Suboptimal Bone Health Management After Kidney Transplantation and Dialysis Initiation

Background: Patients undergoing kidney transplantation (KT) or initiating dialysis are at high risk for osteoporosis and fractures. However, real-world patterns of bone mineral density (BMD) testing and treatment initiation remain unclear. Methods: We analyzed nationwide insurance claims data for 34,758 KT recipients and 63,674 incident dialysis patients treated between 2003 and 2020. Rates and timing of BMD testing, osteoporosis treatment initiation, and fracture incidence were compared. Osteoporotic fractures were identified using ICD-10 codes, and time-to-event analyses were conducted. Results: KT recipients were younger, predominantly male, and had more prior BMD testing but fewer prior fractures than incident dialysis patients. During follow-up, 63.9% of KT recipients underwent BMD testing, but only 48.6% underwent testing within 1 year post-transplant (median 374 days [IQR 37–1064]). In contrast, only 29.2% of dialysis patients received BMD testing (p < 0.001), with significantly delayed timing. Osteoporosis treatment was prescribed for 15.6% of KT recipients (19.8% within 1 year) and 7.6% of dialysis patients (30.3% within 1 year). Although prescription rates were lower in dialysis, treatments tended to be prescribed earlier. Osteoporotic fractures occurred in 10.6% of KT recipients (median 1990 days [834–3512]), with 11.9% occurring within 1 year. Among dialysis patients, 13.1% experienced fractures (median 1155 days [324–2403]), with 25.0% occurring within 1 year. The 1-year fracture risk was comparable between groups in those with prior fracture. However, among those without prior fracture, dialysis patients had a significantly higher risk (HR 1.49, 95% CI 1.28–1.73). Conclusion: Despite high fracture risk, both BMD testing and osteoporosis treatment remain underutilized in KT and dialysis patients. The low treatment rate may be partly attributable to the limited use of BMD testing, which is often required for reimbursement. Early and proactive bone health assessment is particularly critical in dialysis patients, where fractures occur more frequently and earlier.