Management of bone health in adult solid organ transplant recipients: a multidisciplinary care pathway

Bone fragility is a major cause of morbidity and reduced quality of life among adult solid organ transplant (SOT) recipients. Despite guideline recommendations, bone health screening and posttransplant treatment remain inconsistent, and optimal therapeutic strategies are not well standardized. We reviewed the relevant literature, along with professional society guidance, and integrated institutional clinical experience to develop a streamlined multidisciplinary care pathway and define key performance indicators for transplant and bone health specialist teams. All non-kidney SOT candidates should undergo spine and hip dual-energy X-ray absorptiometry (DXA) with vertebral fracture assessment at listing, whereas kidney transplant candidates should undergo DXA only when the results are expected to influence management. High-risk patients, defined by a fragility fracture or a T-score ≤-2.5, should be referred for specialist care. After transplantation, non-kidney SOT recipients should receive osteoporosis therapy within 2 to 4 months if they have not been treated in the prior year, with treatment guided by renal function and bone turnover status. Kidney transplant recipients should undergo DXA, with referral and treatment tailored to fracture risk, bone turnover, and renal function. Bone biopsy should be considered when the underlying bone disease is unclear. Early risk stratification, standardized assessment, and coordinated multidisciplinary management are essential for fracture prevention and improved outcomes in SOT recipients.