Fractures after kidney transplantation increase health care spending and possibly the risk for early death, a new study finds. Reducing steroid exposure is one mitigating strategy, according to investigators.

Using the 2005-2016 US Renal Data System, investigators studied fractures after kidney transplantation among 67,362 adult kidney transplant recipients with Medicare insurance. Fractures occurred in 7.5% of recipients (8.8% of women, 6.7% of men), and 5.9% and 9.3% of those aged less 55 years and 55 years or more, respectively. Results showed that women (vs men) and patients aged 55 years and older (vs younger patients) had significant 42% and 26% increased risk for developing a fracture from 3 months to 3 years after kidney transplantation, respectively.

Experiencing a fracture was significantly associated with triple the risk of dying from any cause within 3 months, Krista L. Lentine, MD, PhD, of Saint Louis University Transplant Center in St. Louis, Missouri, and colleagues reported in Kidney Medicine. Fractures were also significantly associated with rising Medicare spending: $5122, $10,890, and $11,083 in the first 1, 2, and 3 years after transplantation, respectively.

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The investigators further examined fracture risk by immunosuppressive regimen. The reference regimen (anti-thymocyte globulin or alemtuzumab induction + triple therapy) was used by 44.7% of the cohort. Other regimens were used to a lesser extent: anti-thymocyte globulin or alemtuzumab without prednisone (19.4%), interleukin 2 receptor antibody induction + triple therapy (16.1%), mammalian target of rapamycin inhibitor-based therapy (7.5%), cyclosporine A-based therapy (7.0%), interleukin 2 receptor antibody induction without prednisone (2.3%), and tacrolimus alone or tacrolimus + prednisone with any induction (3.0%).

Induction with anti-thymocyte globulin or alemtuzumab and the avoidance or early withdrawal of steroids significantly reduced the risk for fractures by 37% and 17% in the younger and older age groups, respectively, compared with the reference regimen, the investigators reported. Women appeared to benefit from any steroid-sparing regimen.

“The findings from our current study suggest protective effects of the early withdrawal or avoidance of steroids on the risk of fractures in all age and sex subgroups of kidney transplant recipients,” Dr Lentine’s team wrote.

According to the investigators, it remains important to balance the risks of complications such as fractures and infections, along with the risk of rejection, when choosing the appropriate immunosuppressive regimen for an individual. Among the study’s limitations, the investigators did not have information on why a particular regimen was chosen for a particular patient.

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.


Kuppachi S, Cheungpasitporn W, Li R, et al. Kidney transplantation, immunosuppression and the risk of fracture: clinical and economic implications. Kidney Med. 4(6):100474. doi:10.1016/j.xkme.2022.100474