Looking after your bones

This section highlights practical ways to combat bone and gum disease, which transplant recipients can be susceptible to.

While transplant medications can weaken bones and affect your teeth, you can take control to enhance your strength and protect your mouth.

Transplant Australia has sourced a world-class dental care resource for recipients, and provided strategies, including weight-bearing exercises and tips on getting more vitamin D and calcium, to strengthen your bones.

Bone health

The side effects of your immune medications and long-term therapy with steroids could thin and weaken your bones. You are especially at risk of rapid loss of bone density in the first year following transplantation.

Additional factors that could contribute to low bone mass or bone disease include:

  • Lack of exercise
  • Traditional osteoporosis risk factors like age, family history, hormonal status, nutrition
  • Other secondary diseases and medications
  • Factors like smoking, diabetes and menopause
  • Bone disease caused by your failing organ, or the treatment for the condition that caused your organ to fail

Thinning of bones or osteoporosis can lead to brittle bones, joint problems and fractures particularly in the spine and ribs. A suppressed immune system, medications, low vitamin D levels and hyperparathyroidism may cause bone pain that often appears at night. Consult your bone specialist if you get bone pain.

You may get pain in your joints in the first few weeks after transplantation. This condition, called ‘post-transplant distal limb syndrome’, usually resolves itself with rest and pain relief medications after a few weeks.

look after your bones

Common causes of bone diseases in transplant candidates:

Lung transplant candidates

Severe chronic obstructive pulmonary disease (COPD): Changes in bone density can be caused not only by COPD’s systemic inflammation, but also due to vitamin D deficiency and the glucocorticosteroids used for treatment.

Cystic fibrosis: Changes in the production of sex hormones, decrease in the absorption of vitamins caused by pancreatic inadequacy, physical inactivity, treatment of the condition with glucocorticoid and depletion of vitamin D are likely factors contributing to bone disease.

Kidney transplant candidates

There are a number of diseases that could lead to deteriorating kidneys. When the kidneys start to malfunction, problems with calcium, phosphate and the parathyroid hormone levels can occur causing the kidneys to stop making a form of vitamin D called calcitriol. The body then can’t absorb calcium from food and starts removing it from the bones, causing bone disease. This condition, called osteodystrophy, is commonly seen in people with kidney diseases and impacts those on dialysis. Visit Kidney Health Australia for more on kidney health.

Children with kidney diseases are seriously impacted by osteodystrophy because their bones are still growing. This condition slows bone growth, affecting height and causes bone deformities.

In adults with kidney disease, bone changes from osteodystrophy occur years before symptoms manifest. Symptoms are also not evident in adults on dialysis until many years after they’ve been dialising. Older women with renal disease and those who’ve gone through menopause are even more vulnerable to this. Click for more on bone disease after kidney transplantation.

Liver transplant candidates

Liver patients’ bone diseases depend on the type of liver disease they have. Patients with alcoholic liver cirrhosis may have low bone density due to the effects of alcohol, malnutrition and lower vitamin D levels.

Patients with primary biliary cirrhosis, a disease that causes destruction of bile ducts, may have vitamin deficiencies. A lack of bile affects their digestive system’s ability to absorb fats and the fat-soluble vitamins A, D, E and K. Low vitamin D levels in the blood affects bone formation. Hence, they have an increased risk of weak and brittle bones that may break more easily.

Heart transplant candidates 

Patients with severe heart conditions that affect the heart muscle (cardiomyopathy) and are on loop diuretics to manage fluid retention may have vitamin D deficiency, impaired renal function and hyperparathyroidism. All of these factors are associated with bone loss.

Prevention and management

Screening

Even before a transplant, you may already have bone disease caused by your failing organ, or the treatment for the condition that caused your organ to fail. Because osteoporosis has no symptoms, you may not be aware that you have decreased bone density (osteopenia) or osteoporosis unless you’ve been diagnosed. Screening tests like bone mineral density tests to assess levels of calcium and minerals/the presence of risk factors for fracture, help in timely detection of bone diseases.

Calcium

Adding the following foods to your diet is a great way to boost calcium levels: dairy products like low-fat milk, yoghurt, hard cheese and non-dairy foods like broccoli, kale, edamame, bok choy, figs, white beans, okra and tofu.

Click here to view the amount of calcium in selected foods.

Opt for mostly reduced-fat varieties and consult a dietician to manage your daily intake of these foods.

Bone health varies across recipients and everyone does not have the same calcium requirements. You may be prescribed additional calcium supplementation.

For more on healthy eating click here. For general information on the amount of calcium essential for building and maintaining bones, click here.

Fall prevention

If you’ve been diagnosed with bone disease and have weak bones, you must take precautions against falling. Three factors are related to whether or not a bone breaks from a fall: the fall itself, the force and direction of the fall, and how fragile the bones are.

Weight-bearing exercises to boost bone health

Exercises and physical activity are essential for maintaining healthy bones and muscles. Commence with a simple activity like walking, and increase activity level as you start feeling better and can mobilise without impacting your surgical scar.

Examples of weight-bearing activities (activities done on your feet so you bear your own weight) include walking outdoors or on the treadmill, climbing stairs, tennis, jogging, low-impact strength training and dancing. Before starting any physical activity, you should consult your transplant specialist.

Remember!

  • Exercises like cycling or swimming which are beneficial for general health are not weight-bearing and have minimal benefit for bone health
  • If you’ve been diagnosed with osteoporosis, avoid high-impact exercises like jumping, running and high-impact dancing. Consult an exercise physiologist and come up with an exercise schedule you can follow regularly

For more on physical activity and osteoporosis, click here.

Vitamin D and other supplements

Your doctor may prescribe additional supplements like vitamin D to support bone health. Although the sun is one of the main sources of vitamin D, you must be careful not to expose yourself to sunlight. Transplant medications make your skin extra sensitive and susceptible to skin and lip cancers.

Dental health

Maintaining healthy teeth and gums is an important part of your care after transplant. Not only will you be prone to infections due to immunosuppressants; some of your medications may have side effects that cause gum and dental problems. You need to beware of tooth decay, mouth ulcers, dry mouth, gum disease and mouth infections.

Examine your mouth regularly. Contact your doctor or dentist if you notice chipped or cracked teeth, any swellings in your mouth, ulcers, tooth pain, bleeding; white patches in your mouth, tongue or lining of your mouth.

You can stay on top of this if you visit a dentist every 6 months or more frequently if you develop any infections or problems. Maintaining mouth hygiene is simple: brush after meals and floss regularly to remove particles and plaque.

If you’re having any dental work done that may injure your gums, contact your transplant doctor in advance, as you may need to commence antibiotics before the procedure.

For more information, click on What Every Transplant Patient Needs to Know About Dental Care.

https://transplant.org.au/wp-content/uploads/2017/01/Dental-Health_Final.pdf

Acknowledgements

Transplant Australia gratefully acknowledges the contribution of Dr Mirna Vucak-Dzumhur, Staff Specialist Nephrologist at Westmead Hospital, Blacktown Hospital and Auburn Hospital for reviewing the article on bone health.