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The musculoskeletal complications in recipients of renal allografts functioning for >20 years and treated with prednisone have not been reported. Of 511 renal transplants done at the Cleveland Clinic from January 1963 to January 1976,79 (15.4%) (48 M/31F) are known to have functioned > 20 years (Level 5A): 18/304 CAD (6%), 61/200 LRD (30.5%) and, 0/7 LURD. Bone mineral density (SMD) studies of the lumbar spine and hips in 35 patients (24 LRD/l1 CAD; 25M/10F; 20 > 50 years; 13 diabetics; 15 with Scr > 1.4 mg/dl) by the widely used WHO criteria with local subclassifications of osteopenia showed: osteoporosis and/or moderate/severe osteopenia in 26 (74%) (Group I), and mild osteopenia and/or normal results in 9 (26%) (Group II). Those affected were somewhat atypical for osteoporosis/osteopenia with a predominance of males and non-diabetics, as well as many with good renal function (Scr < 1.4 mg/dl), prednisone dosage < 10 mglday, and age < 50 years:
The clinical profile in Group I differed for males and females: > 50 years old (11/20 vs 5/6), diabetic (1O/20 vs l/6), Scr > 1.4 mg/dl(12/20 vs 2/6), and prednisone dose >10 mg/day (12/20 vs 3/6). All 10 patients in Group I who were < 50 years old (9 males, 1 female) had > 2 risk factors (diabetes, Scr ) 1.4 mg/dl, or prednisone dose >10 mg/day). Of 6 females >50 years old, 5 were in Group I, 4 of whom had only O-l other risk factor. Treatment included calcium and vitamin D, alenndronate, calcitonin nasal spray, or estrogen in post-menopausal females. Gout in 8 patients was successfully treated with a modified protocol of oral colchicine in order to avoid diarrhea and myoneuropathic toxicity, and prophylaxed with low doses of allopurinol and reduced doses of azathioprine. A protocol for tophaceous gout included the uricosuric agent probenecid and urine alkalinization. Avascular necrosis involved the hips in 3 patients who had hip replacements. Conclusion: Musculoskektal morbidity is common in 20 year renal transplant recipients. Osteoporosis affects both those with typical risk factors (females >50 years old, prednisone therapy, Scr > 1.4 mg/dl, diabetics) and those without (males <50 years old, Scr >1.4 mg/dl, non-diabetics). Improved diagnostic and therapeutic approaches should lessen the adverse impact of musculoskeletal diseases, particularly osteoporosis, on otherwise successful long-term allograft recipients.