Collapsing focal segmental glomerulosclerosis in a liver transplant recipient on alendronate

Association between Anti-Osteoporotic Drugs and Risk of Acute Kidney Injury: A Cross-Sectional Study Using Disproportional Analysis and a Pharmacovigilance Database

The number of fractures related to osteoporosis is expected to increase. Therefore, clarifying the risk of acute kidney injury (AKI) associated with each type of anti-osteoporotic drug may avoid discontinuation of osteoporosis pharmacotherapy due to onset of AKI. This cross-sectional study using disproportional analysis and a pharmacovigilance database assessed the risk of AKI with various anti-osteoporotic drugs by analyzing data entered into the US Food and Drug Administration's Adverse Event Reporting System (FAERS) from April 2014 to March 2021 and the Medical Data Vision (MDV) database in Japan in November 2021. All anti-osteoporotic drugs were investigated, including bisphosphonates, selective estrogen receptor modulators, denosumab, romosozumab, abaloparatide, and teriparatide. In the analysis of FAERS data, disproportionality for decreasing AKI was observed for oral ibandronate [reporting odds ratios (ROR) 0.22, 95% confidence interval (CI) 0.09-0.45, P < 0.01], bazedoxifene (ROR 0.26, 95% CI 0.05-0.77, P = 0.01), and intravenous ibandronate (ROR 0.39, 95% CI 0.14-0.86, P = 0.01). In the analysis of the MDV data, the incidence of AKI was lower in patients taking intravenous ibandronate [odds ratio (OR) 0.22, 95% CI 0.06-0.89, P = 0.03], and the incidence of AKI was higher in patients taking oral alendronate (OR 2.40, 95% CI 2.08-2.77, P < 0.01). Risk of AKI may differ even among oral anti-osteoporotic drugs, and the evidence of this association should be assessed further in future drug safety studies. This article is protected by copyright. All rights reserved.

Optimization of osteoporosis and osteopenia management among renal transplant recipients

Background

Osteoporosis and osteopenia occur frequently in renal transplant recipients due to long-term use of immune-suppressants including corticosteroids. Previous treatment options like bisphosphonates had acceptable but rather unsatisfactory results after transplant. The aim of the current study is to directly compare the efficacy of denosumab and oral ibandronate in late RTR with low bone mineral density.

Results

The study was conducted Iin Hamed Al-Essa Kidney transplant center, Kuwait, in 2020. The data of 52 denosumab and 48 ibandronate patients were collected at the baseline and after one year of treatment. Spine and hip T-score readings, side effects, and other laboratory results were analyzed to evaluate the use of both medications. The mean number of months after transplant was 25 (± 13.9) months. After one year of treatment, denosumab alleviated both spinal osteoporosis and osteopenia T-score values from −3.13 to −2.4 (p = 0.008) and from −1.9 to −1.5 (p = 0.015), respectively. Besides, it reduced hip osteoporosis and osteopenia insignificantly from −3.45 to −3.1 and from −1.5 to −1.3, respectively (p > 0.05). Ibandronate improved spinal osteopenia from −1.6 to −1.55 (p = 0.97) and failed to show any positive impact on other sites; the spinal osteoporosis changed from −2.8 to −3 and hip osteoporosis and osteopenia changed from −3.1 to −3.12 and from −1.4 to −1.45, respectively (p > 0.05). The use of ibandronate was more associated with gastrointestinal tract (GIT) side effects, while hypocalcemia episodes were significantly higher in the denosumab group.

Conclusion

Denosumab improved both spinal and hip T-score values in comparison with ibandronate in RTR. Close monitoring is required for denosumab patients to prevent the associated hypocalcemia.

Graphical Abstract

Bisphosphonate nephropathy: A case series and review of the literature

From rat studies, human case reports and cohort studies, bisphosphonates seem to impair renal function. However, when critically reviewing the literature, zoledronate and pamidronate are more frequently involved in renal deterioration than other bisphosphonates. When bisphosphonate nephropathy occurs, zoledronate more frequently induces tubular toxicity whereas pamidronate typically induces focal segmental glomerulosclerosis. Thus, although bisphosphonates are highly effective in preventing complications for patients with osseous metastases and are highly effective in preventing fractures for patients with osteoporosis, renal function should be monitored closely after initiation of these drugs.

Collapsing glomerulopathy: update

Collapsing glomerulopathy (CG) is a rare entity as a glomerular disease. Although it has been considered as a variant of focal segmental glomerulosclerosis, the fact is that the podocyte lesions show different features with respect to the typical focal segmental glomerulosclerosis, an aspect that has been attributed to a type of podocytopathy. In CG, the podocyte lesion is typically characterised by a dysregulated podocyte phenotype, reflected by the loss of expression of mature podocyte markers. CG can be a primary disease or it can be associated with several causal factors that develop a common histopathological entity. The clinical expressiveness of CG is often characterised by the presence of a nephrotic syndrome and a rapid deterioration of the renal function than other variants of the focal segmental glomerulosclerosis. The prognosis of these patients is a rapid progression towards end-stage renal disease with poor response to treatment.

Drug-induced glomerular disease: direct cellular injury

The potential of medications to cause kidney injury is well known. Although nephrotoxicity is most commonly associated with injury in the tubulointerstitial compartment as either acute tubular necrosis or acute interstitial nephritis, a growing body of literature has also highlighted the potential for drug-induced glomerular lesions. This review surveys the three primary patterns of drug-induced glomerular diseases stratified by the cell type at which the glomerular lesion is focused: visceral epithelial cell (or podoctye) injury, endothelial cell injury, and mesangial cell injury. A number of commonly prescribed medications, including IFNs, bisphosphonates, nonsteroidal anti-inflammatory drugs, antiplatelet agents, and antiangiogenesis drugs, that are both prescribed and available over the counter, have been implicated in these iatrogenic forms of glomerular disease. Recognition of these drug-induced etiologies of glomerular disease and rapid discontinuation of the offending agent are critical to maximizing the likelihood of renal function recovery.

Collapsing focal segmental glomerulosclerosis resulting from a single dose of zoledronate

Bisphosphonates are commonly used for the treatment of osteoporosis, Paget's disease, multiple myeloma and hypercalcemia. Collapsing focal segmental glomerulosclerosis (FSGS) is known to occur uncommonly with exposure to bisphosphonates, specifically pamidronate and alendronate; it has rarely and equivocally been reported with zoledronate therapy. We describe the case of a 36-year-old African American female with metastatic breast cancer who presented with nephrotic-range proteinuria and acute kidney injury within 2 weeks of exposure to a single dose of zoledronate. The patient had a partial recovery of her renal function and showed improved proteinuria to a subnephrotic level after discontinuing zoledronate. In contrast to 2 prior reports of zoledronate-induced collapsing FSGS, the causative role of the exposure described here is certain. Our case necessitates the addition of zoledronate to the list of known causes of collapsing FSGS. Furthermore, it highlights the importance of periodically monitoring renal function and urine protein excretion with the use of zoledronate, which allows prompt diagnosis and withdrawal of the drug to increase the probability of renal recovery.

Alendronate associated focal segmental glomerulosclerosis: a case report and review of the literature

Although kidney injury associated with intravenous bisphosphonate therapy is well documented, there are very few reported instances of oral bisphosphonate therapy leading to focal segmental glomerulosclerosis (FSGS) and kidney failure. We report the case of a 79-year-old woman who developed acute kidney injury due to collapsing FSGS while receiving therapy with weekly oral alendronate therapy for osteoporosis. Withdrawal of alendronate and treatment with corticosteroids resulted in partial recovery of kidney function for a period of 16 months until she developed progressive kidney failure needing long-term dialysis. This case report and the literature review highlight the fact that oral bisphosphonates may be associated with a risk of developing FSGS.

Collapsing glomerulopathy and hemolytic uremic syndrome associated with falciparum malaria: completely reversible acute kidney injury

Acute kidney injury (AKI) is one of the most dreaded complications of severe malaria. Herein, we report a case of spontaneous resolution of AKI due to collapsing glomerulopathy (CG) and hemolytic-uremic syndrome (HUS) associated with P. falciparum malaria. Our case report highlights the fact that early intervention on the triggering cause of CG without a long course of steroids may obtain a remission of this severe subset of CG and may obtain a remission of HUS without therapeutic plasmapheresis The etiologic treatment of CG and HUS may avoid progression to end-stage renal disease.

Nephrotic syndrome after oral bisphosphonate (alendronate) administration in a patient with osteoporosis

Alendronate is a widely used bisphosphonate in the treatment of osteoporosis. Although it has been proven to be a very useful drug, it has some side effects as well. In this paper, we describe a case of nephrotic syndrome due to alendronate administration. A 36-year-old man was admitted to the nephrology outpatient clinic with widespread edema 4 months after initiation of alendronate. He had a 13-kg weight gain within a 2-week period. He had no clinical or laboratory problems apart from osteoporosis, which was the indication for initiation of the drug. Physical examination at admission was unremarkable, but for nephrotic edema. Laboratory studies revealed nephrotic range proteinuria (13.5 g/day), normal renal function, hypoalbuminemia (1.7 g/dl), and also hypercholesterolemia (400 mg/dl). A kidney biopsy was performed. Light microscopic evaluation revealed a slight increase in mesangial cells and matrix; however, no abnormalities in the tubules or interstitium were noted. Alendronate was withdrawn and diuretic therapy was initiated. Patient's weight gradually decreased from 84 to 67 kg within a 1-week period. No other drugs for the treatment of nephrotic syndrome were administered. During the clinical course, serum creatinine remained stable, and proteinuria gradually decreased and disappeared 40 days after stopping alendronate. It was noted that alendronate administration can give rise to nephrotic syndrome, while discontinuation of this drug may improve the pathology without any specific treatment.

Oral bisphosphonate use in the elderly is not associated with acute kidney injury

Intravenous bisphosphonates can cause acute kidney injury; however, this risk was not found with oral bisphosphonates in randomized clinical trials with restrictive eligibility criteria. In order to provide complementary safety data, we studied the risk of acute kidney injury in a population-based cohort of 122,727 patients aged 66 years and older discharged from hospital following a new fragility fracture and no history of bisphosphonate use in the prior year. Bisphosphonate treatment was identified within 120 days after discharge and event rates were measured from 90 days of therapy initiation. The primary outcome was hospitalization with acute kidney injury with secondary outcomes of new nephrology consultation and, in a subset of patients with laboratory values, acute kidney injury was defined as an increase in serum creatinine. We identified 18,286 bisphosphonate users and 104,441 non-users with a mean age of 81 years. Of 5772 patients with laboratory values, 40% had chronic kidney disease (eGFR <60 ml/min per 1.73 m(2)). Overall, there was no statistically significant difference in the risk of acute kidney injury among bisphosphonate users compared to non-users (adjusted odds ratio 1.03), and no significant differences in other outcomes or in subgroups of patients with baseline chronic kidney disease. Thus, in this older population-based cohort, oral bisphosphonate use was not associated with acute kidney injury.

Use of oral bisphosphonates by older adults with fractures and impaired renal function

BACKGROUND

The manufacturers of oral bisphosphonates (alendronate, risedronate) recommend avoiding use of these drugs in patients with renal impairment. However, many patients who have osteoporosis or who are at risk of fracture are elderly and may have renal impairment. This situation poses a quandary for clinicians in deciding how best to manage osteoporosis in this high-risk population.

OBJECTIVE

To synthesize published evidence regarding the use and safety of oral bisphosphonates for patients with impaired renal function.

METHODS

The following databases were searched up to October 2010: PubMed, MEDLINE, Embase, the Cochrane Library, and International Pharmaceutical Abstracts. The following key words and terms were used for the searches: bisphosphonates, alendronate, risedronate, Fosamax, Actonel, "renal failure", "renal insufficiency", "chronic kidney disease", and "end-stage renal disease". The manufacturers of Fosamax and Actonel were asked to provide information about use of their products in patients with renal impairment, including unpublished pharmacokinetic studies or reports of adverse drug events.

RESULTS

The search yielded 2 post hoc analyses of safety data, 1 case-control study, 1 case series, 4 retrospective chart analyses, and 2 prospective studies. According to these publications, numerous patients with decreased renal function have received bisphosphonates and have experienced improvement in bone mineral density and/or reduction in risk of fractures, with no increase in adverse effects. Increased renal damage occurred in some individuals with underlying renal disorders, as described in case reports.

CONCLUSIONS

Although the literature is limited, there is evidence that alendronate and risedronate are well tolerated and effective when used by individuals with renal impairment. Further research is required to confirm the benefits and risks of using these medications in patients with renal impairment.

Adverse effects of bisphosphonates

Use of bisphosphonates has been growing steadily in the last decade. This follows the introduction of simpler dosing regimes, the availability of lower-priced generics, and concerns about the safety of hormone-replacement therapy. Bisphosphonates have a relatively good safety record and are tolerated by the majority of patients, but serious adverse events have been recorded in some cases. Only the most common of adverse effects are robustly observable in clinical trials. In general, studies were not powered to detect effects that were lower in incidence than fractures. This review of adverse events in bisphosphonate-treated patients was based on published information from case reports, case series, claims databases, national databases, surveys, adverse event reporting databases, and single or pooled clinical trials. The most common acute adverse events with bisphosphonates for osteoporosis are gastrointestinal discomfort and acute influenza-like illness. Renal complications are very rare with oral bisphosphonates and rare with i.v. bisphosphonates when used appropriately. Based on our current knowledge, skeletal events in the form of osteonecrosis of the jaw and atypical fragility fractures are rare compared with the risk of osteoporotic fractures, at least in patients with the same risk of fractures as those in the phase III trials. It is biologically plausible that atypical fragility fractures could follow from suppression of bone remodeling, but high-quality studies proving causality are lacking. Physicians are advised to critically reassess BMD and risk profile after 3-5 years of therapy to avoid treatment in patients at low risk.

Nephrotic syndrome and renal failure as an unusual presentation of solid tumour

Glomerular diseases may occur as primary manifestation of cancer, especially in patients older than 60 years. Among glomerulopathies, membranous nephropathy is preferentially associated with respiratory and gastrointestinal tract adenocarcinomas, whereas minimal change disease is most often seen in haematological malignancies. Though breast cancer is one of the most frequent malignancies in women, paraneoplastic glomerular disease is rarely observed. We describe the case of a 79-year-old female patient who presented with nephrotic syndrome and renal failure. Breast cancer was found. Pathological studies of kidney and breast biopsy revealed a minimal change disease and an infiltrating ductal carcinoma, respectively.

Emerging therapy-related kidney disease

CONTEXT

Many new therapies have emerged within the last 5 to 10 years to treat a variety of conditions. Several of these have direct or indirect renal toxicities that may go undiagnosed without careful attention of the pathologist to a patient's clinical history, particularly the addition of new medications or treatments.

OBJECTIVE

To discuss patterns of renal injury resulting from medications or therapeutic regimens that have been introduced within the last 10 years. Recognition of these patterns may allow the pathologist to alert the attending clinician to a possible drug-induced renal injury and prevent further deterioration of renal function and possible chronic kidney disease.

DATA SOURCES

A review of recent literature and unpublished observations of case-derived material.

CONCLUSIONS

A number of newer therapies have emerged as agents of renal toxicity, producing a variety of pathologic changes in the kidney. The outcome can be acute or chronic glomerular, tubular, interstitial, and/or vascular injury. Some drugs will result in irreversible changes and end-stage renal disease, whereas many of the alterations can be reversed with removal of the offending agent, avoiding potential long-term kidney injury.

Pamidronate in the prevention of bone loss after liver transplantation: a randomized controlled trial

Rapid bone loss and high rates of fractures occur following liver transplantation. To analyze the effect of intravenous pamidronate on bone loss after liver transplantation. A randomized, double-blind, placebo-controlled study was performed. Seventy-nine patients were randomized to two groups of treatment: the pamidronate group (n = 38) was treated with 90 mg/IV of pamidronate within the first 2 weeks and at 3 months after transplantation; the placebo group (n = 41) received glucose infusions at the same time points. All patients received calcium and vitamin D. Bone mineral density (BMD) at the lumbar spine (L(2)-L(4)) and proximal femur using dual energy X-ray absorptiometry and also spinal X-rays were performed before, and at 6 and 12 months after liver transplantation. Biochemical and hormonal determinations were performed previous to transplantation, at 24 h before and after treatment, as well as at 6 and 12 months after liver transplantation. At 12 months after transplantation, there were significant differences in lumbar BMD changes (6 months: pamidronate 1.6% vs. placebo 0.8%, P = NS; 12 months: pamidronate 2.9% vs. placebo 1%, P < 0.05). Femoral neck BMD decreased in the pamidronate- and placebo groups during the first 6 months (6 months: pamidronate -3.1% vs. placebo -2.9%, P = NS; 12 months: pamidronate -3.2% vs. placebo -3.1%, P = NS). BMD at the trochanter remained stable in the pamidronate group, whilst a reduction was observed in the placebo group at 6 months (6 months: pamidronate -0.7% vs. placebo -3.7%, P < 0.05; 12 months: pamidronate -0.5% vs. placebo -1.2%, P = NS). Moreover, no significant differences in the incidence of fractures, serum parathyroid hormone and serum 25-hydroxyvitamin D values between both groups were found. Pamidronate did not increase the risk of serious adverse events. The results of this study show that 90 mg of intravenous pamidronate within the first 2 weeks and at 3 months following liver transplantation preserve lumbar bone mass during the first year, without significant adverse events. However, pamidronate does not reduce bone loss at the femoral neck and furthermore it does not reduce skeletal fractures.

Massive proteinuria and acute renal failure after oral bisphosphonate (alendronate) administration in a patient with focal segmental glomerulosclerosis

A 61-year-old Japanese man with nephrotic syndrome due to focal segmental glomerulosclerosis was initially responding well to steroid therapy. The amount of daily urinary protein decreased from 15.6 to 2.8 g. Within 14 days of the oral bisphosphonate (alendronate sodium) administration, the amount of daily urinary protein increased rapidly up to 12.8 g with acute renal failure. After discontinuing the oral alendronate, the patient underwent six cycles of hemodialysis and four cycles of LDL apheresis. Urinary volume and serum creatinine levels recovered to the normal range, with urinary protein disappearing completely within 40 days. This report demonstrates that not only intravenous, but also oral bisphosphonates can aggravate proteinuria and acute renal failure.

Bisphosphonates and bone fractures in long-term kidney transplant recipients

BACKGROUND

There is little information on the role of bisphosphonates and bone mineral density (BMD) measurements for the follow-up and management of bone loss and fractures in long-term kidney transplant recipients.

METHODS

To address this question, we retrospectively studied 554 patients who had two BMD measurements after the first year posttransplant and compared outcomes in patients treated, or not with bisphosphonates between the two BMD assessments. Kaplan-Meier survival and stepwise Cox regression analyses were performed to examine fracture-free survival rates and the risk-factors associated with fractures.

RESULTS

The average time (+/-SE) between transplant and the first BMD was 1.2+/-0.05 years. The time interval between the two BMD measurements was 2.5+/-0.05 years. There were 239 and 315 patients in the no-bisphosphonate and bisphosphonate groups, respectively. Treatment was associated with significant preservation of bone loss at the femoral neck (HR 1.56, 95% CI 1.21-2.06, P=0.0007). However, there was no association between bone loss at the femoral neck and fractures regardless of bisphosphonate therapy. Stepwise Cox regression analyses showed that type-1 diabetes, baseline femoral neck T-score, interleukin-2 receptor blockade, and proteinuria (HR 2.02, 0.69, 0.4, 1.23 respectively, P<0.01), but not bisphosphonates, were associated with the risk of fracture.

CONCLUSIONS

Bisphosphonates may prevent bone loss in long-term kidney transplant recipients. However, these data suggest a limited role for the initiation of therapy after the first posttransplant year to prevent fractures.