Bone Mineral Density Loss after Kidney Transplantation: Metabolic Determinants, Diagnostic Approaches and Preventive Strategies

Mineral and bone disease (MBD) is a frequent complication after solid organ transplantation. The rapid decline in bone mineral density (BMD) during the first year after kidney transplantation reflects complex interactions between immunosuppressive therapy, metabolic factors and pre-existing chronic kidney disease (CKD)-MBD. This narrative review summarizes the magnitude and time course of BMD loss after kidney transplantation, the underlying metabolic and pharmacologic mechanisms, and associated fracture risk. Diagnostic strategies including dual-energy X-ray absorptiometry (DXA), quantitative computed tomography (QCT), high-resolution peripheral QCT(HR-pQCT), finite element analysis (FEA), and biochemical markers are reviewed alongside preventive and therapeutic approaches. Recent data highlight early deterioration of cortical bone structure, persistent hyperparathyroidism, and the limited predictive value of DXA alone. Integration of advanced imaging and bone-turnover markers as well as markers of mineral metabolism could improve risk stratification. Emerging artificial intelligence-based modeling and HR-pQCT-guided phenotyping may enable individualized prevention strategies in kidney transplant recipients (KTRs).