Diagnosis and management of mineral and bone disorders in paediatric kidney transplant recipients: a position statement from the European Society for Paediatric Nephrology

Children after kidney transplantation (KTx) are prone to mineral and bone disease (MBD) including growth restriction, bone pain, skeletal deformities, fractures, and vascular calcifications. We present a position paper on the diagnosis and management of post-transplant MBD in this population based on the available evidence and the opinion of experts from the European Society for Paediatric Nephrology (ESPN) CKD-MBD, Dialysis and Transplantation Working Groups. PICO (Patient, Intervention, Comparator, Outcomes) questions were generated, and structured literature searches were conducted for a population of children under 18 years of age who were kidney transplant recipients with a functioning allograft. Patients with a failing allograft (i.e., with an eGFR less than 30 mL/min per 1.73 m²) are not discussed here. Clinical practice points (CPPs) were developed and graded using the American Academy of Pediatrics grading matrix. A Delphi consensus method was followed. We present 46 CPPs for the diagnosis and management of MBD in paediatric KTx, including assessment and management before and after KTx, highlighting the specifics of monitoring post-transplant MBD between 0 and 3 months after KTx, and including the impact of steroid minimization and withdrawal. As there are few high-quality studies in this field, the strength of most statements is weak to moderate and may need to be adapted to individual patient needs by the treating physician. Research recommendations to study key outcome measures in this unique population are suggested.