DÄ internationalArchive3/2010Recommended Fluid Intake Should Be Tailored to the Individual
LNSLNS We wish to comment on two critical issues in this otherwise excellent article.

• Complex bone disease after renal transplantation (NTX) is not the same as steroid induced osteoporosis. Bisphosphonates after NTX should not be used in analogy to the guidelines from the umbrella organization for osteology (Dachverband Osteologie, DVO e.V.) as a general rule (use during steroid treatment >3 months or in patients with an osteoporotic fracture + T score <-1.5), because:

– Although bone density after NTX increases when bisphosphonates are given, this is not a good predictor for fractures after NTX, and a drop in the incidence of fractures has not been shown (1).

– Adynamic bone disease is the most common bone pathology in dialysis patients. It often persists after NTX. Using antiresorptive drugs in such situations seems a questionable approach (long term complications?) (2).

– The optimum dosage and duration of bisphosphonate use, and the best administration method, remain unclear.

Current nephrology guidelines (KDOQI, Kidney Disease Outcome Quality; KDIGO, Kidney Disease Improving Global Outcomes; EBPG, European Best Practise Guidelines) do not provide a clear recommendation for the use of bisphosphonates after NTX. In an NTX patient with unsuppressed bone metabolism who is at a high risk of fractures, bisphosphonates certainly feature among the individualized treatment options. In addition to bone densitometry, however, clinical risk factors should be included in any assessment of fracture risk. The cornerstones of therapy primarily include adjusting immunosuppression, optimizing renal osteodystrophy therapy, physical activity, and preventing falls.

• A global recommendation for fluid intake of more than 2 liters/day should be made on an individual basis only. It is indicated in NTX patients with recurrent urinary tract infections, for example. On the other hand, reports are increasing that in patients with impaired renal function, drinking more than 2 L/d accelerates the further loss of kidney function (3). Although this has not been the subject of formal studies in the context of NTX, we think that a daily intake of 1.5–2 L is sufficient in most renal transplant patients.
DOI: 10.3238/arztebl.2010.0037b

Prof. Dr. med. Jürgen Floege
Dr. med. Vincent Brandenburg
Medizinische Klinik II
Klinik für Nephrologie, UK Aachen
Paulwelstr. 30
52074 Aachen, Germany
Vincent.Brandenburg@post.rwth-aachen.de
1.
Conley E, Muth B, Samaniego M, et al.: Bisphosphonates and bone fractures in long-term kidney transplant recipients. Transplantation 2008; 86: 231–7.
2.
Coco M, Glicklich D, Faugere MC, et al.: Prevention of bone loss in renal transplant recipients: a prospective, randomized trial of intravenous pamidronate. J Am Soc Nephrol 2003; 14: 2669–76.
3.
Hebert LA, Greene T, Levey A, Falkenhain ME, Klahr S: High urine volume and low urine osmolality are risk factors for faster progression of renal disease. Am J Kidney Dis 2003; 41: 962–71.
4.
Schrem H, Barg-Hock H, Strassburg CP, Schwarz A, Klempnauer J: Aftercare for patients with transplanted organs [Nachsorge bei Organtransplantierten]. Dtsch Arztebl Int 2009; 106(9): 148–55.
1. Conley E, Muth B, Samaniego M, et al.: Bisphosphonates and bone fractures in long-term kidney transplant recipients. Transplantation 2008; 86: 231–7.
2. Coco M, Glicklich D, Faugere MC, et al.: Prevention of bone loss in renal transplant recipients: a prospective, randomized trial of intravenous pamidronate. J Am Soc Nephrol 2003; 14: 2669–76.
3. Hebert LA, Greene T, Levey A, Falkenhain ME, Klahr S: High urine volume and low urine osmolality are risk factors for faster progression of renal disease. Am J Kidney Dis 2003; 41: 962–71.
4. Schrem H, Barg-Hock H, Strassburg CP, Schwarz A, Klempnauer J: Aftercare for patients with transplanted organs [Nachsorge bei Organtransplantierten]. Dtsch Arztebl Int 2009; 106(9): 148–55.