Transplantation is an established therapy for end-stage diseases of the kidney, endocrine pancreas, heart, liver, and lung, and for many hematologic disorders. Improved survival rates have been accompanied by increased recognition of previously neglected long-term complications of transplantation such as fractures and osteoporosis. Pretransplantation bone disease and immunosuppressive therapy result in rapid bone loss and increased fracture rates early after transplantation. Patients should be assessed and pretransplantation bone disease should be treated. Preventive therapy initiated in the immediate posttransplantation period is indicated in patients with osteopenia or osteoporosis, as further bone loss will occur in the first several months after transplantation. Long-term organ transplant recipients should also have bone mass measurement and treatment of osteoporosis. Bisphosphonates are the most promising approach for the management of transplantation osteoporosis. Active vitamin D metabolites may have additional benefits in reducing hyperparathyroidism, particularly after kidney transplantation. Large, multicenter treatment trials with oral or parenteral bisphosphonates and calcitriol are recommended.