Background: Skeletal fractures increase morbidity and mortality in kidney transplant recipients yet the incidence and risk factors for fracture in recipients remains uncertain. We conducted a systematic review to assess the incidence and risk factors for fractures in this population.

Methods: We considered all cohort studies that reported fracture incidence and risk factors in kidney transplant recipients. We abstracted data in duplicate and assessed the methodological quality of each study using a modified version of the Downs and Black checklist, measured on a 17-point scale (17 representing the highest quality).

Results: Ten studies totaling 262,678 recipients were reviewed (mean 26,268 recipients, range 61 to 77,430). The average follow-up ranged from 1.7 to 5.3 years. The study quality scores ranged from 8 to 13. The reported incidence rate of fractures in kidney transplant recipients was highly variable ranging from 3.3 to 99.6 fractures per 1000 person-years. The 5-year cumulative incidence of fracture ranged from 5% to 27%. Studies found that the most common risk factors associated with an increased risk of fracture were: presence of diabetes (n=4), receipt of dialysis prior to transplant (n=4), older age (n=3), women (n=3), and white race (n=3). Other statistically significant risk factors associated with an increased risk of fracture were history of a prior fracture (n=2) and recipient of a kidney from a deceased donor (n=2).

Conclusions: The incidence rate for fractures in kidney transplant recipients varies widely in the literature. Based on current literature a precise estimate of fracture risk is not possible. Future studies need to better define these estimates for the purposes of prognostication, understanding disease impact, and sample sizes of intervention trials to help reduce this event.

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