Bone Health in Allogeneic Stem Cell Transplant Patients

Bone health is a concern after bone marrow transplant (BMT). BMT patients are at higher risk of bone mineral density (BMD) loss and fragility fractures. Incidence of BMD loss is 50-75% after allogeneic BMT, with early significant changes within 3-6 months after transplant. Prevalence of fragility fractures is 2-8%, eight times that of age matched population. The American Society for Transplantation and Cellular Therapy (ASTCT) recently published expert opinion guidelines. Our goal was to evaluate the allogenic BMT population at our academic medical center in light of these guidelines to improve management.

Methods:

We performed a retrospective chart review, analyzing the charts of 47 patients who underwent allogeneic BMT between July 2015 and October 2019.

Results:

There were 14 females, and 33 males, median (interquartile range (IQR)) age at BMT was 55 (40-65). Forty-two of the patients were classified as White, 2 Black, 1 Hispanic, 2 Other. Primary diagnoses included acute lymphoblastic leukemia, Hodgkin's lymphoma, mycosis fungoides, acute myeloid leukemia, and chronic myeloid leukemia. Median (IQR) body mass index (BMI) was 30 (27-34). Graft versus host disease (GVHD) was present in 39 patients, 2 had possible but not confirmed GVHD, 6 did not have GVHD. Median (IQR) 25-hydroxy-vitamin D level was 29 ng/ml (21-40). Thirty-six patients were on vitamin D supplements, 11 were not. Fourteen patients were on calcium supplementation, 33 were not. Five patients were treated with bisphosphonates. Forty-four had dual-energy X-ray absorptiometry (DXA) completed post BMT on median (IQR) day 99 (97-106). Median (IQR) T-score at the spine was 1.1 (0.30-1.65), at the hip was 0.2 (-0.60-0.40), and at femoral neck was 0.1 (-0.60-0.50). In our population 5 patients (10% of population) had fragility fractures in the first-year post BMT. Out of those, 2 had normal BMD by DXA, 2 had osteopenia (although would qualify for treatment by Fracture Risk Assessment Tool (FRAX)), and 1 patient had osteoporosis. Overall population mortality was 13 patients out of 47 at 1 year after BMT. Based on the ASTCT guidelines, 25 met criteria for osteoporosis medications, 17 did not, and 5 patients below the age of 30 were not categorizable.

Discussion/Conclusion:

While it is known that bone health deteriorates after BMT, due to factors such as high steroid doses and other medications, research on management is limited. As a result, some patients who may benefit from treatment do not receive it (20 out of 25 in our population). If we had used the recently published consensus guidelines in our institution, it would have resulted in significantly higher percentage of patients being treated, potentially reducing the risk of fragility fractures.