Chronic glucocorticoid therapy is a well-recognized risk factor for osteoporosis and fragility fractures due to its adverse effects on bone remodeling, reducing bone formation while increasing bone resorption.1 In individuals with a history of renal transplantation, the risk of bone loss is further exacerbated by factors such as long-term immunosuppressive therapy, pre-existing metabolic abnormalities, and secondary consequences of the underlying disease.2 Immunosuppressive therapy, particularly glucocorticoids and calcineurin inhibitors, has been associated with reduced bone formation and increased bone resorption, contributing to post-transplant bone loss.3

Managing low bone mineral density (BMD) in this population presents unique challenges, requiring a careful balance between optimizing skeletal health and preserving graft function while minimizing treatment-related complications.4

Bone turnover markers (BTMs) and imaging modalities, such as dual-energy X-ray absorptiometry (DXA) and trabecular bone score (TBS), play a critical role in the non-invasive assessment of bone health in these patients. DXA provides a quantitative measure of BMD, whereas TBS offers valuable insights into bone microarchitecture and quality, particularly in cases where bone biopsy, the gold standard for diagnosing bone disease, is impractical.5 DXA provides a spectrum of quantitative and surrogate qualitative assessments of bone health, including BMD as a measure of bone mass, and the TBS, which estimates trabecular microarchitecture and is considered a surrogate for bone quality.6 According to the 2023 ISCD Official Positions, TBS is not routinely recommended for individuals under the age of 40 years due to the lack of well established reference standards and unclear clinical interpretation in this age group7. Therefore, in this patient, TBS was interpreted cautiously and in conjunction with other clinical parameters.

Current guidelines for managing glucocorticoid-induced osteoporosis (GIOP) emphasize stratifying patients based on fracture risk and tailoring interventions accordingly. However, these guidelines often lack specific recommendations for patients with unique risks, such as those on chronic immunosuppressive therapy following renal transplantation.8

This case report presents the evaluation and management of a post-renal transplant patient with low BMD, normal BTMs, and long-term glucocorticoid use. It highlights the importance of comprehensive risk assessment and the role of TBS in guiding treatment decisions, demonstrating how conservative monitoring can prevent premature pharmacological intervention in low-risk patients while maintaining a focus on individualized care.