored graft survival was evaluated as a secondary outcome using standard Cox regression. Results: There were 489 patients included in the study, 203 of which were in the bisphosphonate group. The cause-specific hazard model suggested a 64% lower risk of nonvertebral fracture in the bisphosphonate group ( P = 0.02). The Fine–Gray hazard model treating death as a competing risk did not show lower relative incidence of nonvertebral fracture. Bisphosphonate treatment was associated with lower death-censored graft failure ( P = 0.002). Conclusions: Bisphosphonate use after kidney transplantation may be associated with a lower risk of nonvertebral fracture after transplant. Bisphosphonate use in this study was also associated with lower death-censored graft failure. Caution is advised when interpreting these results given the retrospective nature of the study.

Objective: Routine screening for cardiovascular disease before kidney transplantation remains controversial. This study aims to compare cardiac testing rates in patients with end-stage renal disease, referred and not referred for transplantation, and assess the impact of testing on transplant wait times. Methods: This is a retrospective cohort study of 22 687 end-stage renal disease patients from 2011 to 2022, within an integrated health system. Cardiac testing patterns, and the association between cardiac testing and transplant wait times and post-transplant mortality were evaluated. Results: Of 22 687 patients (median age 66 years, 41.1% female), 6.9% received kidney transplants, and 21.0% underwent evaluation. Compared with dialysis patients, transplant patients had a 5.6 times higher rate of stress nuclear myocardial perfusion imaging with single-photon emission (rate ratio (RR) 5.64, 95% CI 5.37 to 5.92), a 6.5 times higher rate of stress echocardiogram (RR 6.51, 95% CI 5.65 to 7.51) and 16% higher cardiac catheterisation (RR 1.16, 95% CI 1.06 to 1.27). In contrast, revascularisation rates were significantly lower in transplant patients (RR 0.46, 95% CI 0.36 to 0.58). Transplant wait times were longer for patients who underwent stress testing (median 474 days with no testing vs 1053 days with testing) and revascularisation (1796 days for percutaneous intervention and 2164 days for coronary artery bypass surgery). No significant association was observed with 1-year post-transplant mortality (adjusted OR 1.99, 95% CI 0.46 to 8.56). Conclusions: This study found a higher rate of cardiac testing in dialysis patients evaluated for kidney transplants. Cardiac testing was associated with longer transplant wait time, but no association was observed between testing and post-transplant mortality.

Joseph M Kahwaji, MD, MPH; Ryszard R Dudek, MD Fall 2006 - Volume 10 Number 3 Case Summary A 25-year-old man with a history of perinuclear antineutrophil cytoplasmic antibodies-associated vasculitis presented to the ambulatory clinic with five days o