{"entity":{"id":"rejuv-tx-bone-eyes-kidneys-lungs","kind":"technology","name":"Bone, eyes, kidneys and lungs after transplant","aka":["avascular necrosis after transplant","osteonecrosis after HSCT","cataract after total body irradiation","chronic kidney disease after HSCT","restrictive lung disease after transplant"],"tldr":"Four problems that turn up years later and are easy to miss because each belongs to a different specialty: bone that thins or, less often, dies at the hip; cataract, which is common after total body irradiation and is fixed by an operation; kidney function that drifts down; and lungs that stiffen rather than obstruct. Each has a cheap test.","summary":"Bone: loss of density and avascular necrosis. Two separate problems. Bone mineral density falls after transplant from the combination of gonadal failure, corticosteroids, calcineurin inhibitors, immobility and poor nutrition, and it falls fastest in the first six to twelve months. Avascular necrosis, the death of a segment of bone from loss of its blood supply, is the less common and more disabling one; it affects the femoral head most often, is strongly associated with cumulative corticosteroid dose, and presents as groin or hip pain on weight-bearing with normal plain radiographs early on, so MRI is the test. Both appear in the international screening recommendations: bone density by DXA for allogeneic recipients and for anyone on prolonged corticosteroids, with calcium, vitamin D, weight-bearing exercise and bone-modifying drugs where indicated, and MRI for a transplant survivor with unexplained joint pain rather than reassurance from a normal radiograph. OnCo covers the general survivorship bone problem on `cancer-treatment-bone-loss`; the transplant-specific additions are the steroid dose and the avascular necrosis risk that comes with it.\n\nEyes: cataract. Common after total body irradiation and strongly influenced by how the radiation was fractionated and by steroid exposure. In 209 patients given hyperfractionated total body irradiation at a median 14.4 Gy in 12 fractions before autologous transplant, cataract occurred in 28 of 85 examined patients, 32.9 per cent, at a median of 47 months, with surgery in 6 of the 28. Where total body irradiation was given in one or two large fractions the picture was heavier: in 93 patients the cataract incidence was 89 per cent, with median time to cataract of 58 months after autologous transplant and 33 months in allogeneic patients treated with steroids for GvHD against 46 months in those not; high-grade cataract occurred in 93 per cent of allogeneic patients treated with steroids against 35 per cent of those not. In a prospective paediatric series of 139 children followed a median of eight years after allogeneic transplant, 19 of 131 developed cataract requiring surgery and 46 developed lesser lens opacities, with 50 per cent of all patients having opacities or cataract by 10.2 years; total body irradiation raised the risk (P less than 0.0001). A dose-effect review across 17 published series derived a threshold biologically effective dose of around 40 Gy below which severe cataract seldom occurs, and recommended fractionating total body irradiation to stay below it. The practical point is simple: cataract after transplant is common, it is treated by an operation that works, and the thing that catches it is an eye test rather than waiting for vision to be obviously poor. Chronic ocular GvHD is a separate problem and is covered on `gvhd-organ-by-organ`.\n\nKidneys. Chronic kidney disease after transplant is multifactorial: calcineurin inhibitor exposure, repeated episodes of acute kidney injury during the transplant admission, nephrotoxic antimicrobials, thrombotic microangiopathy and, where used, radiation to the kidneys. The same dose-effect review found a threshold biologically effective dose of around 16 Gy for late renal toxicity, lower than for cataract, and recommended fractionation and kidney shielding for almost all myeloablative total body irradiation regimens. Monitoring is a creatinine, an estimated GFR and a urine albumin-to-creatinine ratio, and the reason to measure albuminuria rather than creatinine alone is that in one prospective series the degree of albuminuria in the first 100 days after transplant was associated with subsequent mortality.\n\nLungs, the restrictive pattern. Distinct from bronchiolitis obliterans syndrome, which is obstructive and is covered on its own record. A restrictive defect, reduced volumes with preserved or increased flow ratios, follows chest or total body irradiation and sometimes chronic GvHD, and in the European series of atypical chronic GvHD manifestations restrictive lung disease was one of the few that contributed to non-relapse mortality. The same spirometry that screens for the obstructive pattern detects it.","status":"established","asOf":"2026-10-02","wikipedia":"https://en.wikipedia.org/wiki/Avascular_necrosis","links":[{"label":"Zierhut et al., Cataract incidence after total-body irradiation (Int J Radiat Oncol Biol Phys 2000)","url":"https://doi.org/10.1016/S0360-3016(99)00354-5"},{"label":"van Kempen-Harteveld et al., Cataract-free interval and severity of cataract after total body irradiation and bone marrow transplantation: influence of treatment parameters (Int J Radiat Oncol Biol Phys 2000)","url":"https://doi.org/10.1016/S0360-3016(00)00669-6"},{"label":"Tear Fahnehjelm et al., Cataract after allogeneic hematopoietic stem cell transplantation in childhood (Acta Paediatr 2015)","url":"https://doi.org/10.1111/apa.13173"},{"label":"Dose-effect relationships for severe cataract and late renal dysfunction after total body irradiation (Anticancer Res 2009), PubMed 19661349","url":"https://pubmed.ncbi.nlm.nih.gov/19661349/"},{"label":"Majhail et al., Recommended screening and preventive practices for long-term survivors after hematopoietic cell transplantation (Biol Blood Marrow Transplant 2012)","url":"https://doi.org/10.1016/j.bbmt.2011.12.519"},{"label":"Inamoto and Lee, Late effects of blood and marrow transplantation (Haematologica 2017)","url":"https://doi.org/10.3324/haematol.2016.150250"},{"label":"Doering et al., Incidence and outcome of atypical manifestations of chronic graft-versus-host disease (Transplant Cell Ther 2023)","url":"https://doi.org/10.1016/j.jtct.2023.09.016"}],"tags":["rejuvenation","survivorship","transplant","late-effects","organ"],"related":["rejuv-tx-late-effects-overview","gvhd-lung-bronchiolitis-obliterans","gvhd-organ-by-organ","cancer-treatment-bone-loss","rejuv-tx-endocrine-and-cardiometabolic","rejuv-tx-long-term-follow-up-frameworks"],"cancers":[],"sections":["rejuvenation","supportive-care"],"technologies":["allogeneic-hsct","total-body-irradiation","survivorship-care-plan"],"targets":[],"drugs":[],"companies":[],"institutions":[],"pathways":[],"terms":["late-effects","conditioning-regimen"],"trials":[],"people":[],"bottlenecks":["b-survivorship","b-toxicity-qol"],"keyPapers":[],"journals":[],"dependsOn":[],"notes":[],"principle":"These four share a mechanism in different tissues: a cell population with limited renewal capacity is depleted or its microvasculature injured, and the deficit appears when physiological reserve runs out rather than when the injury occurs. Osteocyte and endothelial death in bone, lens epithelial cell damage that only becomes visible as the opacity migrates into the visual axis, nephron loss, and alveolar and interstitial fibrosis all show the same latency of years.","strengths":["Each has a cheap, available test: DXA, MRI for suspected avascular necrosis, slit-lamp examination, creatinine with urine albumin, spirometry","Cataract is correctable by surgery","The radiation dose-response for cataract and renal toxicity is quantified, so fractionation and shielding reduce both","All four appear in the published long-term screening recommendations"],"limitations":["Avascular necrosis is not visible on early plain radiographs, so a normal film is not reassurance","Much of the cataract data comes from older, less fractionated total body irradiation regimens","No randomised evidence that any screening interval after transplant improves outcomes","Chronic kidney disease after transplant has several simultaneous causes, so attribution and prevention are both imprecise"]},"route":"/technologies/rejuv-tx-bone-eyes-kidneys-lungs/","neighbours":{"technology":[{"id":"rejuv-tx-what-to-ask-for","kind":"technology","name":"After a transplant or cell therapy: what to ask for","route":"/technologies/rejuv-tx-what-to-ask-for/"},{"id":"allogeneic-hsct","kind":"technology","name":"Allogeneic stem cell transplantation","route":"/technologies/allogeneic-hsct/"},{"id":"cancer-treatment-bone-loss","kind":"technology","name":"Bone loss caused by cancer treatment, and what rebuilds it","route":"/technologies/cancer-treatment-bone-loss/"},{"id":"gvhd-organ-by-organ","kind":"technology","name":"Chronic GvHD organ by organ: skin, mouth, eyes, gut, liver, joints and genital tract","route":"/technologies/gvhd-organ-by-organ/"},{"id":"rejuv-tx-endocrine-and-cardiometabolic","kind":"technology","name":"Hormones, metabolism and the heart after transplant","route":"/technologies/rejuv-tx-endocrine-and-cardiometabolic/"},{"id":"rejuv-tx-iron-overload","kind":"technology","name":"Iron overload after transplant","route":"/technologies/rejuv-tx-iron-overload/"},{"id":"rejuv-tx-late-effects-overview","kind":"technology","name":"Late effects after a stem cell transplant","route":"/technologies/rejuv-tx-late-effects-overview/"},{"id":"survivorship-care-plan","kind":"technology","name":"Survivorship care and late-effects surveillance","route":"/technologies/survivorship-care-plan/"},{"id":"gvhd-lung-bronchiolitis-obliterans","kind":"technology","name":"The lungs after transplant: bronchiolitis obliterans syndrome","route":"/technologies/gvhd-lung-bronchiolitis-obliterans/"},{"id":"total-body-irradiation","kind":"technology","name":"Total body and total marrow irradiation","route":"/technologies/total-body-irradiation/"},{"id":"rejuv-tx-long-term-follow-up-frameworks","kind":"technology","name":"Who is supposed to be watching: EBMT, CIBMTR, FACT-JACIE, and what a survivor is actually offered","route":"/technologies/rejuv-tx-long-term-follow-up-frameworks/"}],"section":[{"id":"rejuvenation","kind":"section","name":"Recovery & Rejuvenation","route":"/fronts/rejuvenation/"},{"id":"supportive-care","kind":"section","name":"Supportive Care & Survivorship","route":"/fronts/supportive-care/"}],"term":[{"id":"conditioning-regimen","kind":"term","name":"Conditioning regimen (myeloablative, reduced-intensity)","route":"/terms/conditioning-regimen/"},{"id":"late-effects","kind":"term","name":"Late effects and survivorship toxicity","route":"/terms/late-effects/"}],"bottleneck":[{"id":"b-survivorship","kind":"bottleneck","name":"Survivorship and late effects are neglected","route":"/bottlenecks/b-survivorship/"},{"id":"b-toxicity-qol","kind":"bottleneck","name":"Toxicity and quality of life are undervalued","route":"/bottlenecks/b-toxicity-qol/"}]}}