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

Abstract

Although best characterized in chronic cholestatic liver disease, osteopenic bone disease and fracturing are wellrecognized complications of cirrhosis, particularly after liver transplantation. We sought to compare the prevalence of osteopenia and osteoporosis, to assess the effect of orthotopic liver transplantation (OLT) on bone density, and to determine fracture rates before and after OLT in three groups of patients with advanced cirrhosis: patients with cirrhosis from hepatitis C virus ( T he association between osteopenia and various types of liver disease has been described for more than half a century. 1 The clinical course of osteopenia has been best characterized in the chronic cholestatic liver diseases, but is also known to occur in alcoholic, autoimmune, and viral liver disease. 2,3 Before orthotopic liver transplantation (OLT), osteopenia and its more severe form, osteoporosis, are usually asymptomatic. In the early months after liver transplantation, however, an increased rate of bone loss occurs, and the increased osteopenia causes a high incidence of symptomatic fractures. At the time of transplantation, 50% of patients with primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC) have osteoporosis, 4 and up to 40% of these patients will sustain spontaneous fractures in the first postoperative year. 5 The main risk for posttransplantation fractures is the presence of pretransplantation osteopenia; therefore, the identification of osteopenic patients at high risk of fracturing is of considerable importance, particularly in the setting of liver transplantation.The relationship between osteopenic bone disease and noncholestatic liver disease is less well defined. Recent reports suggest its possible relationship with viral hepatitis B and C 6 and with end-stage hepatitis C. 7 This study investigates osteopenic bone disease in three groups of patients with advanced cirrhosis: hepatitis C alone (HCV), alcoholic cirrhosis alone (ALD), and cirrhosis caused by hepatitis C and alcohol abuse (HCV؉ALD). The goals of our study were to determine in each of these groups (1) the prevalence of osteopenia and osteoporosis, (2) the early effect of OLT on bone density, and (3) fracture rates before and in the first year after OLT. Methods Patient PopulationA total of 841 patients underwent 928 OLTs at the Mayo Clinic, Rochester, MN, between January 1991 and September 2001. All adult recipients undergoing primary liver transplantation with a single cadaver organ were reviewed to identify patients with HCV, ALD, and HCVϩALD. The study was approved by the Mayo Foundation Institutional Review Board. Diagnostic Criteria for Patient GroupsThe clinical diagnoses were confirmed by review of clinical and psychiatric history, biochemical and serologic testing, and histologic examination of liver biopsy and/or explanted liver. Patients were classified by the presence of all of the following criteria: HCV by (1) presence of anti-HCV and/or HCV RNA by reverse transcriptase polymerase chain reaction (RT-PCR), (2) ...

Bone disorders in chronic liver disease

“…Various studies over the last 2 decades have shown that the prevalence of osteoporosis in patients with cirrhosis is between 12% and 55% 12,[16][17][18][19][20][21][22][23][24] (Table 2). The difference between studies is probably a reflection of differences in age, liver disease etiology, nutritional state, hypogonadism, and liver disease severity.…”

Serum sclerostin in hepatitis C virus infected patients

“…[20] On the other hand, adiponectin may stimulate proliferation, differentiation and mineralization of osteoblasts. [17] Several studies report osteopenia among patients with HCV infection, [21][22][23][24][25] although possibly osteopenia is rather related to liver function derangement and/or altered nutritional status than to virus infection. In fact, some studies including relatively large series fail to detect significant bone alterations in HCV patients.…”

Is Liver Cirrhosis a Risk Factor for Osteonecrosis of the Femoral Head in Adults? A Population-Based 3-Year Follow-Up Study

“…Liver cirrhosis itself has been proven to cause a loss of bone mass due to poor cholecalciferol absorption through the intestine, poor activation of vitamin D, and chronic hypogonadism in men (29)(30)(31)(32); however, osteoporosis itself appears insufficient to cause OFH. Interleukin-6 (IL-6) is a proinflammatory cytokine.…”