*Purpose: Disorders of bone and mineral metabolism frequently develop with advanced kidney disease, may be exacerbated by immunosuppression (ISx) after kidney transplant (KTx), and may increase the risk of fracture. We examined relationships between fractures and ISx among older and younger adults in a national sample of Medicare beneficiaries.

*Methods: We examined SRTR data (2005-2017) to explore associations of ISx regimens (within 6 mo) with osteoporosis and fracture diagnoses >6 mo-to-3 yr post-KTx among Medicare-insured younger (age <55) and older (aged ≥ 55) adults. We used multivariate Cox regression with inverse propensity weighting to compare cancer risk (adjusted hazard ratio, _{95% LCL} aHR _{95% UCL}) vs. reference regimen of Thymoglobulin (TMG) or Alemtuzumab (ALEM) + Tacrolimus (Tac) + mycophenolic acid (MPA) + prednisone [Pred

*Results: Fractures were identified in 7.5% of KTx (women: 8.8% vs. men: 6.7%; age<55 years: 5.9% vs ≥55 years: 9.3%) during observation. In time-varying regression, fractures were associated with substantially increased risk of subsequent death within 3 months of diagnosis (aHR, _2.453.06_3.81). Fractures were also associated with increased Medicare spending (fracture in the 1^st year: $5122.5, p<.0001, 2^nd year: $10,890, 3^rd year: $11,082) (Fig 1).

Cell-depleting induction and early steroid withdrawal/avoidance (ESW) ISx significantly reduced fracture risk in younger (aHR, ₀₇₄0.83_0.94) and older (aHR, _0.540.63_0.73) patients (Fig 2A). ESW with any induction was associated with reduced fracture risk in women (Fig 2B).

*Conclusions: Fracture after KTx is associated with significantly increased clinical complications and costs. ESW after induction with TMG/ALEM reduces the risk of fracture after KTx and should be considered for high-risk patients including older adults and women.

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