Grant support was withdrawn from Amgen Pharmaceuticals

Organ transplant recipients are known to suffer from bone loss and subsequent fractures after the transplant operation with the most rapid bone loss occurring within the first 3-12 months. Guidelines for prevention and treatment of this serious complication are only written by individual medical societies interested in each organ (separate kidney from liver or heart transplants management) and they are based on studies done with limited medications choices. The majority of studies are done with the use of bisphosphonates, and there are very limited, or no data, on the effect of other medications used for Osteoporosis, including the use of denosumab. This study will focus on the evaluation of the efficacy and safety of denosumab 60mg use early (within first 3 months) after Liver Transplantation in the management of bone loss and prevention of fragility fractures. Different tests will be used to study the effect of the medication on the skeleton, including imaging studies as well as specific labwork.

Inclusion Criteria:

• Age >=18 years old
• First-time Liver transplant Recipients
• All men, postmenopausal women and women with history of hysterectomy or tubal ligation
• Patients who have not been treated with medications for Osteoporosis within the past 12 months before the liver transplant
• Patients able and agreeable to follow up at out Institution for the duration of the study
• Patients hospitalized for less than 45 consecutive days after the liver transplant surgery
• Patients with GFR>30ml/min (calculated by Cockcroft-Gault equation, see Table 3 for details)
• Patients with corrected Calcium >= 8.5
• Patients with PTH intact levels WNL (as per lab values)
• Patients with vit D>=20; NOTE: patients with vit D <20 will be treated with high dose Ergocalciferol 50,000 units daily and rechecked in 2 weeks
• Patients with t-score >=-3.5 at all sites checked by DEXA scan
• Patients agree to sign an informed consent form to be in the study
• Can be treated with denosumab or placebo within 3 months from the liver transplant date

Exclusion Criteria:

• Patients with previous transplants
• Patients that are getting 2 simultaneous transplants, like combined kidney and liver transplants
• Age < 18 year old
• Patients hospitalized for over 45 days after the liver transplant surgery
• Patients with GFR< 30ml/min
• Patients with hypocalcemia defined as corrected calcium < 8.5
• Patients with extensive dental problems, previous hx of Osteonecrosis of the jaw (ONJ) and/or high risk for developing ONJ
• Patients with current Hyperthyroidism
• Patients with current Primary Hyperparathyroidism defined by the combination of elevated calcium and PTH intact levels
• Patients with severe Osteoporosis as defined by t-score <-3.5 at any site shown by DEXA scan
• Women of reproductive age without history of tubal ligation or hysterectomy
• Patients who cannot read or understand the Informed Consent Document or study instructions
• Patients with diagnosis of dementia, or otherwise unable to give informed consent
• Patients unable to follow up in our Institution for the duration of the study