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408
Table 14.3 Screening for and prevention of osteoporosis in solid organ transplant recipients
Solid organ
transplant
(Society)
Pre-transplant
screening Post-transplant screening
Calcium and Vitamin D
supplementation, daily
Prophylactic anti -resorptive
therapy Comments
Liver
(AASLD) [17]
N/A DXA every 2–3years if BMD
normal; or yearly if osteopenia
present, for the rst 5years
post-transplant. Individualize
screening beyond 5years
post-transplant
Calcium 1000–1200mg
Vitamin D 400–1000IU
as needed to main
serum 25-OH-D
level>30ng/mL
Consider if:
T score≤2.5 or history of
pathologic fracture, OR
T score−1.5 to −2.5 and
other osteoporosis risk
factors present
Heart (ISHLT)
[35]
– Baseline
DXA
– Consider
spine x-rays
to evaluate
for prevalent
vertebral
fractures
DXA 1-year post-transplant.
Repeat DXA annually for
patients receiving
glucocorticoids and/or
bisphosphonate therapy
Normal BMD, repeat DXA every
3years; Osteopenia, repeat DXA
every 2years
Calcium 1000–1200mg
Vitamin D 600–800IU
as needed to main
serum 25-OH-D
level>20ng/mL
Consider for all heart
transplant patients through
the rst post-transplant year
(individualized
consideration)
Bisphosphonates are rst
line followed by calcitriol
or estrogen/progesterone in
hypogonadal women.
Consider stopping
antiresorptive therapy if
corticosteroids have
stopped and T
score≥−1.5
R. S. Gold and L. Marcotte
409
Kidney
(KDIGO) [40,
41]
N/A DXA in patients with eGFR
>30mL/min /1.73m2 within
3months of transplant if
receiving corticosteroids or have
osteoporosis risk factors.
Routine screening not
recommended if eGFR <30mL/
min/1.73m2 post-transplant.
Vitamin D 400–1000IU
as needed to main
serum 25-OH-D
level>30ng/mL
Consider within rst-year
post- transplant if eGFR
>30mL/min/1.73m2 and
low bone mineral density
Consider a bone biopsy to
guide treatment of
osteoporosis, particularly
prior to bisphosphonate
use.
Frequently monitor serum
calcium, phosphorus, PTH,
alkaline phosphatase, and
25-OH-Vitamin D
Lung (No
consensus
guidelines)
N/A Some authors recommend: [44]
Baseline DXA (time not
specied, most would assess
within rst year). Osteopenia,
repeat DXA every 2–3years;
Osteoporosis, treat and measure
annually
Some authors
recommend: [44]
Calcium
1000–1500mg/d
Vitamin D
400–800IU/d
Potential benet, but limited
data and no consensus
recommendations
AASLD American Association for the Study of Liver Diseases, BMD bone mineral density, DXA dual-energy x-ray absorptiometry, ISHLT International Society
for Heart and Lung Transplantation, KDIGO Kidney Disease Improving Global Outcomes
14 Preventive Health intheAdult Solid Organ Transplant Recipient
410
phonate therapy reduced vertebral bone loss without causing medication-
associated adverse events; fracture prevention was not formally evaluated given
inconsistent assessment of bone fractures and fracture sites across studies and
small sample sizes [36]. While bisphosphonate therapy was previously recom-
mended for all heart transplant recipients in the rst year after transplant [37],
more recent guidelines [35] recommend “individualized consideration” for
bisphosphonates early after transplant. For patients with osteoporosis, bisphos-
phonates can be used up to 3-years post-transplant. The role of newer agents
(e.g., recombinant human parathyroid hormone, monoclonal antibody deno-
sumab, monoclonal antibody romosozumab) has not been well-studied in heart
transplant recipients.
• Kidney transplant recipients: The risk of osteoporosis in kidney transplant recipi-
ents is higher, and screening and treatment are more complicated than in other
organ transplant populations due to pre-existing metabolic bone disease associ-
ated with end stage renal disease. The fracture risk after renal transplantation is
estimated to be almost four times higher than that of the general population [38].
Age, female gender, and duration of pre-transplant dialysis increase the risk of
hip fracture [38]. Similar to other solid organ transplant recipients, kidney trans-
plant recipients have the most rapid decrease of bone density within the rst
6–12months after transplant. However, unlike other solid organ transplant recip-
ients whose risk of osteoporosis decreases thereafter, the risk in kidney trans-
plant recipients persistently increases following the rst year after transplant,
although at a slower rate [39].
• The 2009 Kidney Disease Improving Global Outcomes (KDIGO) guidelines
[40] recommend measurement of BMD before and within 3months of trans-
plant. Updated guidelines in 2017 for metabolic bone disease [41] specically
recommend considering treatment for low BMD with vitamin D, calcitriol and/
or antiresorptive agents within the rst year after transplant. However, they cite
equivocal evidence for antiresorptive agents in kidney transplant recipients and
highlight that there is not sufcient current data to demonstrate decreased frac-
ture risk with antiresorptive treatment in the kidney transplant population. They
also recommend considering bone biopsy (an ungraded recommendation) to
characterize bone osteodystrophy to guide treatment in renal transplant patients
with osteoporosis and/or elevated fracture risk. The 2017 guidelines state that
there is insufcient evidence to make recommendations past the rst year after
kidney transplant. Because of the complexity of management considerations in
kidney transplant recipients, the primary care provider should address modiable
risk factors and if osteopenia or osteoporosis is identied, work with the trans-
plant nephrologist to optimize therapy.
• Lung transplant recipients: There are relatively less data regarding incidence of
osteoporosis in lung transplant recipients (few studies with small number of
patients), however, in an analysis of multiple solid organ transplant recipients,
lung transplant recipients had the highest risk of post-transplant osteoporosis
[42]. In a retrospective analysis of 72 lung transplant recipients, 36% had osteo-
penia prior to transplant and 31% had osteoporosis without signicant changes
R. S. Gold and L. Marcotte
411
in BMD a year following transplant [43]. There are no current guidelines for
osteoporosis screening in the lung transplant population; however, based on
demonstrated increased risk of osteoporosis, experts recommend pre-transplant
DXA scans and vitamin D levels and post-transplant bone density monitoring in
addition to 1000–1500mg/d calcium and 400–800IU cholecalciferol daily as
well as regular weight-bearing exercise and avoidance of alcohol and tobacco
[44]. Two studies suggest potential benet with bisphosphonate as prophylactic
therapy in lung transplant patients, although are limited by small sample
sizes [45].
14.4 Immunizations inSolid Organ Transplant Recipients
Solid organ transplant recipients should receive the same vaccinations as the general
population except for live vaccines which are contraindicated, although there is
emerging data that some may be safe in select patients. Recommendations for solid
organ transplant recipients are based on the routine schedule for immunocompetent
individuals according to age, vaccination status, and exposure history and are sum-
marized in Table14.4 [46]. Primary care providers and specialists share the respon-
sibility for ensuring that appropriate vaccinations are administered to solid organ
transplant recipients and for recommending appropriate vaccinations for household
members and close contacts [47].
Since solid organ transplant recipients receive life-long immune suppression,
they may have lower rates of serological conversion, lower mean antibody titers,
and waning of protective immunity over a shorter period as compared to the general
population [48]. Therefore, it is important that vaccines, especially live vaccines
(such as measles, mumps, rubella [MMR] and varicella), be given to the patient
prior to transplant, if possible. Live vaccines should be given at least 4weeks before
transplant, whereas inactivated vaccines can be given up to 2weeks before. If an
inactivated vaccination series is started but not completed pre-transplant, it can be
continued in the post-transplant period. Most transplant centers review and update
vaccines as part of the pre-transplant evaluation. However, if transplants are done
more urgently, vaccinations are not always given. At the initial primary care visit,
the patient’s pre-transplant vaccination history should be reviewed. (See Chap. 2.)
After transplantation, it is extremely important that patients are kept up-to-date
on their immunizations, as they are more susceptible to infections and their compli-
cations. For example, a systematic review of the incidence of invasive pneumococ-
cal disease (IPD) in immunocompromised patients found that the IPD incidence
was 465/100,000 in solid organ transplant recipients versus only 10/100,000 in
healthy controls [49]. There is no evidence that vaccines lead to allograft rejection
in solid organ transplant recipients; there should be no hesitation in administering
them [50]. For patients who are non-immune, vaccines can be administered starting
3–6months after transplant when baseline immunosuppression levels are attained
[46]. Vaccinations should be withheld from solid organ transplant recipients during
14 Preventive Health intheAdult Solid Organ Transplant Recipient
412
Table 14.4
Vaccine recommendations for adult solid organ transplant recipients
Vaccine Post-Transplant Comments
Inuenza Annually starting >1-month
post-transplant
Inactivated or recombinant vaccines, trivalent
or quadrivalent, high-dose trivalent may be
preferred [54]. Intranasal and adjuvanted
contraindicated.
Tdap Single dose if >10years from
prior, resume 6-months
post-transplant
Repeat Td booster every
10years
At least one dose of acellular pertussis should
be given in adulthood (e.g., Tdap), with
particular attention to women of child-bearing
age and those in contact with infants.
Pneumococcal
– No prior vaccine: 1 dose
of PCV21
– Prior PCV13 only: 1 dose
of PCV21>1yr after
– Prior PPSV23 only: 1
dose of PCV21>1yr after
– Prior PCV13 and
PPSV23: 1 dose of PCV21 at
least 5years after last dose of
PPSV23
If PCV21 unavailable, can instead provide
PCV20, or PCV15 followed by
PPSV23≥8weeks later.
Shingrix® If not completed prior to
transplant: 2 doses, start or
resume Shingrix® 12-months
post-transplant and at least
6months after any rejection
treatments (due to adjuvant)
Safe, effective, and recommended for all adults
≥18years on chronic immunosuppression.
HPV If not completed prior to
transplant: 3-doses through
the age of 45years, can
resume or start >6-months
post-transplant
Should receive 3-doses total, even if vaccine
initiated at age 9 through 14years
Meningococcal If asplenic or planning
treatment with eculizumab,
give MenACWY and MenB;
can start or resume at
>6-months post-transplant
MenACWY is 1 or 2 doses, depending on
indication. MenB is 3 doses.
Hepatitis B If not completed prior to
transplant: 2 or 3 doses
depending on vaccine, may
start or resume at 6-months
post-transplant
Serology-dependent: give if anti-HBs titer
<10IU/mL, then re-check titers about 4weeks
after the last dose. Consider ongoing
intermittent testing if ongoing risk and provide
booster if waning immunity. Consider 40 mcg
dose. Consider Twinrix (Hep A/B combo) if
protection for both required.
Note: if heplisav-B is used post-transplant, it
should not be started/resumed until 12-months
post-transplant due to the adjuvant
(continued)
R. S. Gold and L. Marcotte
413
Table 14.4
(continued)
Vaccine Post-Transplant Comments
Hepatitis A If not completed prior to
transplant: 2–3 doses
depending on vaccine, may
start or resume at 6-months
post-transplant
Serology-dependent: give if seronegative and
wants protection or is at risk, e.g., traveling to
high-risk country. Consider Twinrix (Hep A/B
combo) if protection for both required.
MPox 2 doses if at risk See text for risk factors.
SARS-CoV-2 2–3 doses depending on
vaccine, given at least
2weeks prior to transplant or
1month after
Any further additional doses should be
administered at least 2months after the last
updated dose. Refer to CDC guidelines for
immunocompromised schedule.
RSV Shared decision-making
(generally recommended),
age≥60years,
recommended for all
≥75years
Solid organ transplant recipients not included
in clinical trials.
May be considered in adult lung transplant
recipients under age 60 (practices vary).
H inuenza
type B
Indicated before or after
splenectomy, start or resume
6months post
Recommend checking serologic response
(>0.15mg/L protective).
intensied immunosuppression, including the rst 3months after transplant, or in
the setting of treatment for rejection, because of the likelihood of inadequate
immune response. Inactivated vaccines can be safely administered post-transplant
after 3 months, with the exception of inuenza, COVID-19/SARS-CoV-2, and
respiratory syncytial virus (RSV) which can be given as early as 1month if during
respiratory virus season.
Providers can consider evaluating for seroconversion using available serologic
assays after a minimum of 4weeks from vaccine administration [46]. However,
serology is not always an accurate measure of immunity in the post-transplant
period and more research is needed. Vaccine guidelines change frequently, and pri-
mary care providers will need to check updated recommendations from either the
CDC or the World Health Organization (WHO), as well as their local public health
organizations. The following information is relevant for solid organ transplant
recipients regarding specic vaccines:
• Pneumococcal vaccine. If not completed pre-transplant, solid organ transplant
recipients should be vaccinated against pneumococcus according to the most
recent guidelines [51, 52]. Based on the US Advisory Committee on Immunization
Practices (ACIP) 2024 update solid organ transplant recipients should receive
PCV21 to complete pneumococcal vaccination [53]. PCV21 contains eight sero-
types not included in other licensed vaccines. If PCV21 is not available, immu-
nization with PCV20, or PCV15 followed by PPSV23≥8weeks after, are also
options. For certain patient populations who are at increased risk of serotype 4
(e.g., residents of Navajo nation, individuals residing in the Western US who
have substance use disorder or experience homelessness), PCV20 is preferred
instead of PCV21. In summary:
14 Preventive Health intheAdult Solid Organ Transplant Recipient
414
– If no prior pneumococcal vaccine: 1 dose of PCV21 and vaccination is
complete
– If prior PCV13 only: 1 dose of PCV21 at least 1year after PCV13 and vac-
cination is complete
– If prior PPSV23 only: 1 dose of PCV21 at least 1year after PPSV23 and vac-
cination is complete
– If prior PCV13 and PPSV23: 1 dose of PCV21 at least 5years after last dose
of PPSV23 and vaccination is complete
• Inuenza vaccine. There are two types of inactivated vaccines, trivalent and
quadrivalent. The high-dose trivalent is safe and immunogenic in solid organ
transplant recipients. The inactivated inuenza vaccine has been conrmed to be
safe and effective as early as 1-month post-transplant [54]. Many experts recom-
mend the high-dose trivalent vaccine with evidence of better immunogenicity
than the standard dose in adult transplant recipients [55].
• COVID-19/SARS-CoV-2 vaccine. SARS-CoV-2 vaccination is recommended for
all solid organ transplant recipients without contraindication. Vaccine doses
should follow the general dose and interval guidelines for individuals with severe
immunocompromise (check CDC website for most recent recommendations, as
these change often). SARS-CoV-2 vaccine should be given at least 2weeks prior
to transplant or 1month after, although the ideal timing is not known [56].
• Zoster vaccine. When Shingrix
®
was rst approved, it was not recommended for
solid organ transplant recipients due to a concern that its immunogenicity may
affect allografts by causing rejection. However, later studies found that Shingrix
®
is safe and effective in solid organ transplant recipients, leading to its recommen-
dation for adults ≥18years who are receiving chronic immunosuppressive ther-
apy. CDC recommends administration at least 6–12months after transplantation,
preferably at a time of stable graft function (no recent rejection), and on mainte-
nance immunosuppression [57].
• Meningococcal vaccine. Meningococcal disease does not occur at higher rates
after transplant, so it is not routinely prescribed for solid organ transplant
recipients except for those with risk factors. Risk factors include properdin or
terminal complement component deciency (including those receiving eculi-
zumab which is used for treatment of antibody mediated rejection post- transplant)
[58], functional or anatomic asplenia, being a member of the military or a rst-
year college student living on campus, or travel to high-risk areas. The quadriva-
lent conjugated vaccine (MenACWY) is preferred post-transplant as it provides
the widest coverage. Those who are asplenic or are being treated with eculi-
zumab should also receive MenB [46].
• Hepatitis B. Vaccination against hepatitis B, with serologic assay conrmation of
immunity, helps prevent de novo hepatitis B infection post-transplant and should
ideally be completed pre-transplant. There are various formulations of the
Hepatitis B vaccine, which vary by the amount of surface antigen (10, 20, and
40μg). Post-transplant patients may benet from higher doses although response
rates may be poor [46]. It is recommended to check hepatitis B surface antibody
(anti- HBs) titers 4weeks after the last vaccine dose to conrm a protective level
R. S. Gold and L. Marcotte
415
(anti- HBs >10IU/mL). Providers can consider serial period monitoring of titers
if patients have ongoing risk for hepatitis B exposure or travel to a high-risk area.
Non-responders or patients with waning immunity can be re-vaccinated with
either a complete series, ideally of high-dose (40μg) vaccine, or one dose of
booster followed by re-checking titers. The Heplisav
®
hepatitis B vaccine con-
tains an adjuvant which may confer higher seropositivity in immunocompro-
mised hosts; however, because of a theoretical risk of rejection, it is recommended
to wait until 12months after transplantation to administer [59, 60]. Because of
these varied options, it is recommended to consult with a transplant infectious
disease specialist prior to selecting a hepatitis B vaccination strategy.
• HPV. As discussed above, transplant recipients are at an increased risk for malig-
nancy related to HPV infection. Vaccination is indicated for ages 9–45 years
[46]. The 3-dose series should be given ideally prior to transplantation, but if all
doses are not given, then additional doses can be given beginning 3–6months
post-transplant.
• Respiratory syncytial virus (RSV). Transplant recipients are at high risk for RSV
disease and complications, particularly post-lung transplant. Organ transplant recip-
ients and other immunocompromised patients were excluded from the trials that led
to approval of the rst two recombinant subunit RSV vaccines [61], so efcacy and
safety data are lacking, although prospective studies among high- risk adults includ-
ing solid organ transplant recipients are underway. The ACIP recommends shared
decision-making regarding risks and benets of vaccination in those ≥60years old
[62]. Given the increased risks of severe RSV disease in transplant recipients, trans-
plant infectious disease specialists typically do recommend the RSV vaccine.
• Mpox. There are two vaccines for the prevention of Mpox. ACAM2000 is contra-
indicated in transplant recipients because it contains a replication-competent live
virus [63]. JYNNEOS, which is FDA-approved for the prevention of both small-
pox and Mpox in high-risk individuals, contains a replication-decient live virus
and is the preferred vaccine in transplant recipients. The CDC recommends
post- exposure prophylaxis with JYNNEOS ideally within 4 days, but up to
14days, after exposure to Mpox. There is limited data on pre-exposure vaccina-
tion among solid organ transplant recipients, but it can be considered among
patients who are high-risk for Mpox. A 2 dose-vaccine series, given 28 days
apart, is recommended for patients at risk for Mpox. Risk factors include [64]:
– Persons who are gay, bisexual, or other same-gender loving men who have
sex with men, transgender, and nonbinary partners, who in the past 6months
have had:
• ≥1 sexually transmitted infection
• ≥1 sexual partners
• Sex at a commercial sex venue
• Sex in association with a large public event in a geographic area where
Mpox transmission is occurring
– Persons who are sexual partners of a person at risk of Mpox, as described above
– Persons who have sexual or intimate contact with someone who may
have Mpox
14 Preventive Health intheAdult Solid Organ Transplant Recipient
416
14.5 Safe Living Practices
In addition to vaccinations, solid organ transplant recipients need to take other pre-
cautions due to their high risk for infections. Most organisms are acquired through
direct contact (e.g., hands, fomites), ingestion, or inhalation [65]. As such, frequent
and thorough handwashing, and avoidance of others with respiratory or gastrointes-
tinal illnesses is recommended. Food and water safety are also very important.
Household members and other close contacts should be up-to-date in their vaccina-
tions. Household members may receive both live and inactivated vaccines except for
the smallpox and oral live polio vaccine, which is easily transmitted via the oral-
fecal route and therefore is considered unsafe for solid organ transplant recipi-
ents [46].
The AASLD [17] and AST [65] additionally recommend wearing gloves when-
ever handing heavily contaminated material like soil, moss, or manure; avoid going
barefoot; shoes, socks, long-sleeved shirts, and long pants to be worn during any
activities that involve soil or possible tick exposure (e.g., gardening, yard work,
farming, or being in parks or wooded areas). Providers should review high-risk hob-
bies or work environments, such as construction, animal care settings, landscaping,
and farming, to develop strategies for preventing high-risk exposures, such as fre-
quent hand hygiene, using gloves and masks. If unable to avoid close contacts with
respiratory illness, both the infected person and the transplant recipient should wear
a standard surgical mask. Solid organ transplant recipients should consider avoiding
overly crowded areas such as shopping malls or public transportation. Though con-
tinually avoiding these areas is unrealistic, caution is advised during periods of
enhanced immunosuppression or increased community viral circulation, such as
inuenza. Particularly during these periods, individuals should wear a mask and
practice frequent hand washing while in these spaces.
Waterborne infections can occur with inadvertent consumption of contaminated
water during swimming, diving, or boating, as such precautions should be taken
surrounding freshwater contact in lakes and rivers. Cryptosporidium has increas-
ingly been reported to cause severe infection among solid organ transplant recipi-
ents, as it is resistant to chlorine and other chemicals [65]. As such, patients should
avoid untreated tap water and instead consider boiling water (particularly when a
“boil water” advisory is issued by local authorities), personal-use lters, or drinking
high-quality bottled water (i.e., that has been distilled or pasteurized). AST suggests
for individuals who have treated water supplies, the expense of buying bottled water
is usually not warranted.
Solid organ transplant recipients are at an increased risk for food-associated
pathogens such as Listeria, Salmonella, and norovirus. To minimize risk, patients
should generally avoid unpasteurized milk products, raw or undercooked eggs and
meats (particularly uncooked pork, poultry, sh, and seafood), and raw seed sprouts
such as alfalfa or mung beans. As able, transplant recipients and their families
should pay attention to news recommendations when outbreaks occur to avoid
exposure to contaminated or recalled foods. Transplant teams may also recommend
avoiding high-risk pets, such as rodents, reptiles, chicks, ducklings, and birds. When
R. S. Gold and L. Marcotte
417
Table 14.5
Strategies for disease prevention in solid organ transplant recipients [65, 66]
Hand hygiene
Wash hands after eating or preparing food, touching plants or dirt, using the restroom, changing
diapers, touching animals, and so on.
Water sources
Avoid drinking water from private wells and ingesting water exposed to human or animal waste.
Avoid drinking fresh water from lakes or rivers.
Foodborne illness
Avoid unpasteurized dairy products, undercooked meats, unwashed fruits/vegetables, raw
seafood.
Avoid Exposures
Avoid visiting prisons, homeless shelters or other high-risk areas for tuberculosis
Avoid tattooing, self-piercing, sharing needles
Avoid close contact with individuals with respiratory/gastrointestinal illnesses or herpes zoster
outbreak.
Avoid high-risk hobbies and work environments such as construction or landscaping.
able, patients should avoid cleaning cages, litter boxes, or aquariums, or wear gloves
and masks if necessary. Pets should also receive routine vaccines.
Solid organ transplant recipients need to minimize their sun exposure as they are at
high risk for developing skin cancers, especially squamous cell cancer. Providers
should discuss sun block and protective clothing and encourage patients to perform
self-skin-exams on a regular basis and seek care for any concerning lesions. Additionally,
patients should be counseled on safer sexual practices, such as always using latex con-
doms [65] and vaccinating against HPV, HBV, and Mpox, when indicated [46].
Primary care physicians should attempt as able to practice shared decision-
making and individualize recommendations to consider each patient’s degree of
immunosuppression, values, goals, preferences, and other personal circumstances.
For example, early post-transplant and during times of intensied immunosuppres-
sion, increased vigilance is likely warranted; while later among patients who are
clinically stable or receiving minimal immunosuppression, some guidelines may be
more loosely interpreted [65]. Recommendations are summarized in Table14.5.
14.5.1 Travel Immunizations andRecommendations
Solid organ transplant recipients are living longer and traveling internationally, so it
is important that they receive appropriate travel advice, as they are at increased risk
of developing opportunistic and non-opportunistic infections. Ideally, travel plans,
particularly to developing countries, should be reviewed with the medical team at
least 4–6weeks in advance [67]. Surveys of transplant centers found signicant rates
of illness in transplant recipients during foreign travel with insufcient rates of pre-
travel counseling and interventions [68]. Travel clinics provide the best comprehen-
sive care for solid organ transplant recipients, but these are not always available.
Therefore, primary care providers need to be able to appropriately counsel and
14 Preventive Health intheAdult Solid Organ Transplant Recipient