OSTEOPOROSIS IN LUNG TRANSPLANTATION CANDIDATES WITH END-STAGE PULMONARY-DISEASE

PURPOSE: Fractures, a common complication of cardiac and liver transpl antation, have not been reported in association with lung transplantat ion. However, many patients with end-stage pulmonary disease have mult iple risk factors for osteoporosis, and several studies have suggested that osteoporosis before transplantation may increase the risk of fra cture after transplantation. Therefore, we evaluated a group of patien ts with end-stage pulmonary disease who were awaiting lung transplanta tion to determine the prevalence of osteoporosis. METHODS: Seventy pat ients (aged 18-70 years) were evaluated consecutively with bone densit ometry by dual-energy x-ray absorptiometry. The patients were predomin antly Caucasian (96%). Bone mass was expressed as bone mineral density (BMD; g/cm(2)), as the number of standard deviations (SD) below peak bone mass (T score), and as bone mineral apparent density (BMAD; g/cm( 3)), a measurement that minimizes the effects of bone size on BMD. Spi ne radiographs were obtained in a subset of 50 consecutive patients to detect vertebral compression fractures. Vitamin D status was assessed with serum concentrations of 25-hydroxyvitamin D. The patients were s orted into groups by pulmonary diagnosis: chronic obstructive pulmonar y disease (COPD; n = 28); cystic fibrosis (n = 11); idiopathic pulmona ry fibrosis; and other lung diseases (Other; n = 31). RESULTS: In the group as a whole, osteoporosis (T score below -2.5) was present in 30% of the patients at the lumbar spine and 49% at the femoral neck. Oste openia (T score between -1 and -2.5) was present in an additional 35% at the lumbar spine and 31% at the femoral neck. The average femoral n eck T score of patients with COPD and cystic fibrosis fell into the os teoporotic range (-2.7 +/- 0.3 and -2.6 +/- 0.3, respectively), signif icantly (P < 0.01) below that of the patients in the Other category (- 1.5 +/- 0.3). The average lumbar spine T score fell into the osteopeni c range in all three groups. Low BMAD in patients with cystic fibrosis confirmed that their low BMD was not due to their smaller body size. The prevalence rate of vertebral fractures was 29% in patients with CO PD and 25% in those with cystic fibrosis. Vitamin D deficiency (25-hyd roxyvitamin D levels less than or equal to 10 ng/ml) was present in 36 % of patients with cystic fibrosis and 20% with COPD and Other lung di seases. Lumbar spine BMD tended to be lower in cystic fibrosis patient s with vitamin D deficiency. Patients with exposure to glucocorticoids (n = 46) had significantly more vertebral fractures (P < 0.05) and du ration of exposure correlated negatively with lumbar spine BMD (r = -0 .398; P = 0.008). COPD and Other patients not on glucocorticoids had m ild lumbar spine osteopenia (0.972 +/- 0.06 g/cm(2); T = -1.2 +/- 0.6) . Very few of the patients on glucocorticoids were on any regimen to p revent osteoporosis. CONCLUSIONS: Osteoporosis and vitamin D deficienc y are extremely common in patients with end-stage pulmonary disease. O nly 34% of patients had normal lumbar spine BMD and only 22% had norma l BMD at the hip. Patients with cystic fibrosis and glucocorticoid-tre ated patients with COPD were most severely affected. Therapies to prev ent bone loss and treat established osteoporosis are uncommonly utiliz ed in glucocorticoid-treated patients with end-stage pulmonary disease . Candidates for lung transplantation should be evaluated for osteopor osis and vitamin D deficiency at the time of acceptance to the transpl ant waiting list.