Abstract: In this 2019 update, 65 studies (involving 3598 participants) were eligible; 45 studies contributed data to our meta-analyses (2698 participants). Treatments included bisphosphonates, vitamin D compounds, teriparatide, denosumab, cinacalcet, parathyroidectomy, and calcitonin. Median duration of follow-up was 12 months. Forty-three studies evaluated bone density or bone-related biomarkers, with more recent studies evaluating proteinuria and hyperparathyroidism. Bisphosphonate therapy was usually commenced in the perioperative transplantation period (within 3 weeks) and regardless of BMD. Risks of bias were generally high or unclear leading to lower certainty in the results. A single study reported outcomes among 60 children and adolescents. Studies were not designed to measure treatment effects on fracture, death or cardiovascular outcomes, or graft loss. Compared to placebo, bisphosphonate therapy administered over 12 months in transplant recipients may prevent fracture (RR 0.62, 95% CI 0.38 to 1.01; low certainty evidence) although the 95% CI included the possibility that bisphosphonate therapy might make little or no difference. Fracture events were principally vertebral fractures identified during routine radiographic surveillance. It was uncertain whether any other drug class decreased fracture (low or very low certainty evidence). It was uncertain whether interventions for bone disease in kidney transplantation reduce all-cause or cardiovascular death, myocardial infarction or stroke, or graft loss in very low certainty evidence. Bisphosphonate therapy may decrease acute graft rejection (RR 0.70, 95% CI 0.55 to 0.89; low certainty evidence), while it is uncertain whether any other treatment impacts graft rejection (very low certainty evidence). Bisphosphonate therapy may reduce bone pain (RR 0.20, 95% CI 0.04 to 0.93; very low certainty evidence), while it was very uncertain whether bisphosphonates prevent spinal deformity or avascular bone necrosis (very low certainty evidence). Bisphosphonates may increase to risk of hypocalcaemia (RR 5.59, 95% CI 1.00 to 31.06; low certainty evidence). It was uncertain whether vitamin D compounds had any effect on skeletal, cardiovascular, death, or transplant function outcomes (very low certainty or absence of evidence). Evidence for the benefits and harms of all other treatments was of very low certainty. Evidence for children and young adolescents was sparse. Bisphosphonate therapy may reduce fracture and bone pain after kidney transplantation, however low certainty in the evidence indicates it is possible that treatment may make little or no difference. It is uncertain whether bisphosphonate therapy or other bone treatments prevent other skeletal complications after kidney transplantation, including spinal deformity or avascular bone necrosis. The effects of bone treatment for children and adolescents after kidney transplantation are very uncertain.

Plain-language summary: In 2019, there are 65 research studies (involving 3598 people) that looked at whether medicines can prevent bone fractures after kidney transplant. The most common medicine in the studies was a bisphosphonate which slows bone breakdown. Bisphosphonates were given at around the time of kidney transplantation (generally just before or within a few weeks) and continued for about one year on average. Other treatment options in the studies were vitamin D, calcitonin, denosumab, teriparatide, or cinacalcet. Bisphosphonate treatment given after a transplant possibly prevents fractures and bone pain, however the range where the actual effect of treatment might be (the "margin of error") indicates that treatment might make little or no difference. Bisphosphonates possibly lower the chances of a rejection of the transplant kidney but because of problems with the research studies, we can't be very certain that this is true. Bisphosphonates caused low blood calcium levels for some people. There was low or very low confidence in the information about all the other possible treatments for bone fractures after a kidney transplant, as the studies were often too small. There was only one study for medicines in children so we don't know whether these drugs are useful and safe for younger people. It is still unclear whether bisphosphonate therapy makes any difference to bone fractures or are safe for both adults and children with a kidney transplant.