Use of Bisphosphonates in Intestinal Transplant Recipients

Presentation Number: SUN 310
Date of Presentation: April 2nd, 2017

Maryam Taufeeq* and Leila Zeinab Khan
Cleveland Clinic Foundation, Cleveland, OH



Recipients of visceral transplant are at increased risk of impaired bone health both before and after surgery. This can be attributed to many factors including impairment of gut homeostasis from primary disease, long term parenteral nutrition, associated malnutrition, and hepatic impairment. Post surgery, this problem is further aggravated by immunosuppressive regimens including high dose steroids. Fat malabsorption and gut dysmotility post surgery can result in further worsening of bone health.

To date, there are no guidelines for management strategies to preserve bone health before and after intestinal transplantation. 



SM is a 33 year old male who presented to the Cleveland Clinic Endocrinology department for evaluation of bone health before multi visceral transplant surgery. He had a past medical history of obesity for which he had Roux-en-Y gastric bypass six years prior. This surgery had numerous complications including internal hernia repair, and its correction resulted in small bowel and gastric ischemia requiring enterectomy and removal of gastric remnant resulting in short gut syndrome. SM became dependent on TPN (total parenteral nutrition) after these procedures and needed intestinal transplant for preservation of his nutritional status and quality of life. 


Initial DEXA (dual-energy X-ray absorptiometry) scan showed lowest Z-score of -2.9 (BMD 0.891 g/cm2) at the left hip and -2.2 (BMD 0.622 g/cm2) at the lumbar spine in October 2013. Vitamin D level was mildly decreased at 17.6 ng/ml (31.0-80.0 ng/ml). His daily TPN contained 15 mEq of calcium per bag and he took 50,000 units of oral Vitamin D daily. Due to low BMD and his continued risk of malabsorption, especially with upcoming transplant, decision was made to give him 5 mg Zoledronic acid injection intravenously in January 2014. 


Few days after the Zoledronic acid infusion, SM received multi visceral transplant, including stomach, small intestine and pancreas. Post surgery, he received very large doses of steroid bursts and was started on Prednisone 15 mg and Tacrolimus 2 mg daily, further increasing his risk of osteoporosis. On a follow up visit in April, his BMD had decreased to 0.559 g/cm2 at the left hip and 0.800 g/cm2 at the lumbar spine. His Vitamin D level subsequently normalized and he received three additional Zoledronic acid infusions annually. His most recent DEXA scan in May 2016 showed statistically significant increase in his bone mineral density, being 0.72 g/cm2 at the left hip and 0.937 g/cm2 at the lumbar spine. Over these three years, he did not suffer from any fractures or height loss.



Along with calcium and vitamin D supplements, bisphosphonates have a role in improving bone health and preventing its further deterioration in the setting of multi visceral transplant. 


Nothing to Disclose: MT, LZK