*Purpose: The incidence of osteoporotic fractures in lung transplant recipients (LTxR) is 35-50%. Due to this high incidence, we perform regular DEXA scans [pre-Tx, every two years post-Tx], calcium/vitamin D repletion, and universal bisphosphonate administration. Our retrospective study aims to assess the effects of this strategy on pre-and post-transplant BMD and incidence of fractures.

*Methods: We conducted a retrospective, single-center study on 203 adults with LTx performed between 2015-2020 and meeting the inclusion/exclusion criteria. Primary endpoints – changes in BMD, the incidence of fractures, and osteopenia in the pre-and post-transplant groups. In addition, we assessed the side-effects of bisphosphonate therapy and risk factors for osteoporosis as secondary outcomes.

*Results: Bisphosphonates were initiated at the discharge from the index stay. LTxR with established osteoporosis was started either on alendronate 70mg weekly [CrCl more than 35] and on denosumab 60mg q 6 months [CrCl less than 35]. In contrast, osteopenic received a lower dose of alendronate [35 mg weekly]. Median follow-up was 1034 days [185, 2348]. 85% of the recipients were Caucasians with a median age of 61 years [23, 75] and an average BMI of 14.4 kg/m2. Idiopathic pulmonary fibrosis [38%], COPD [34%], cystic-fibrosis [5.6%] were the commonest etiologies for LTx. Risk factors such as Age >50 years [88%, 178/203], smoking [75%, 152/203], episode of rejection [62%, 126/203], female gender [42%, 85/203], menopause [40%, 81/203], BMI of < 23 kg/m2 [29%, 59/203], hypovitaminosis D (<20ng/mL,26/203, 13%) were common. 81% of patients with ≥ 3 risks had an episode of post-transplant fractures. Prevalence of pre-transplant osteopenia [T score < - 1] in the lumbar region was 39% and improved to 23% post-transplant with the bisphosphonate therapy. Similarly, the prevalence of osteopenia in the hip region improved from 47% pretransplant to 41% post-transplant. Approximately 16% of recipients had a history of pre-transplant fractures. 14% of recipients had new, and 2% had additional post-transplant fractures despite bisphosphonate therapy. Both Lumbar BMD [0.04 gm/cm2 (-0.001, 0.09), p-value 0.054] and Hip BMD [-0.01 +/- 0.02 gm/cm2 (-0.04 to 0.03), p-value 0.7] stayed preserved during the follow-up period, and the difference in the median was not statistically significant. Vertebral, ankle, and femoral were the commonest fracture sites. More than 95% of patients were on calcium/vitamin D supplements. Cumulative steroid exposure (prednisone) was 461mg [0, 17015] but the dose was not predictive for fractures. GI side effects were commonest (4%), followed by jaw pain (0.4%) and stress fracture (0.8%).

*Conclusions: LTxR is at high risk for osteoporotic fractures and causes significant morbidity. Preventive strategies such as treating with bisphosphonate can help stabilize the BMD and decrease the fracture risk.

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