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Maintaining Skeletal Health for the Transplant Recipient

Maintaining Skeletal Health for the Transplant Recipient. Suzanne Jan de Beur, MD Johns Hopkins School Of Medicine. Overview. The Skeleton: A Dynamic O rgan Organ Failure and Transplantation Impact on the Skeleton Understanding Your Risk for Fracture Preventing Bone Loss & Fracture

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Maintaining Skeletal Health for the Transplant Recipient

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  1. Maintaining Skeletal Health for the Transplant Recipient Suzanne Jan de Beur, MD Johns Hopkins School Of Medicine

  2. Overview • The Skeleton: A Dynamic Organ • Organ Failure and Transplantation Impact on the Skeleton • Understanding Your Risk for Fracture • Preventing Bone Loss& Fracture • Nutrition: calcium and D • Weight bearing and resistance exercise • Fall Prevention • Lifestyle Intervention

  3. The Skeleton is Dynamic

  4. The Amazing Skeleton • Storehouse for calcium • Storehouse for Growth Factors • Senses oxygen • Sensitive to mechanical force • Beautiful balance of bone formation and bone resorption

  5. Normal Bone Remodeling Osteoclast precursors Osteoblasts Lining cells Lining cells Osteoclasts Bone remodeling unit Resting stage Reversal phase Remodeling completed Activation Resorption Formation 2–4 weeks 3–4 months

  6. Osteoporosis is a skeletal disease characterized by low bone mass and micro-architectural deterioration Increased susceptibility to fracture Painless and asymptomatic until a fracture occurs Osteoporosis

  7. Osteoporotic Fractures Occur Frequently After Transplant • In the past, fracture incidence • 10-36% post cardiac transplant • 24-65% post liver transplant

  8. Rate of Post-Transplant Fractures are Declining • Early Treatment of Osteoporosis • Reduced dose and duration of steroids • With interventions, one study showed rates as low as 3.5%

  9. Fractures Occur Early After Transplant • At yr 2-3, Post transplant, spine bone density recovers but femoral neck bone density does not return to baseline Shane et al, JCEM, 1996

  10. Some Immunosuppressants are Harmful to Bone • Steroids • Decreases bone formation • Increases bone resorption • Induces hypogonadism • Cyclosporine >Tacrolimus • Increases bone resorption • Mycophenylate, rapamycin, azathioprine show no effect on bone in animal models

  11. Normal Bone Remodeling Osteoclast precursors Osteoblasts Lining cells Lining cells Osteoclasts Bone remodeling unit Resting stage Reversal phase Remodeling completed Activation Resorption Formation 2–4 weeks 3–4 months

  12. Bone Health Recommendations for Transplant Recipients • Smoking cessation and alcohol moderation • Lowest dose steroids compatible with graft survival • Calcium and vitamin D • Early mobilization and Regular weight bearing exercise • Fall Prevention

  13. Recommendations Pre-Transplant • Measure BMD by DXA • If low BMD or fracture, lab evaluation for secondary causes and treat if found • General Measure to improve skeletal health

  14. Know Your Risk

  15. DEXA

  16. Who should we screen with DXA measurements? • ALL patients in pre transplant evaluation • ALL women age >65 and ALL men >70 • Post menopausal women and men 50-70 with risk factors • Adults 50+ with Low trauma fracture • Radiographic evidence of osteopenia • Long term glucocorticoid therapy • Men with low testosterone • Patients with hyperparathyroidism • Patients with height loss >1.5 inches

  17. Pre Transplant Risk Factors for Fracture Low Bone Density Related to Underlying Disease: Hepatic Osteodystrophy Osteoporosis of End-stage Lung Disease Renal Osteodystrophy Heart Failure Diabetes

  18. Pre transplant Risk Factors for Fractures • Advanced Age • Poor nutrition • Vitamin D deficiency • Reduced Activity • Smoking • Excessive Alcohol • Low body weight • Hormonal Disorders • Hypogonadism • Hyperparathyroidism • Medications • Steroids • Heparin • Loop diuretics

  19. Post TransplantationRisk Factors for Fracture • Medications • Glucocorticoids • Cyclosporine, Tacrolimus • Hypogonadism • Poor Nutrition • Vitamin D def • Immobilization • Life style • Smoking • Excessive Alcohol • Inactivity

  20. Risk Factors in Renal Transplant • Hyperparathyroidism • Diabetes • Metabolic Acidosis

  21. Prevention Strategies

  22. Bone is a structured complex of protein and minerals

  23. How much Calcium? Institute of Medicine • Calcium • up to age 50: 1000 mg/d • Age 50-70: 1000 mg (M), 1200 mg (W) • ages 71+: 1200 mg/d • maximum: 2500 mg/d • Vitamin D • up to age 50: 600 IU/d • ages 51-70: 600 IU/d • ages 71+: 800 IU/d • maximum: 4000 IU/d

  24. Consensus on Calcium Supplements and the Heart “Calcium with or without vitamin D intake from food or supplements has no relationship to the risk for cardiovascular and cerebrovascular disease, mortality, or all cause mortality in generally healthy adults.” • National Osteoporosis Foundation (2016) • American Society for Preventive Cardiology (2016) • International Foundation for Osteoporosis (2017) • European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis, and Musculoskeletal Diseases (2017)

  25. Take Home Point:Get Calcium from Dietary Sources

  26. Dietary Calcium

  27. Adequate Calcium intake is Equivalent to 3 glasses of Milk

  28. Non-Dairy Sources of calcium • Soy milk • Almond milk (450 mg/cup) • Almonds (300 mg/cup whole) • Black strap molasses (50 mg/tbsp) • Kale, collard greens (100 mg/cup raw) • Spinach, broccoli (50 mg/cup raw) • Tofu with ca sulfate (400 mg/0.5 cup)

  29. Getting Calcium ThroughYour Diet www.healthyeating.org/Healthy-Eating/Healthy-Eating-Tools/Calcium-Quiz.aspx

  30. For Strong Bones: Calcium Meals 700 mgs Calcium Supplement 500 mgs 1200 mgs + Goal :1000-1200 mg/day

  31. Many Preparations of Calcium are Available • Tablets • Chewables • Soft Chews • Liquid/dissolvable

  32. Calcium Preparations • Calcium Carbonate • Oscal • Caltrate • Tums • Viactiv • Calcium Citrate • Citracal • Calcium Phosphate • Posture and Posture D

  33. Percent of Elemental Calcium in Calcium Compounds

  34. How many pills do you need to get daily allowance of calcium?

  35. Effectively Reading Labels

  36. Effectively Reading Labels

  37. Take Home Point:Calcium and Vitamin D are Needed Together

  38. Calcium and D Partners for Good Bone Health

  39. Vitamin D Synthesis • Requires intact skin, gut, liver, kidney • Those with disorders that involve these organs are at higher risk of Vitamin D deficiency • Greater than 90% derived from sunlight exposure • Lack of sun exposure, sun screen and darker skin pigment make it difficult to get enough vitamin D • There are few dietary sources

  40. Vitamin D: Clinical Skeletal Effects • Vitamin D levels of 40 ng/dL associated with higher bone density • In controlled trials, vitamin D supplementation had a threshold effect: • 400 units daily no reduction in fractures • 800 units daily reduced fractures by 26% • Need to be taken with calcium

  41. Dietary Sources of Vitamin D

  42. Sun Exposure (3000U) (10 min to legs arms) Sun-dried Shiitake Mushrooms 3.5 oz (1600U) Salmon: fresh, wild 3.5 oz (600-1000U) Cod liver oil: 1 tsp (400-1000U) Canned fish: 3.5 oz (250-300U) Fortified Food: per serving (100U) Vitamin D Content

  43. The Balancing Act • Maintain 1000-1200 mg daily calcium intake for skeletal benefits • Get calcium from your diet when possible • Get 800-1000 units of D and maintain a level of 40 ng/ml

  44. Benefits of Exercise Increase Muscle Strength Improve Balance Improve Posture Improve Sense of Well Being Maintain Independence

  45. Exercise for Osteoporosis Goals Weight bearing Exercise: 30 min most days Muscle-strengthening: 20 min 2-3 days/week Flexibility/Balance/Posture: Daily Rotate

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