The new research, conducted at Rabin Medical Center, the largest solid organ transplant center in Israel, and published in Archives of Osteoporosis, followed 39 adults who received teriparatide, a recombinant analogue of human parathyroid hormone, after kidney, lung, or liver transplantation. The investigators report that patients treated with the drug for a median of more than 22 months gained significant bone mineral density at the lumbar spine, femoral neck, and total hip, while clinicians observed acceptable metabolic safety and no episodes of graft rejection during therapy. The findings offer some of the most detailed evidence to date on anabolic osteoporosis treatment in a population that has long been underrepresented in bone research.

The scale of the skeletal problem after transplantation is difficult to overstate. In this cohort, 90 percent of patients had already suffered at least one fragility fracture before starting teriparatide, and 79 percent had multiple broken bones. The immune-suppressing glucocorticoids that nearly all transplant recipients take, at an average dose of around 7 milligrams of prednisone-equivalent per day in this study, directly impair the bone-forming cells called osteoblasts while accelerating bone resorption. Combined with pre-existing organ dysfunction, vitamin D deficiency, and the metabolic upheaval of end-stage organ disease, the result is a skeleton under relentless attack in patients who often cannot tolerate standard therapies.

Teriparatide works differently from the antiresorptive drugs, such as bisphosphonates, that are usually the first line of defense against post-transplant bone loss. Rather than slowing bone breakdown, it stimulates new bone formation by mimicking intermittent pulses of parathyroid hormone, a signal that activates osteoblasts when delivered in daily injections. This anabolic mechanism has made it a first-line option for severe glucocorticoid-induced osteoporosis in the general population. But transplant medicine has harbored a persistent worry: laboratory and clinical studies have suggested that bones in chronic kidney disease and after transplantation may become resistant to parathyroid hormone signaling, a condition linked to adynamic bone disease in which the cellular machinery for building bone falls silent. Skeptics questioned whether an anabolic drug could overcome that resistance.

The new data argue that, in many patients, it can. Among the subset of participants with paired bone density scans taken at the start and end of therapy, lumbar spine bone mineral density rose by an average of 11 percent, femoral neck density by 8 percent, and total hip density by 11 percent, gains that the authors note are comparable to responses reported in non-transplant populations and exceed what antiresorptive drugs typically achieve in transplant recipients. Statistically, the increases reached significance at all three skeletal sites. Treatment was started a median of 36 months after transplantation, once graft function and immunosuppressive regimens had often stabilized, and continued for a median of 22.3 months, a longer exposure than in most previous reports.

Fracture outcomes, though limited by small numbers, added a reassuring note. Six patients broke bones after starting teriparatide, but only two of those fractures occurred while the drug was actively being taken; the other four happened months to years after treatment had stopped. Given that nearly every participant entered the study with an already shattered fracture history, the apparent stabilization of fracture incidence during therapy is clinically meaningful, even though the retrospective design and small sample size prevented the study from formally demonstrating fracture reduction.

Safety, particularly for the transplanted organ itself, was a central question. Kidney function, measured by estimated glomerular filtration rate, declined modestly during the first six months of therapy, from an average of 73 to 64 milliliters per minute per 1.73 square meters, and then stabilized through the remainder of treatment and follow-up. Crucially, a contemporaneous matched group of transplant recipients who never took teriparatide showed a broadly similar decline over the same period, suggesting the change reflected the natural course of post-transplant kidney function rather than a drug effect. No patient progressed to end-stage kidney disease or required dialysis, and metabolic complications were rare: a single case of hypercalcemia, which resolved when the drug was stopped, and no cases of significant hypercalciuria despite most patients taking calcium and vitamin D supplements.

The study’s authors are careful to frame these results within the limits of a single-center, retrospective design. Patients were not randomly assigned; teriparatide was reserved for those with the most severe disease, often after failure of or intolerance to bisphosphonates, a selection reinforced by national reimbursement criteria in Israel. The matched control group was used only to contextualize kidney function trends, not to compare treatment effects, and causality cannot be inferred. Yet the very severity of the treated cohort strengthens the clinical signal: these were patients whose skeletons had already failed, and they still built substantial new bone. Only one randomized trial has previously tested teriparatide after transplantation, a short six-month study in kidney recipients begun during the intense immunosuppression of early recovery, which found no density gains but did prevent bone loss compared with placebo.

By including lung and liver recipients alongside kidney patients, the new study extends the evidence base to populations for which no dedicated osteoporosis treatment guidelines exist, in contrast to the organ-specific guidelines published for heart, kidney, and liver transplant care. The results align with recent observational work showing that teriparatide outperformed alendronate in renal transplant recipients and produced meaningful density gains in patients with low bone turnover, and they add histological and clinical weight to case reports of improved bone formation in heart transplant patients. Taken together, the picture emerging is that skeletal resistance to parathyroid hormone after transplantation, while a real phenomenon, is not an insurmountable barrier when therapy is timed after graft stabilization and sustained for nearly two years.

For clinicians, the message is one of selective optimism rather than blanket prescription. Teriparatide is expensive, requires daily injections, and carries a limited treatment duration, so it is unlikely to become a universal post-transplant remedy. But for the growing population of transplant survivors with severe osteoporosis, prior fractures, and few remaining options, the study suggests a viable path: an anabolic window that can rebuild what immunosuppression has torn down, administered with routine monitoring of calcium and kidney function. The authors call for prospective trials to define the optimal timing, duration, and sequencing of anabolic therapy after transplantation, questions that will only grow more urgent as transplant medicine continues to extend survival and shifts its focus toward the long-term quality of the lives it saves.

Subject of Research: Teriparatide treatment of severe osteoporosis in solid organ transplant recipients

Article Title: Teriparatide treatment of osteoporosis in solid organ transplant recipients—a single-center experience

Article References: Diker Cohen, T., Shraga-Slutzky, I., Kaminer, K., Gorshtein, A., Dotan, I., & Tsvetov, G. (2026). Teriparatide treatment of osteoporosis in solid organ transplant recipients—a single-center experience. Archives of Osteoporosis, 21(1), Article 136. https://doi.org/10.1007/s11657-026-01751-4

Image Credits: AI Generated

DOI: 10.1007/s11657-026-01751-4

Keywords: teriparatide, osteoporosis, solid organ transplantation, bone mineral density, fragility fractures, glucocorticoid-induced osteoporosis, anabolic therapy, kidney transplant, lung transplant, liver transplant, kidney function, transplant immunosuppression

The scale of the problem is staggering. In 2019 alone, an estimated 4.3 million new fragility fractures occurred across the EU27, Switzerland, and the United Kingdom, including approximately 827,000 hip fractures. The direct cost of these new fractures reached 36.3 billion euros, with an additional 19.0 billion euros attributable to long-term disability from fractures sustained in previous years. When pharmacological assessment and treatment costs of 1.6 billion euros are added, the total direct cost climbed to 56.9 billion euros in a single year. Healthcare costs remain elevated above pre-fracture levels for five full years after the injury, placing an unsustainable strain on health systems already stretched by aging populations.

What makes these figures particularly troubling is how preventable many of these fractures are. More than 95 percent of hip fractures are caused by falling, yet the clinical systems designed to prevent falls and those designed to prevent fractures operate almost entirely in isolation from one another. Hip fracture outcomes are grim: one-year mortality reaches 20 to 24 percent, and among survivors, 40 percent are unable to walk independently while 60 percent still require assistance a full year after injury. Approximately one-third of patients become fully dependent or require residential care within twelve months of sustaining a hip fracture.

The biological logic for integration is compelling. The paper presents a conceptual framework showing how bone fragility and fall risk jointly determine fracture probability, with their relative contributions shifting over time. A common geriatric syndrome called osteosarcopenia—the combination of sarcopenia and osteopenia or osteoporosis—illustrates this overlap, affecting an estimated 5 to 37 percent of community-dwelling older adults and elevating the risk of both falls and fractures simultaneously. Crucially, researchers have documented an imminent subsequent fracture risk after both an incident fracture and an incident fall, and conversely, an increased risk of falling soon after a fracture. This bidirectional cascade means that missing one risk dimension inevitably undermines the other.

Despite this, clinical practice lags badly. In a recent survey among European healthcare professionals, fewer than 60 percent of respondents reported including fracture risk assessment often or always within the multifactorial fall risk assessment. On the fracture side, fall risk assessment is not routinely performed in many Fracture Liaison Services, the specialized secondary prevention programs established after a first fracture. In a 2025 national UK evaluation, only about 65 percent of FLS patients received or were referred for a fall risk assessment, with substantial variation between services, and the picture is likely worse or entirely absent in many other countries. The authors contend that FLS programs are uniquely positioned to operationalize integrated care but frequently remain predominantly bone-focused rather than comprehensively risk-focused.

The paper lays out a detailed technical roadmap for how fracture risk assessment can be embedded within fall prevention services, drawing on the 2022 World Guidelines for Fall Prevention and Management. These guidelines introduce a fall risk stratification algorithm for community-dwelling older adults and recommend that those at moderate to high risk of falls undergo bone health assessment using validated tools. Fracture risk calculators such as FRAX, Garvan, and QFracture can identify older adults at high fracture risk, with Garvan and QFracture already incorporating falls as a predictor. FRAXplus further refines conventional FRAX estimates by accounting for the number of falls in the previous year, allowing clinicians to treat fall history as a modifiable fracture risk amplifier that directly informs both risk stratification and therapeutic choice.

Conversely, established osteoporosis management pathways should embed fall prevention. An internationally applicable algorithm for postmenopausal women categorizes fracture risk into low, intermediate, and very high zones using FRAX, with bone densitometry and recalculation refining intermediate cases. Women with a prior fragility fracture are automatically considered at least high risk. The authors emphasize that fall prevention strategies must be embedded within treatment pathways for patients at high and very high fracture risk, and that cognitively impaired and dementia patients should never be denied fracture prevention measures, including pharmacological osteoporosis treatments. This population deserves particular attention: 60 to 80 percent of people with dementia fall annually, and cognitive impairment is present in approximately 40 percent of all older adults with hip fractures.

Education represents another critical pillar. Among nearly 4,000 European healthcare professionals surveyed, approximately 12 percent reported low or very low knowledge of both falls and bone health, and 35.9 percent reported low knowledge of orthogeriatric care. Only about a quarter of surveyed professionals agreed that their undergraduate education adequately prepared them for fall prevention in clinical practice. The authors call for interprofessional training that bridges medicine, physiotherapy, nursing, pharmacy, and dietetics, alongside a core set of competencies for integrated fall and fracture assessment that local teams can adapt to their resources while remaining evidence-based.

On the policy front, the paper argues that integrated fall and fracture prevention must be recognized as a public health priority and incorporated into national healthy aging strategies aligned with the WHO’s Decade of Healthy Ageing. Promising national initiatives already exist: France launched a 2022 plan targeting a 20 percent reduction in fall-related fractures and deaths; the Netherlands has introduced an Integrated Approach to Fall Prevention strategy; and Belgium operates a dedicated Center of Expertise for Falls and Fracture Prevention in Flanders. Hip fracture registries, another policy instrument, should include fall prevention quality markers, as the Danish National Hip Fracture Database has done since 2010.

Emerging technologies offer powerful new tools. Wearable sensors capturing real-world balance and mobility data, combined with AI-driven predictive models, demonstrate superior fall prediction performance compared with traditional approaches, while in silico clinical trials enable simulation of virtual populations to optimize preventive interventions before deployment. Emerging pharmacological findings add intrigue: pooled analyses suggest that romosozumab and denosumab may each reduce fall risk in postmenopausal women with osteoporosis, hinting at mechanisms that might involve muscle mass, though the authors caution that studies with falls as the primary outcome are still needed. The WHO and ESCEO have signed a five-year collaboration agreement to develop a strategic global roadmap on bone health and aging, signaling that momentum toward truly integrated prevention may finally be building. The authors’ message is unambiguous: unify the science, unify the services, and millions of preventable fractures and falls could be avoided.

Subject of Research: Integrated fall and fragility fracture prevention in older adults through coordinated international clinical, educational, policy, and research strategies

Article Title: Position paper: a coordinated approach to fracture and fall prevention from seven international organizations

Article References: van der Velde, N., Seppala, L. J., Bahat, G., Blain, H., Casas Herrero, A., Harvey, N. C., Masud, T., Rizzoli, R., Reginster, J.-Y., Ruggiero, C., Barbagallo, M., de Lima, A. B., Bonnici, M., Bousquet, J., Cortet, B., Chiari, L., Dionyssiotis, Y., Dreinhöfer, K., Duque, G., … Öztürk, Y. (2026). Position paper: a coordinated approach to fracture and fall prevention from seven international organizations. European Geriatric Medicine. https://doi.org/10.1007/s41999-026-01596-7

Image Credits: AI Generated

DOI: 10.1007/s41999-026-01596-7

Keywords: fall prevention, fragility fractures, osteoporosis, geriatric medicine, Fracture Liaison Services, hip fracture, osteosarcopenia, integrated care, healthy aging, bone health, wearable sensors, public health policy