To the Editor:
Cohen et al.(1) have given an exciting review of the current knowledge about the management of bone loss after organ transplantation. In addition to the discussed prophylactic and therapeutic strategies, we want to raise the issue of which time-point could be best to start osteoprotective therapy for patients undergoing solid organ transplantation, particularly cardiac transplantation. This issue has not been thoroughly addressed in former studies,(2, 3) and the authors recommend “to begin bisphosphonate therapy as soon as practical after surgery.”
In the light of very high doses of corticosteroids used in the first weeks after cardiac transplantation and the occurrence of incident fractures even within the first month after transplantation, we propose that patients should receive osteoprotective therapy before transplantation. Again, this refers especially to cardiac transplantations with an average of 5–24 months on the waiting list, which allows for a reasonable (short) pretreatment period. Furthermore, the long-acting effect of oral aminobisphosphonates (and some intravenous bisphosphonates not already approved for treatment of osteoporosis by the drug-regulating authorities in the United States and Europe) on suppression of bone turnover could cover a short treatment-free interval that may be necessary in the early postoperative period after transplantation. Additionally, because significant bone loss may occur in patients with severe heart failure,(4) presurgical bisphosphonate therapy may help prevent deterioration of bone quality before the event of heart transplantation.
We are convinced that presurgical bisphosphonate treatment could prevent fractures in cardiac transplant recipients. The proposed strategy is an intermediate step until well-performed clinical trials yield the missing data. However, why should we withhold from our patients the chance of an important advantage in the absence of a significant disadvantage?