Bone Mineral Density in the Long Term after Liver Transplantation

Abstract

Hepatic osteodystrophy is a complication of chronic liver disease and bone mass is known to decline further in the first year after liver transplantation. The present study focused on bone mineral density (BMD) between 1 and 15 years after liver transplantation under a prednisolone- and azathioprine-based immunosuppressive regimen. Three groups of adult patients were studied: group 1, 45 patients with a follow-up of 5-9 years after transplantation, had BMD measurements done at 1, 2 and 5 years after transplantation; group 2, 17 patients with a follow-up of 10-14 years, had BMD measurements done at 5 and 10 years; group 3, 4 patients with a follow-up of more than 15 years, had BMD measurements done at 10 and 15 years. BMD of lumbar spine (L1-L4) and proximal femur was measured using dual-energy X-ray absorptiometry, and at the same time radiographs of the spine and hips were made. Spinal BMD increased significantly, during the second post-transplant year; subsequently no significant changes were seen. Proximal femur BMD decreased slightly, but significantly during the second year, and remained stable afterwards. About one-third of patients had a BMD below the fracture threshold (= 0.798 g/cm2 for the lumbar spine and 0.675 g/cm2 for the hip) during the follow-up. In 5 of the 66 patients studied, new vertebral fractures occurred. No fractures or avascular necrosis of the hips were seen. Furthermore, after transplantation lower Z-scores of the hip were found in patients with pre-transplant cholestatic liver diseases, and lower Z-scores of the lumbar spine were found in men compared with women. Long-term follow-up of BMD up to 15 years after transplantation revealed an improvement mainly in the second postoperative year with no deterioration afterwards. Nevertheless a substantial number of patients (around one-third) kept a BMD below the fracture threshold, and new fractures may occasionally occur. The overall outcome appeared somewhat less favorable in men and patients transplanted for cholestatic liver diseases.

Osteopenia and osteoporosis in patients with end-stage liver disease caused by hepatitis C and alcoholic liver disease: Not just a cholestatic problem

“…These patients suffered even more fracturing in the first year after OLT, especially in sites of trabecular bone, as has been previously described in other populations of liver transplant recipients. 3,[26][27][28] The incidence and timing of fracturing in patients with ALD, and to a lesser extent HCVϩALD, is very different. Before OLT, patients with ALD had the least osteopenia but a much higher incidence of fracturing than patients with HCV (31% versus 12%).…”

Osteoporosis after liver transplantation

“…[6][7][8][9][10][11][12][13][14][15] Most of these fractures occurred in the spine; however, since in some of these studies spinal X-rays were not routinely performed, the true number of vertebral fractures is likely to have been underestimated. In some studies, however, lower fracture rates have been reported.…”

“…In a smaller study of 28 patients, spine bone mineral density had returned to pre-transplantation levels by a mean of 85 months. 27 However, Monegal et al 15 reported recovery of bone mineral density in the spine but not the proximal femur by 36 months after transplantation and Hamburg et al 14 found that recovery of bone mineral density was often incomplete up to 15 years post-transplantation.…”

Posttransplantation care: Role of the primary care physician versus transplant center

“…51 Interestingly, bone recovery continues for up to 2 to 7 years after transplantation. [52][53][54] Crosbie et al 55 reported that accelerated bone loss in the transplant setting is caused by more bone resorption exceeding bone formation. Furthermore, calculation of an uncoupling index (osteocalcin-deoxypyridinoline) correlated well with bone mineral density and may serve as a noninvasive means to identify high-risk individuals.…”