Bone mineral density, serum insulin-like growth factor I, and bone turnover markers in viral cirrhosis

Changes in thoracic radio density after living donor liver transplantation

BACKGROUND

The outcomes after liver transplantation have greatly improved, which has resulted in greater focus on improving non-hepatic outcomes of liver transplantation. The present study aimed to evaluate thoracic spine radio density in children and adolescents after liver transplantation.

METHODS

A total of 116 patients who underwent living donor liver transplantation were retrospectively analyzed. The radio density at the eleventh thoracic vertebra was measured using computed tomography scan performed preoperatively then annually for 5 years postoperatively and subsequently every 2 or 3 years.

RESULTS

The mean thoracic radio density of male recipients of male grafts had the lowest values during the study. The radio density of patients receiving a graft from a female donor was higher than in recipients with grafts from males. Total mean radio density decreased for first 5 years postoperatively and then increased. Changes in radio density were equally distributed in both steroid withdrawal and no steroid withdrawal groups for 5 years, after which patients with steroid withdrawal had a greater increase. Changes in radio density were equally distributed in both the steroid withdrawal and no steroid withdrawal groups up to age 20, after which patients in the steroid withdrawal group had a greater increase.

CONCLUSIONS

Gender differences may affect the outcome of radio density changes after transplantation. Given the moderate association between thoracic radio density and bone mineral density in skeletally mature adults and further studies are needed to validate this relationship between thoracic radio density and bone mineral density changes in pediatric liver transplantation.

Extrahepatic Manifestations of Chronic Hepatitis C Virus (HCV) Infection

Hepatitis C virus (HCV) is a well-recognized, major cause of various liver-related conditions such as chronic hepatitis, liver cirrhosis, and hepatocellular carcinoma. Apart from liver disease, chronic HCV infection is also associated with several extrahepatic manifestations that can lead to significant morbidity and mortality. These extrahepatic manifestations include essential mixed cryoglobulinemia (EMC), lymphomas, porphyria cutanea tarda, lichen planus, necrolytic acral erythema, glomerulonephritis, subclinical autoantibody formation, immune thrombocytopenia, thyroid disease, Sjögren's disease/sicca symptoms, diabetes mellitus, ocular diseases, musculoskeletal disorders, cardiovascular diseases, neurocognitive dysfunction, and leukocytoclastic vasculitis. We are presenting a case of chronic HCV infection linked to the extrahepatic manifestations of the disease which can be directly related to HCV or indirectly related to EMC from HCV. An awareness and knowledge of these extrahepatic manifestations will highlight the importance of recognizing the symptoms for an early diagnosis and effective anti-viral treatment in order to improve or resolve the long-term complications of chronic HCV infection.

Osteoporosis and Fragility Fractures in Patients with Liver Cirrhosis: Usefulness of FRAX® as a Screening Tool

PURPOSE

The purpose of this study is to assess the prevalence of osteoporosis and fragility fractures in patients with liver cirrhosis (LC) and determine the associated risk factors, evaluating the usefulness of FRAX® as a screening method to identify patients at a higher risk of fracture.

METHODS

This was a cross-sectional study. Demographic, clinical, and analytical data were collected in a randomized sample of LC patients attending the Hepatology Department of a university hospital. We assessed the absolute risk of fracture at 10 years (FRAX®) and based on the bone mineral density (BMD), the presence of morphometric vertebral fracture with a vertebral fracture assessment (VFA), or a thoracic and lumbar X-ray and bone microarchitecture with a trabecular bone score (TBS).

RESULTS

Ninety-two patients were included (71% male); the mean age was 63 ± 11.3 years. The main etiology of LC was alcoholism (52.2%), and most patients were Child-Pugh A (80.4%), with a mean model for end-stage liver disease (MELD) score of 10.1 ± 3.6. Sixteen patients (17.4%) had osteoporosis, and fifty-four (58.7%) had osteopenia. Eight patients (8.7%) had suffered at least one fragility fracture. The absolute risk of a major fracture according to FRAX without the BMD was 5.7 ± 4.5%. Risk factors associated with osteoporosis were age and the female sex. BMI > 30 was a protective factor. A FRAX cut-off point for a major fracture > 6.6% had a sensitivity of 69% and a specificity of 85% for a diagnosis of osteoporosis.

CONCLUSIONS

The prevalence of osteoporosis and fractures in patients with LC is high, particularly in older women. FRAX® may be a useful method to identify candidates for bone densitometry. A FRAX value below 6.6% without the BMD can avoid unnecessary testing.

Vitamin D status & bone health in patients with liver cirrhosis

Background & objectives

Vitamin D plays an important role in bone metabolism, and liver is the intermediary site of vitamin D metabolism. The purpose of this study was to study the prevalence of vitamin D deficiency and bone health in patients with cirrhosis.

Methods

Prospectively, serum 25-hydroxy vitamin D [25(OH)D] level were assessed in cirrhotics by chemiluminescence method. Endocrine Society Clinical practice guideline was used to define deficiency and insufficiency of vitamin D. Bone mineral density (BMD) was assessed using dual-energy X-ray absorptiometry and the World Health Organization criteria was used to define osteoporosis and osteopenia. The lowest T score at the left hip neck or lumbar spine was taken as osteoporosis or osteopenia. The Child-Turcotte-Pugh score was used to assess the severity of cirrhosis.

Results

Cirrhotics (n=350, male: 278, compensated: 210) were included. Mean serum 25(OH)D level was 8.75 ng/ml. The prevalence of vitamin D deficiency (VDD) and low-BMD (osteopenia and osteoporosis) was 89.4 and 86 per cent, respectively. VDD, insufficiency and osteoporosis was found in 86.7, 11.9 and 33.8 per cent, respectively, in patients with compensated cirrhosis; and 93.6, 3.6 and 40 per cent, respectively, in patients with decompensated cirrhosis. Body mass index of >25 kg/m2 was protective for bone health.

Interpretation & conclusions

VDD and low-BMD is prevalent in Indian patients with cirrhosis and should be looked for in patients with cirrhosis for its prevention.

Sarcopenia in chronic viral hepatitis: From concept to clinical relevance

Although the frequency of metabolic risk factors for cirrhosis and hepatocellular carcinoma (HCC) is increasing, chronic hepatitis B (CHB) and chronic hepatitis C (CHC) remain the most relevant risk factors for advanced liver disease worldwide. In addition to liver damage, hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are associated with a myriad of extrahepatic manifestations including mixed cryoglobulinaemia, lymphoproliferative disorders, renal disease, insulin resistance, type 2 diabetes, sicca syndrome, rheumatoid arthritis-like polyarthritis, and autoantibody production. Recently, the list has grown to include sarcopenia. Loss of muscle mass or muscle function is a critical feature of malnutrition in cirrhotic patients and has been found in approximately 23.0%-60.0% of patients with advanced liver disease. Nonetheless, among published studies, there is significant heterogeneity in the aetiologies of hepatic diseases and measurement methods used to determine sarcopenia. In particular, the interaction between sarcopenia, CHB and CHC has not been completely clarified in a real-world setting. Sarcopenia can result from a complex and multifaceted virus-host-environment interplay in individuals chronically infected with HBV or HCV. Thus, in the present review, we provide an overview of the concept, prevalence, clinical relevance, and potential mechanisms of sarcopenia in patients with chronic viral hepatitis, with an emphasis on clinical outcomes, which have been associated with skeletal muscle loss in these patients. A comprehensive overview of sarcopenia in individuals chronically infected with HBV or HCV, independent of the stage of the liver disease, will reinforce the necessity of an integrated medical/nutritional/physical education approach in the daily clinical care of patients with CHB and CHC.

SIRT2 regulates extracellular vesicle-mediated liver-bone communication

The interplay between liver and bone metabolism remains largely uncharacterized. Here, we uncover a mechanism of liver-bone crosstalk regulated by hepatocyte SIRT2. We demonstrate that hepatocyte SIRT2 expression is increased in aged mice and elderly humans. Liver-specific SIRT2 deficiency inhibits osteoclastogenesis and alleviates bone loss in mouse models of osteoporosis. We identify leucine-rich α-2-glycoprotein 1 (LRG1) as a functional cargo in hepatocyte-derived small extracellular vesicles (sEVs). In SIRT2-deficient hepatocytes, LRG1 levels in sEVs are upregulated, leading to increased transfer of LRG1 to bone-marrow-derived monocytes (BMDMs), and in turn, to inhibition of osteoclast differentiation via reduced nuclear translocation of NF-κB p65. Treatment with sEVs carrying high levels of LRG1 inhibits osteoclast differentiation in human BMDMs and in mice with osteoporosis, resulting in attenuated bone loss in mice. Furthermore, the plasma level of sEVs carrying LRG1 is positively correlated with bone mineral density in humans. Thus, drugs targeting hepatocyte-osteoclast communication may constitute a promising therapeutic strategy for primary osteoporosis.

Bone loss in chronic liver diseases: Could healthy liver be a requirement for good bone health?

Given that the liver is involved in many metabolic mechanisms, it is not surprising that chronic liver disease (CLD) could have numerous complications. Secondary osteoporosis and increased bone fragility are frequently overlooked complications in CLD patients. Previous studies implied that up to one-third of these individuals meet diagnostic criteria for osteopenia or osteoporosis. Recent publications indicated that CLD-induced bone fragility depends on the etiology, duration, and stage of liver disease. Therefore, the increased fracture risk in CLD patients puts a severe socioeconomic burden on the health system and urgently requires more effective prevention, diagnosis, and treatment measures. The pathogenesis of CLD-induced bone loss is multifactorial and still insufficiently understood, especially considering the relative impact of increased bone resorption and reduced bone formation in these individuals. It is essential to note that inconsistent findings regarding bone mineral density measurement were previously reported in these individuals. Bone mineral density is widely used as the “golden standard” in the clinical assessment of bone fragility although it is not adequate to predict individual fracture risk. Therefore, microscale bone alterations (bone microstructure, mechanical properties, and cellular indices) were analyzed in CLD individuals. These studies further support the thesis that bone strength could be compromised in CLD individuals, implying that an individualized approach to fracture risk assessment and subsequent therapy is necessary for CLD patients. However, more well-designed studies are required to solve the bone fragility puzzle in CLD patients.

Bone disease in patients with cirrhosis of different etiology and severity; are Klotho protein and osteoprotegerin potential biomarkers?

BACKGROUND AND AIMS

Cirrhosis is associated with increased risk for osteoporosis and osteopenia. This study aims to further investigate this relationship by examining if etiology and severity of cirrhosis are independent predictors of bone mineral density (BMD) loss. Furthermore we examined the serum levels of osteoprotegerin (OPG) and Klotho proteins that have been involved in bone metabolism.

METHODS

Seventy-four patients with cirrhosis of different etiology and 25 matched healthy controls were included in this study. Bone mineral densitometry at both lumbar spine and femoral neck was measured. Serum total OPG, Klotho protein and vitamin D levels were also determined. Comparisons were performed according to etiology and severity of cirrhosis.

RESULTS

Decreased bone density was observed in cirrhotic patients compared to healthy controls with T = -1.46 and T = -1.37 in lumbar spine and femoral bone respectively compared to T = -0.396 and T = -0.672 in the control group. In the cirrhotic group, osteopenia was observed in 46% in lumbar spine and 51% in femoral bone whereas osteoporosis was observed in 20% in lumbar spine and 9% in femoral bone. Decreased bone density was confirmed, regardless of cirrhosis etiology or stage of liver function. Patients were found to have higher levels of OPG than the control group (136 pg/ml vs. 67 pg/ml, p < 0.001), but lower levels of Klotho protein (1051 pg/ml vs. 1842 pg/ml, p < 0.001) regardless etiology and severity of cirrhosis. High OPG levels were found to be associated with low femoral bone density.

CONCLUSIONS

BMD is lower in cirrhotic patients regardless etiology and severity of liver disease with osteopenia and osteoporosis be present in 50% and 20%, respectively. Higher levels of OPG and lower levels of Klotho protein were observed in cirrhotic patients regardless etiology and severity in comparison to matched healthy group.

Prevalence of Osteoporosis in Cirrhosis: A Systematic Review and Meta-Analysis

The prevalence of osteoporosis in individuals with cirrhosis varies based on the diagnostic approach and etiology of the underlying liver disease. This systematic review aims to evaluate the prevalence of osteoporosis in individuals with cirrhosis. Electronic databases were searched for studies reporting the prevalence of osteoporosis among patients with cirrhosis. The primary outcome was the presence of osteoporosis, as determined by a dual-energy x-ray absorptiometry (DEXA) scan. Secondary outcomes were levels of biochemical markers of bone metabolism, including calcium, vitamin D, phosphorus, and parathormone (PTH) levels. A cohort of 836 patients from 10 studies was included in the final analysis. The pooled rate of osteoporosis was 14.80% (95% CI: 14.19-15.49). Pooled levels of biochemical markers of bone metabolism were as follows: calcium 9.09 mg/dL (95% CI: 8.73-9.45), 25-hydroxyvitamin D (25-OH vitamin D) 15.41 ng/mL (95% CI: 14.79-16.03), phosphorus 15.41 mg/dL (95% CI: 2.99-3.51), and PTH 26.58 pg/mL (95% CI: 25.45-27.71). Pooled levels of liver biochemistries were: bilirubin 3.04 mg/dL (95% CI: 2.84-3.25), aspartate aminotransferase (AST) 65.35 U/L (95% CI: 61.39-69.31), alanine aminotransferase (ALT) 50.17 U/L (95% CI: 46.18-54.10), alkaline phosphatase 133.31 U/L (95% CI: 124.89-141.73), and albumin 3.25 g/dL (95% CI: 3.05-3.45). Cirrhosis appears to be associated with an increased risk for osteoporosis, with a pooled prevalence of 15%. This can include men and individuals younger than 50 years of age, a cohort not typically considered to be at an increased risk of osteoporosis. Levels of 25-hydroxyvitamin D and insulin-like growth factor-1 (IGF-1) were also significantly low. Further studies are required to evaluate the risk of osteoporosis based on the etiology and stage of cirrhosis, especially in younger males, to incorporate this into future prediction models for fragility fractures.

Decreasing Rates of Fracture-Related Hospitalization With Primary Biliary Cholangitis: Insights From the Nationwide Inpatient Sample

Introduction

Primary biliary cholangitis (PBC) is associated with an increased risk of developing fractures. Current guidelines recommend measures that can help prevent the development of fractures in these patients. The purpose of this study was to trend the rates of hospitalizations related to fractures and their burden on healthcare.

Methods

We performed a retrospective, cohort study of adults hospitalized in the United States with PBC between 2010 and 2014. Patients were identified using the Nationwide Inpatient Sample (NIS). Temporal analysis of PBC patients with a co-diagnosis of hip, vertebral, or wrist fractures (the study group) was performed with regards to the total number of inpatient admissions, inpatient mortality, length of stay, and total charges associated with hospitalization. Descriptive analyses were performed using the t-test for continuous data and the chi-square test for categorical data.

Results

During the five-year study period, there were 308,753 hospitalizations for PBC. There has been a downward trend (p=0.02) in fracture-related admissions among patients with PBC during this study period. Length of stay was higher in the PBC-fracture group (10.85 days vs 7.36 days; p<0.001). Total hospitalization charges were higher among the PBC-fracture patients when compared to the control group ($98,444 vs $72,964; p=0.004).

Conclusion

There has been a gradual reduction in the rate of fracture-related hospitalizations in patients with PBC. However, patients with PBC who have fractures have increased the utilization of health care resources as compared to their cohort admitted for reasons other than for a fracture.

Prevalence and predictors of post-liver transplantation metabolic bone diseases

Introduction

Post-liver transplantation (LTx) bone diseases have been poorly investigated. The frequency of bone diseases (osteopenia and osteoporosis) after LTx is unknown.

Aim of the study

To define prevalence and risk factors of bone disorders following LTx.

Material and methods

This prospective study was conducted on 100 consecutive adult patients who underwent living donor liver transplantation (LDLT) at the National Liver Institute (NLI) and survived longer than a year. Bone mineral density (BMD) was evaluated by dual-energy X-ray absorption (DEXA), as well as other pre- and postoperative risk factors.

Results

The frequencies of osteopenia and osteoporosis were found to be 14% and 8% among post-LTx patients. Seven recipients of the osteoporotic group were males, with mean age, and body mass index (BMI) before and after LTx 49.5 ±7.4 years, 24.1 ±4.7 kg/m² and 22.8 ±1.5 kg/m², respectively. A significant association between hepatitis C virus (HCV)-related cirrhosis, liver disease severity according to Child-Turcotte-Pugh (CTP) score, and alcoholism with decreased post-LTx BMD was substantiated (p < 0.05, 0.006). Post-LTx development of diabetes mellitus (DM), weight gain, use of corticosteroids and basiliximab all significantly affected decreased post-LTx BMD (p < 0.05). However, binary regression revealed that post-LTx occurrence of DM (p = 0.012, odds ratio [OR] = 0.099), the severity of liver disease (p = 0.023, OR = 0.217), and HCV (p = 0.011, OR = 0.173) are the main independent predictors of metabolic bone disease (MBD) occurrence one year after LTx.

Conclusions

Post-LTx bone disorders are not infrequent complications and should be more considered in those with HCV-related severe liver disease or developed DM after LTx.

Effect of Vitamin D Supplementation on Vitamin D Level and Bone Mineral Density in Patients With Cirrhosis: A Randomized Clinical Trial

INTRODUCTION

In patients with cirrhosis, highly prevalent vitamin D deficiency and low bone mineral density (BMD) increase the burden of disease, and role of vitamin D supplementation is not clear. So, our aim was to determine the effect of vitamin D supplementation on vitamin D level and BMD in patients with cirrhosis.

METHODS

Patients with cirrhosis (18-60 years) of any etiology were enrolled. We measured serum 25(OH)D, parathyroid hormone, thyroid-stimulating hormone, free T4, bone-specific alkaline phosphatase, insulin-like growth factor (IGF)-1, and health-related quality of life at entry and at 1 year; however, serum calcium was measured at 3-month interval. BMD was measured by dual-energy x-ray absorptiometry at lumbar spine and left hip neck at entry and after 1 year. Statistical analysis was performed according to intention-to-treat analysis.

RESULTS

Of 390 screened patients with cirrhosis, 164 participants (82 in each group) were randomized. There was significant increase in 25(OH)D levels in intervention group after 1 year (33.7 [24.3-45.7] ng/mL vs 23.1 [17-28.2] ng/mL; P < 0.001) when compared with placebo. The mean difference in BMD at lumbar spine and left hip neck was not significantly changed after 1 year of intervention with vitamin D between both groups. There was no significant change in both the groups in levels of calcium, thyroid-stimulating hormone, parathyroid hormone, free T4, IGF-1, and bone-specific alkaline phosphatase and quality of life.

DISCUSSION

Supplementation with vitamin D for 1 year improves vitamin D levels but did not result in improvement in BMD at lumbar spine and left hip neck in patients with cirrhosis.

Determining Bone Turnover Status in Patients With Chronic Liver Disease

Introduction Hepatic osteodystrophy is an osteoporotic bone disease that occurs in chronic liver disease patients. The global prevalence of osteoporosis in patients with chronic liver disease is 30% to 40%. The pathogenesis of hepatic bone disease is not clear, but it occurs due to unstable bone remodeling with increased bone resorption and decreases bone formation. There has been an interest in determining the clinical utility of bone turnover markers (BTMs) in the assessment of osteoporosis in chronic liver patients. Methods This was a cross-sectional study conducted in patients with chronic liver disease at the section of chemical pathology, department of pathology and laboratory medicine, Aga Khan University (AKU). A total of 50 patients with age >8 years and a history of liver disease >6 months were recruited from January to October 2019. Liver function tests, i.e. aspartate aminotransferase (AST), alanine transaminase (ALT), albumin, and bilirubin, along with clinical signs of liver disease chronicity, were noted. The samples for BTMs, i.e. total serum alkaline phosphatase (ALP) and serum C-terminal telopeptide of type-1 collagen (CTX) were withdrawn and analyzed on Microlab (ELItech Group, Puteaux, France) and ADVIA Centaur (Siemens Diagnostics, NY), respectively. Results The majority of patients were males (n=34, 68%). Twenty-four (48%) patients suffered from fibrosis while 26 (52%) were without fibrosis. Median platelet count (68×10⁹/L (102.5-50)) and median cholesterol levels (102.5 mg/dl (147-99.5)) were decreased, whereas gamma-glutamyl transferase (GGT) levels were higher in the fibrosis group as compared to the non-fibrosis group. The median levels of total ALP were 91.5 IU/L (103-82), and the median levels of CTX were 0.24 pg/ml (0.34-0.21). Conclusion In the present study, no significant difference was found in the BTMs of patients with and without chronic liver disease (CLD). However, there was a positive and significant correlation of BTMs, particularly CTX with age, bilirubin levels, and hepatomegaly.

Increased incidence, morbidity, and mortality in cirrhotic patients with hip fractures: A nationwide population-based study

OBJECTIVES

Hip fractures mostly require surgical treatment and are associated with increased health-care costs and mortality rates. Patients with cirrhosis have low bone marrow density and inferior immune status which contribute to a higher fracture rate and higher surgical complication rate. This population-based study evaluated the prevalence, complication, and mortality rates due to hip fractures in cirrhotic patients.

METHODS

Taiwan National Health Insurance Research Database data were used. The study group included 117,129 patients with hip fractures diagnosed from 2004 to 2010, including 4048 patients with cirrhosis. The overall prevalence, morbidity, and mortality rates of the cirrhosis group with hip fractures were compared with the rates of a general group with hip fractures.

RESULTS

The cirrhosis group patients were younger than the general group patients (71.2 vs. 73.96 years, p < 0.001). The annual incidence of hip fractures in the cirrhosis and general groups was 46-54 and 7-7.5 per 10,000 person-years, respectively, with an incidence rate ratio of 6.95 (95% confidence interval 6.74-7.18). The rates of infection, urinary tract infection, and peptic ulcer disease were higher in the cirrhosis group (3.46% vs. 1.91%, 9.56% vs. 9.11%, and 8.05% vs. 3.55%, respectively; all p < 0.001). The mortality rate after hip fracture was also higher in the cirrhosis group than in the general group (within 3 months: 8.76-12.64% vs. 4.96-5.30% and within 1 year: 29.72-37.99% vs. 12.84-14.57%). Conclusion: Cirrhotic patients with hip fractures were relatively younger; had a seven times higher annual hip fracture incidence; had higher complication rates of infection, urinary tract infection, and peptic ulcer disease; and had two to three times higher a mortality rate at 3 months and 1 year. Clinicians should pay particular attention to the possibility of osteoporosis and hip fractures in patients with liver cirrhosis.

LEVEL OF EVIDENCE

Level III, case-control study.

Post-surgery cholecystectomy, hepatectomy, and pancreatectomy patients increase the risk of osteoporotic vertebral fracture

INTRODUCTION

Data is currently lacking regarding association between the cholecystectomy/hepatectomy/pancreatectomy and the development of osteoporotic fracture. A retrospective cohort study was conducted to investigate the relationship between cholecystectomy/hepatectomy/pancreatectomy and the subsequent risk of developing osteoporotic fracture.

MATERIALS AND METHODS

Patients having undergone cholecystectomy, hepatectomy, or pancreatectomy between 2000 and 2012 were selected from the All Population Based Hospitalization File as the surgery cohort (n = 304,081), which was frequency matched with the control cohort (n = 304,081). The Cox proportional hazard model and Kaplan-Meier analysis were applied to measure the hazard ratios and the cumulative incidence of osteoporotic fracture.

RESULTS

A total of 1136 patients in the surgery cohort and 1179 patients in the control cohort were newly diagnosed with osteoporotic fracture. The overall osteoporotic fracture risk in the surgery cohort was 1.12-fold higher [95% confidence interval (CI), 1.03-1.21]. Specifically, surgery cohort had higher vertebral fracture risk than non-surgery cohort [adjusted hazard ratio (aHR) 1.12, Cl, 1.03-1.22]. In addition, patients underwent cholecystectomy (includes open and laparoscopic approaches), hepatectomy (only open approach), and pancreatectomy group (only open approach) were 1.10 (95% CI, 1.01-1.19), 1.49 (95% CI, 1.10-2.01), and 1.88 (95% CI, 1.23-2.87) times more likely to develop osteoporotic fracture, respectively. No significant difference of osteoporotic fracture risk was observed between open and laparoscopic cholecystectomy. The risk of osteoporotic fracture was significantly increased in females, patients aged ≥ 40 years old, and patients with some comorbidity.

CONCLUSIONS

Patients post cholecystectomy, hepatectomy, or pancreatectomy significantly increased risk of developing osteoporotic fracture, suggesting closer attention in post-operative care is needed.

Risk Factors for Hematopoietic Stem Cell Transplantation-Associated Bone Loss

Hematopoietic stem cell transplantation (HSCT), including bone marrow transplantation, is the treatment of choice for many hematologic diseases, including hematologic malignancies and different types of anemia. The use of HSCT is increasing annually, mainly because advanced research that has been conducted in this area has exponentially expanded the indications for HSCT and significantly improved transplantation techniques and supportive care practices. Collectively, these improvements have led to an increase in the overall survival of HSCT patients. However, as post-HSCT survival is increasing, awareness of the potential late complications of HSCT is also growing. Unpredictable bone loss is one of the major post-HSCT complications that can cause significant morbidity and impair the quality of life of survivors. Although the exact mechanism of post-HSCT bone loss is not yet known, previous studies have suggested that numerous factors, including destructive preparative regimens (eg, high-dose chemotherapy, total body irradiation), treatment-related complications (eg, graft-versus-host disease), endocrine abnormalities (eg, diabetes mellitus, thyroid dysfunction, adrenal insufficiency), lack of physical activity, and the underlying disease itself are responsible for HSCT-associated bone loss. Sufficient data have been collected to suggest that post-HSCT bone loss can be prevented and treated using the same preventive and treatment modalities as used for the general population. Various guidelines have been formulated to help keep a check on HSCT recipients' deteriorating bone health.

Triple-Phase Computed Tomography May Replace Dual-Energy X-ray Absorptiometry Scan for Evaluation of Osteoporosis in Liver Transplant Candidates

Assessment of bone density is an important part of liver transplantation (LT) evaluation for early identification and treatment of osteoporosis. Dual-energy X-ray absorptiometry (DXA) is currently the standard clinical test for osteoporosis; however, it may contribute to the appointment burden on LT candidates during the cumbersome evaluation process, and there are limitations affecting its accuracy. In this study, we evaluate the utility of biomechanical analysis of vertebral images obtained during dual-energy abdominal triple-phase computed tomography (TPCT) in diagnosing osteoporosis among LT candidates. We retrospectively reviewed cases evaluated for LT between January 2017 and March 2018. All patients who underwent TPCT within 3 months of DXA were included. The biomechanical computed tomography (BCT) analysis was performed at a centralized laboratory (O.N. Diagnostics, Berkeley, CA) by 2 trained analysts blinded to the DXA data. DXA-based osteoporosis was defined as a T score ≤-2.5 at the hip or spine. BCT-based osteoporosis was defined as vertebral strength ≤4500 N for women or ≤6500 N for men or trabecular volumetric bone mineral density ≤80 mg/cm³ . Comparative data were available for 91 patients who had complete data for both DXA and BCT: 31 women and 60 men, age 54 ± 11 years (mean ± standard deviation), mean body mass index 28 ± 6 kg/m² . Using DXA as the clinical reference, sensitivity of BCT to detect DXA-defined osteoporosis was 83.3% (20/24 patients) and negative predictive value was 91.7%; specificity and positive predictive value were 65.7% and 46.5%, respectively. BCT analysis of vertebral images on triple-phase computed tomography, routinely obtained during transplant evaluation, can reliably rule out osteoporosis in LT candidates. Patients with suspicion of osteoporosis on TPCT may need further evaluation by DXA.

Association between osteoporosis and hepatitis B cirrhosis: a case-control study

Background and aims

Hepatitis B virus (HBV)-related cirrhosis is associated with decreased bone mineral density (BMD); however, the mechanism is yet unknown. To assess the incidence of osteoporosis in patients with HBV-associated cirrhosis and relevant mechanisms.

Methods

A total of 80 hospitalized patients with HBV-associated cirrhosis and 80 healthy controls were enrolled. The levels of serum osteocalcin, total procollagen type 1 amino-terminal propeptide, β-C-terminal telopeptide of type I collagen (β-CTX), and 25-hydroxy vitamin D3 (25(OH)D3) was evaluated in the cirrhosis group.

Results

The BMDs of the lumbar spine (P<0.001) and hip joints (P=0.015) in the cirrhosis group were significantly lower than those in the controls. The incidence of osteoporosis in the cirrhosis group was significantly higher than that in the control group (P<0.001). Compared to the patients of the Child-Pugh grade A and B, the BMD of lumbar spine and 25(OH)D3 was significantly decreased in patients of grade C, while β-CTX was elevated. Patients in the cirrhosis group faced a higher risk of osteoporosis as compared to the controls(P<0.001).

Conclusions

Enhanced bone resorption accounted for increased risk of osteoporosis in severe cirrhosis. Thus, HBV-associated cirrhosis was a risk factor for osteoporosis.

The Impact of Tenofovir Disoproxil Fumarate on Reduced Bone Mineral Density and Fractures in Liver Transplant Recipients

BACKGROUND

Tenofovir disoproxil fumarate (TDF) is associated with reduced bone density in patients with human immunodeficiency virus, but the effect of TDF on bone density in liver transplant (LT) recipients is unknown.

METHODS

We performed a single-center, retrospective study of LT recipients with hepatitis B taking TDF compared to a control group with non-hepatitis B virus viral hepatitis. The primary outcome was reduced bone density, defined as femoral neck or lumbar T-score less than -1. Other outcomes included mean T-score and fractures.

RESULTS

Three hundred ninety-three patients were studied: 52 patients in the TDF group and 341 patients in the control group; 64.3% patients in the TDF group had reduced bone density vs 71.4% in the control group (P = .58) before LT, compared to 75% and 81.5% (P = .57), respectively, after LT. Mean posttransplant lumbar T-scores were lower in the TDF group (-1.74 vs -0.75, P = .04). There was no difference between the 2 groups for the other outcomes. In a multivariate Cox proportional hazards model, TDF use did not affect the risk of post-LT reduced bone density (hazard ratio = 0.99; 95% confidence interval, 0.56-1.76; P = .97).

CONCLUSION

TDF use was not associated with reduced bone mineral density or increased rates of fractures in LT recipients compared to controls in this study.

Hepatic osteodystrophy and fracture risk prediction using FRAX tool in Indian patients with cirrhosis

Background and Aim

The main clinical relevance of hepatic osteodystrophy is the increased risk of fractures. Dual‐energy X ray absorptiometry (DEXA)‐based assessment of bone mineral density, the current gold standard for diagnosing osteoporosis, is not the sole determinant of fracture risk. Other clinical risk factors also play an important role. This study was carried out to assess the prevalence and risk factors of hepatic osteodystrophy and estimate the entailed fracture risk by using the FRAX tool in a cohort of Indian cirrhotics.

Methods

Consecutive patients with cirrhosis (n = 120) were recruited. Etiologic workup, liver function tests, serum calcium, phosphate, 25(OH)D, HbA1c, and DEXA scan were performed. Hepatic osteodystrophy was defined as a T score of < −1. FRAX scores were calculated using the Indian calculator.

Results

The study cohort was predominantly male (86.7%) with a median age of 49 (40–65) years. Alcohol was the most common etiology (80%). All patients had Child‐Turcotte‐Pugh class B (63.3%) or class B (36.7%) cirrhosis. Hepatic osteodystrophy was present in 83.3% patients. On multivariate analysis, smoking (odds ratio [OR]: 3.1 [1.76–4.7], P < 0.001) and serum 25(OH)D (OR: 0.23 [0.09–0.94]; P = 0.03) showed significant association with hepatic osteodystrophy. The 10‐year probability of major osteoporotic fracture and hip fracture was 5.7% (2.1–28.9) and 2.5% (1.4–7.4), respectively. Using a FRAX probability cut‐off of 20% for major osteoporotic fracture and 3% for hip fracture, 30% patients qualified for osteoporosis treatment.

Conclusion

Hepatic osteodystrophy is widely prevalent among Indian patients with cirrhosis and entails a high risk of fractures. Approximately one‐third of patients with cirrhosis need treatment to reduce the risk of osteoporotic fractures.

The Pharmacologic Management of Osteoporosis in Primary Biliary Cholangitis: A Systematic Review and Meta-Analysis

INTRODUCTION

Osteoporosis is a common complication of primary biliary cholangitis (PBC) yet evidence for effective therapy is lacking. We sought to review all randomized controlled trials evaluating pharmacotherapy against placebo or no intervention for treatment of osteoporosis in PBC.

METHODOLOGY

A comprehensive database search was conducted from inception through 29 March 2017. The primary outcome was incidence of fractures; secondary outcomes were change in bone mineral density (BMD) and adverse events. We assessed studies for risk of bias, graded quality of evidence, and used meta-analysis to obtain overall effect by pooling studies of the same drug class.

RESULTS

We identified 11 randomized controlled trials evaluating bisphosphonates (3), hormone replacement therapy (2), ursodeoxycholic acid (1), obeticholic acid (1), cyclosporin A (1), vitamin K (1), calcitriol (1), and sodium fluoride (1). No intervention significantly reduced fractures compared to control. Although significant improvement in BMD was seen in one study with alendronate, a third-generation bisphosphonate, no significant improvement was seen on pooled analysis of all bisphosphonates including first-generation bisphosphonates (standard mean difference 0.41, p = 0.68). On pooled analysis, hormone replacement therapy modestly improved lumbar BMD (standard mean difference 0.69, p = 0.02), but with significantly increased adverse events (odds ratio 8.82, p = 0.01).

CONCLUSIONS

There is a lack of high-quality evidence supporting the efficacy of any treatment of osteoporosis in PBC. This may be explained by lack of power in the included studies. However, our current understanding of PBC-related osteoporosis indicates that it results from decreased bone formation, which may explain the attenuated effect of traditional antiresorptive agents. Future studies should investigate newer anabolic bone agents.

Bone Health in Patients With Liver Diseases

Osteoporosis is the most common bone disease in chronic liver disease (CLD) resulting in frequent fractures and leading to significant morbidity in this population. In addition to patients with cirrhosis and chronic cholestasis, patients with CLD from other etiologies may be affected in the absence of cirrhosis. The mechanism of osteoporosis in CLD varies according to etiology, but in cirrhosis and cholestatic liver disease it is driven primarily by decreased bone formation, which differs from the increased bone resorption seen in postmenopausal osteoporosis. Direct toxic effects from iron and alcohol play a role in hemochromatosis and alcoholic liver disease, respectively. Chronic inflammation also has been proposed to mediate bone disease in viral hepatitis and nonalcoholic fatty liver disease. Treatment trials specific to osteoporosis in CLD are small, confined to primary biliary cholangitis and post-transplant patients, and have not consistently demonstrated a benefit in this population. As it stands, prevention of osteoporosis in CLD relies on the mitigation of risk factors such as smoking and alcohol use, treatment of underlying hypogonadism, and encouraging a healthy diet and weight-bearing exercise. The primary medical intervention for the treatment of osteoporosis in CLD remains bisphosphonates though a benefit in terms of fracture reduction has never been shown. This review outlines what is known regarding the pathogenesis of bone disease in CLD and summarizes current and emerging therapies.

Compromised bone strength in patients with alcoholic liver cirrhosis

Osteoporosis and/or osteopenia are frequently observed complications in alcoholic liver disease patients, especially in its irreversible stage (alcoholic liver cirrhosis - ALC). Current literature review regarding osteoporosis incidence increased fracture risk, bone mineral density changes, micro-structural alteration and pathogenetic mechanisms leading to ALC - induced decrease in bone quality is presented. It has been reported that osteoporosis is influenceing significant number of ALC patients, with particular accent on lumbar spine, as most commonly affected skeletal site. Several risk factors and ethio-pathogenic mechanisms have been associated with the loss of bone mineral density, in patients with ALC and other cirrhosis. Certain authors claim that dominant mechanism in ALC-induced bone loss is decrease in bone formation and osteoblastic function, while other results suggest increased bone remodeling as underlying cause of increased bone fragility in ALC patients. Increased bone fragility and susceptibility to osteoporotic fractures significantly affect life expectancy and quality of life in patients with ALC. Thus, osteological screening and individual fracture risk assessment are highly recommended for all patients with alcoholic liver cirrhosis.

Safety and efficacy of risedronate for patients with esophageal varices and liver cirrhosis: a non-randomized clinical trial

Despite the high prevalence of osteoporosis in liver cirrhosis, the indication of bisphosphonates for patients with esophageal varices has been avoided due to risk of digestive mucosal damage. Therefore, this study aimed to evaluate the safety profile of risedronate treatment for patients with osteoporosis, liver cirrhosis and esophageal varices with low risk of bleeding. A total of 120 patients were allocated into two groups according to their bone mineral density measured by dual-energy X-ray absorptiometry. In the intervention group, 57 subjects with osteoporosis received oral risedronate at 35 mg weekly plus daily calcium and vitamin D supplementation. In the control group, 63 subjects with osteopenia received only calcium and vitamin D. The groups received the treatment for one year and underwent surveillance endoscopies at six and 12 months, as well as a control dual-energy X-ray absorptiometry after a 12-month follow-up. The study received Institutional Review Board approval. The groups had not only comparable Model for End-stage Liver Disease score and esophageal varices degree, but also similar incidence of digestive adverse effects. A significant improvement was achieved in the intervention group in the lumbar spine T score (p < 0.001). The results suggest that risedronate may be safely used in liver cirrhosis and esophageal varices with low bleeding risk under endoscopic surveillance, thus allowing bone mass recovery.

Hepatic Osteodystrophy-Molecular Mechanisms Proposed to Favor Its Development

Almost all patients with chronic liver diseases (CLD) show altered bone metabolism. Depending on the etiology, this manifests in a severe osteoporosis in up to 75% of the affected patients. Due to high prevalence, the generic term hepatic osteodystrophy (HOD) evolved, describing altered bone metabolism, decreased bone mineral density, and deterioration of bone structure in patients with CLD. Once developed, HOD is difficult to treat and increases the risk of fragility fractures. Existing fractures affect the quality of life and, more importantly, long-term prognosis of these patients, which presents with increased mortality. Thus, special care is required to support the healing process. However, for early diagnosis (reduce fracture risk) and development of adequate treatment strategies (support healing of existing fractures), it is essential to understand the underlying mechanisms that link disturbed liver function with this bone phenotype. In the present review, we summarize proposed molecular mechanisms favoring the development of HOD and compromising the healing of associated fractures, including alterations in vitamin D metabolism and action, disbalances in transforming growth factor beta (TGF-β) and bone morphogenetic protein (BMP) signaling with histone deacetylases (HDACs) as secondary regulators, as well as alterations in the receptor activator of nuclear factor kappa B ligand (RANKL)–osteoprotegerin (OPG) system mediated by sclerostin. Based on these mechanisms, we give an overview on the limitations of early diagnosis of HOD with established serum markers.

Severe hypocalcemia following denosumab treatment in a patient with secondary osteoporosis associated with primary sclerosing cholangitis

Primary sclerosing cholangitis (PSC) has been known as a cause of secondary osteoporosis, which often requires medication. Herein, we give the first report of a case of a 38-year-old man with fatigue and paralysis in both upper limbs who had been treated with denosumab for secondary osteoporosis associated with PSC. Since bisphosphonate (alendronate) was ineffective in our patient, the treatment was changed from alendronate to denosumab. Despite replacements with calcium and active vitamin D (alfacalcidol; 1-hydroxycholecalciferol), he developed severe hypocalcemia (albumin-adjusted serum calcium: 5.2 mg/dL) 2 weeks after the second administration of denosumab, which required immediate correction. After that, the corrected serum calcium levels were controlled within the normal range with 0.75 μg of eldecalcitol (1α,25-dihydroxy-2β-(3-hydroxypropyloxy)vitamin D3) and increased doses of calcium (1,500 mg daily) and phosphate (900 mg daily) without denosumab. Even though denosumab treatment had been terminated, the T score of the lumbar spine improved from -4.4 to -2.6 by 1 year after the second administration, possibly due to the amelioration of osteomalacia through the treatment with eldecalcitol and the higher doses of calcium and phosphate. This report indicates that denosumab can cause severe hypocalcemia in patients with osteoporosis associated with chronic diseases of the hepatobiliary system including PSC, in turn suggesting that the possibility of vitamin D deficiency or osteomalacia should be considered before administering treatments and that serum calcium levels should be closely monitored to detect life-threatening hypocalcemia in patients who have high risk factors for hypocalcemia.

The association between liver cirrhosis and fracture risk: A systematic review and meta-analysis

OBJECTIVE

Liver cirrhosis (LC) was associated with an increased risk of osteoporosis; however, the association between LC and fracture risk was inconclusive. Therefore, this systematic review and meta-analysis aims to explore the association between LC and fracture risk.

DESIGN

To identify related literature, a systematic search of PubMed, EMBASE, Web of science and the Cochrane Library from 1965 to July 2017 without language limitation was performed. The random-effects model described by DerSimonian and Laird was used to calculate pooled odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Eventually, 5 cohort and 3 case-control studies were identified, which included 321 035 subjects and 31 272 fracture cases. The pooled OR of the association between LC and any fracture risk, hip fracture, spine/trunk fracture and limb fracture was 1.94 (95% CI, 1.59-2.37), 2.11 (95% CI, 1.34-3.32), 2.00 (95% CI, 1.50-2.67) and 1.82 (95% CI, 1.65-2.01), respectively.

CONCLUSION

In conclusion, this study indicates that cirrhotic patients have an increased risk of fracture. Preventive measures should be instituted as early as possible.

Osteoporosis in primary biliary cholangitis

Primary biliary cholangitis (PBC) is an autoimmune cholestatic liver disease with multiple debilitating complications. Osteoporosis is a common complication of PBC resulting in frequent fractures and leading to significant morbidity in this population, yet evidence for effective therapy is lacking. We sought to summarize our current understanding of the pathophysiology of osteoporosis in PBC, as well as current and emerging therapies in order to guide future research directions. A complete search with a comprehensive literature review was performed with studies from PubMed, EMBASE, Web of Science, Cochrane database, and the Countway Library. Osteoporosis in PBC is driven primarily by decreased bone formation, which differs from the increased bone resorption seen in postmenopausal osteoporosis. Despite this fundamental difference, current treatment recommendations are based primarily on experience with postmenopausal osteoporosis. Trials specific to PBC-related osteoporosis are small and have not consistently demonstrated a benefit in this population. As it stands, prevention of osteoporosis in PBC relies on the mitigation of risk factors such as smoking and alcohol use, as well as encouraging a healthy diet and weight-bearing exercise. The primary medical intervention for the treatment of osteoporosis in PBC remains bisphosphonates though a benefit in terms of fracture reduction has never been shown. This review outlines what is known regarding the pathogenesis of bone disease in PBC and summarizes current and emerging therapies.

Primary biliary cholangitis and bone disease

Osteoporosis, characterized by compromised bone strength leading to fragility fractures, is a common event in patients with primary biliary cholangitis (PBC). Osteomalacia, defined by poor bone mineralization is very uncommon. The pathogenesis of osteoporosis is not well clarified, but it mainly results from low bone formation. Few reports have revealed increased bone resorption, particularly in end-stage disease. The prevalence of osteoporosis is about 35% in the most significant studies, and it depends on the diagnostic criteria and severity of liver damage. Osteoporosis is associated with age, postmenopausal status, duration of PBC and advanced histological stage. Bone densitometry is the common method for the diagnosis of osteoporosis and should be performed in all patients with PBC. Lateral X-rays of the dorsal and lumbar spine should also be carried out to disclose vertebral fractures. There is no specific treatment but bisphosphonates, especially alendronate and ibandronate, efficiently increases bone mass and prevents bone loss. Despite these positive effects on bone mass no clear results on decreasing the fracture rate have been demonstrated, probably because the low number of patients included in the trials. The potential value of new agents requires further evaluation.

Osteoporosis in chronic liver disease

Osteoporosis is a frequent complication in patients with chronic liver disease, especially in end-stages and in chronic cholestasis, in addition to non-alcoholic fatty liver disease, haemochromatosis and alcoholism. Mechanisms underlying osteoporosis are poorly understood, but osteoporosis mainly results from low bone formation. In this setting, sclerostin, a key regulator of the Wnt/β-catenin signalling pathway which regulates bone formation, in addition to the effects of the retained substances of cholestasis such as bilirubin and bile acids on osteoblastic cells, may influence the decreased bone formation in chronic cholestasis. Similarly, the damaging effects of iron and alcohol on osteoblastic cells may partially explain bone disease in haemochromatosis and alcoholism. A role for proinflammatory cytokines has been proposed in different conditions. Increased bone resorption may occur in cholestatic women with advanced disease. Low vitamin D, poor nutrition and hypogonadism, may be contributing factors to the full picture of bone disorders in chronic liver disease.

Association between pre-sarcopenia, sarcopenia, and bone mineral density in patients with chronic hepatitis C

BACKGROUND

Preserved skeletal muscle is essential for the maintenance of healthy bone. Loss of bone mineral density (BMD) and muscle strength, considered a predictor of BMD, have been demonstrated in patients with cirrhosis, but they are poorly studied in chronic hepatitis C (CHC) without cirrhosis. Thus, we aimed to evaluate the prevalence of low BMD and its association with body composition, muscle strength, and nutritional status in CHC.

METHODS

One hundred and four subjects [mean age, 50.5 ± 11.3 years; 75.0% males; 67.3% non-cirrhotic; and 32.7% with compensated cirrhosis] with CHC, prospectively, underwent scanning of the lean tissue, appendicular skeletal muscle mass (ASM), fat mass, lumbar spine, hip, femoral neck, and whole-body BMD by dual-energy X-ray absorptiometry. Muscle strength was assessed by dynamometry. Sarcopenia was defined by the presence of both low, ASM/height2 (ASMI) and low muscle strength according to the European Working Group on Sarcopenia in Older People criteria. The cut-off points for low ASMI and low muscle strength, for women and men, were < 5.45 and < 7.26 kg/m2 and < 20 and < 30 kg, respectively. According to the adopted World Health Organization criteria in men aged > 50 years, the T-score of osteopenia is between -1.0 and -2.49 standard deviation (SD) below the young average value and of osteoporosis is ≥-2.5 SD below the young normal mean for men, and the Z-score of low bone mass is ≤-2.0 SD below the expected range in men aged < 50 years and women in the menacme. Nutritional status evaluation was based on the Controlling Nutritional Status score.

RESULTS

Low BMD, low muscle strength, pre-sarcopenia, sarcopenia, and sarcopenic obesity were observed in 34.6% (36/104), 27.9% (29/104), 14.4% (15/104), 8.7% (9/104), and 3.8% (4/104) of the patients, respectively. ASMI was an independent predictor of BMD (P < 0.001). Sarcopenia was independently associated with bone mineral content (P = 0.02) and malnutrition (P = 0.01). In 88.9% of the sarcopenic patients and in all with sarcopenic obesity, BMI was normal. The mid-arm muscle circumference was positively correlated with ASMI (r = 0.88; P < 0.001).

CONCLUSIONS

This is the first study to demonstrate that ASM is an independent predictor of BMD in CHC. Mid-arm muscle circumference coupled with handgrip strength testing should be incorporated into routine clinical practice to detect low muscle mass, which may be underdiagnosed when only BMI is used. These findings may influence clinical decision-making and contribute to the development of effective strategies to screen the musculoskeletal abnormalities in CHC patients, independently of the stage of the liver disease.

Bone Health and Impact of Tenofovir Treatment in Men with Hepatitis-B Related Chronic Liver Disease

BACKGROUND

Chronic Liver Disease (CLD) has been shown to have an adverse impact on bone health. Hepatitis-B related CLD and its treatment with tenofovir may have additional effects on skeleton.

OBJECTIVE

To study the impact of HBV related CLD and its treatment with Tenofovir on bone health in Indian subjects.

METHODS

This cross sectional study included men (18-60 years) and comprised of three groups: Group-1 was treatment naïve HBV related CLD (n = 79), Group-2 those with HBV related CLD on tenofovir for at least 1 year (n = 136), Group-3 age, sex and Body Mass Index (BMI) matched healthy controls (n = 58). Bone biochemistry and Bone Mineral Density (BMD) at spine, Femoral Neck (FN) and forearm were studied. Independent t-test or ANOVA was used to compare the means of continuous variables and chi-square test for categorical variables. Multiple logistic regression was used to assess the factors causing Low Bone Mass (LBM) at FN.

RESULTS

A significantly greater proportion (P < 0.05) of patients (40%) with CLD (group 1 and group 2) had vitamin D deficiency (<20 ng/ml) in comparison with control group (22%). The mean serum C-Terminal telopeptide was significantly higher (P < 0.05) and the mean BMD was significantly lower (P < 0.05) in subjects with HBV related CLD than controls. The prevalence of LBM was higher in group 1 at the spine (31%) and forearm (18.4%) when compared to controls (8.1% and 7.8% respectively) (P < 0.05). The proportion of patients with LBM at FN was highest in group 2 (12.3%) compared to those in group 1 (8%) and group 3 (4%) (P < 0.05). Advanced age, low BMI, and high viral load (>10,000 IU/ml) emerged as significant risk factors for LBM at FN.

CONCLUSION

The impact of hepatitis-B related CLD as well as its treatment on bone health is significant. Bone health need to be periodically evaluated in these subjects especially in older men who are lean and have a higher viral load.

Bone metabolism dynamics in the early post-transplant period following kidney and liver transplantation

Bone disease contributes to relevant morbidity after solid organ transplantation. Vitamin D has a crucial role for bone metabolism. Activation of vitamin D depends on the endocrine function of both, liver and kidney. Our study assessed key markers of bone metabolism at time of transplantation and 6 months after transplantation among 70 kidney and 70 liver recipients. In 70 kidney recipients 25-OH vitamin D levels did not differ significantly between peri-transplant (median 32.5nmol/l) and 6 months post-transplant (median 41.9nmol/l; P = 0.272). Six months post-transplant median 1, 25-(OH)₂ vitamin D levels increased by >300% (from 9.1 to 36.5ng/l; P<0.001) and median intact parathyroid hormone levels decreased by 68.4% (from 208.7 to 66.0 ng/l; P<0.001). Median β-Crosslaps (CTx) and total procollagen type 1 amino-terminal propeptide (P1NP) decreased by 65.1% (from 1.32 to 0.46ng/ml; P<0.001) and 60.6% (from 158.2 to 62.3ng/ml; P<0.001), respectively. Kidney recipients with incident fractures had significantly lower levels of 1, 25-(OH)₂ vitamin D at time of transplantation and of intact parathyroid hormone 6 months post-transplant. Among 70 liver recipients, 25-OH vitamin D, 1, 25-(OH)₂ vitamin D and intact parathyroid hormone levels were not significantly altered between peri-transplant and 6 months post-transplant. Contrary to kidney recipients, median CTx increased by 60.0% (from 0.45 to 0.72 ng/ml; P = 0.002) and P1NP by 49.3% (from 84.0 to 125.4ng/ml; P = 0.001) in the longitudinal course. Assessed biomarkers didn’t differ between liver recipients with and without fractures. To conclude, the assessed panel of biomarkers proved highly dynamic after liver as well as kidney transplantation in the early post-transplant period. After kidney transplantation a significant gain in 1, 25-(OH)₂ vitamin D combined with a decline in iPTH, CTx and P1NP, whereas after liver transplantation an increase in CTx and P1NP were characteristic.

Risk and adverse outcomes of fractures in patients with liver cirrhosis: two nationwide retrospective cohort studies

OBJECTIVE

The aim of this study is to evaluate fracture risk and post-fracture outcomes in patients with and without liver cirrhosis (LC).

DESIGN

Retrospective cohort study and nested fracture cohort study.

SETTING

This study was based on Taiwan's National Health Insurance Research Database that included information on: (1) 3941 patients aged 20 years and older newly diagnosed with LC between 2000 and 2003; (2) 688290 hospitalised fracture patients aged 20 years and older between 2006 and 2013.

PRIMARY AND SECONDARY OUTCOME MEASURES

Followed-up events of fracture from 2000 to 2008 were noted from medical claims to evaluate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of fracture associated with LC. Adjusted odds ratios (ORs) and 95% CIs of adverse events after fracture were compared among patients with and without LC RESULTS: The incidences of fracture for people with and without LC were 29.1 and 17.2 per 1000 person-years, respectively. Compared with controls, the adjusted HR of fracture was 1.83 (95% CI 1.67 to 2.01) for patients with LC. Previous LC was associated with risks of septicaemia (OR 1.77, 95% CI 1.60 to 1.96), acute renal failure (OR 1.63, 95% CI 1.33 to 1.99), and 30-day in-hospital mortality (OR 1.61, 95 %CI 1.37 to 1.89) after fracture.

CONCLUSION

LC was associated with higher risk of fracture; patients with LC in particular had more complications and 30-day in-hospital mortality after fracture. Fracture prevention and attention to post-fracture adverse events are needed for these susceptible populations.

Significant liver fibrosis assessed using liver transient elastography is independently associated with low bone mineral density in patients with non-alcoholic fatty liver disease

Background

Metabolic bone disorders frequently occur in patients with chronic liver disease; however, the association between liver fibrosis and bone mineral density in patients with non-alcoholic fatty liver disease (NAFLD) is unclear.

Methods

This is a cross-sectional analysis of 231 asymptomatic subjects (160 women, 61.6 years old) from a university hospital setting, between February 2012 and December 2014. Bone mineral density (BMD) was measured at the lumbar spine, femur neck, and total hip using dual-energy X-ray absorptiometry (DXA). Liver fibrosis and steatosis were assessed using transient elastography.

Results

Among a total of 231 individuals, 129 subjects (55.8%) had NAFLD. BMDs at lumbar spine, femur neck, and total hip were significantly lower in patients having NAFLD with significant fibrosis, compared with patients having NAFLD without significant fibrosis (Ps<0.005). In patients with NAFLD, significant liver fibrosis revealed marked negative correlations with BMD at the lumber spine (r = –0.19, P = 0.032), femur neck (r = –0.19, P = 0.034), and total hip (r = –0.21, P = 0.016). A multivariate linear regression analysis revealed that significant liver fibrosis was independently correlated with low BMD at the femur neck (β = –0.18, P = 0.039) and total hip (β = –0.21, P = 0.005) after adjustment for age, sex, BMI, fasting plasma glucose, alanine aminotransferase, high-density lipoprotein cholesterol, and liver steatosis among patients with NAFLD. Using multivariable logistic regression, significant liver fibrosis was independently associated with overall osteopenia and osteoporosis in subjects having NAFLD (OR = 4.10, 95% CI = 1.02–16.45).

Conclusion

The presence of significant liver fibrosis assessed via TE was independently associated with low BMD in NAFLD subjects.

Insulin-Like Growth Factor-1 Deficiency and Cirrhosis Establishment

Cirrhosis represents the final stage of chronic liver damage, which can be due to different factors such as alcohol, metabolic syndrome with liver steatosis, autoimmune diseases, drugs, toxins, and viral infection, among others. Nowadays, cirrhosis is an important health problem and it is an increasing cause of morbidity and mortality, being the 14th most common cause of death worldwide. The physiopathological pathways that lead to fibrosis and finally cirrhosis partly depend on the etiology. Nevertheless, some common features are shared in this complex mechanism. Recently, it has been demonstrated that cirrhosis is a dynamic process that can be altered in order to delay or revert fibrosis. In addition, when cirrhosis has been established, insulin-like growth factor-1 (IGF-1) deficiency or reduced availability is a common condition, independently of the etiology of chronic liver damage that leads to cirrhosis. IGF-1 deprivation seriously contributes to the progressive malnutrition of cirrhotic patient, increasing the vulnerability of the liver to establish an inflammatory and oxidative microenvironment with mitochondrial dysfunction. In this context, IGF-1 deficiency in cirrhotic patients can justify some of the common characteristics of these individuals. Several studies in animals and humans have been done in order to test the replacement of IGF-1 as a possible therapeutic option, with promising results.

Vitamin D deficiency and osteoporosis in hemophilic children: an intermingled comorbidity

The aim of this study is to investigate bone state and factors affecting it in children with hemophilia. This is a case-control study that included 37 children with hemophilia and 37 healthy controls. The patients were selected from the outpatient pediatric hematology clinic of Fayoum University Hospital, Egypt. Bone mineral density, serum vitamin D, parathormone, calcium, phosphorus, and calcium creatinine ratio levels were evaluated. Vitamin D level and bone mineral density were significantly lower in hemophiliacs than in control group (P < 0.0001). About 43.2% of cases had moderate vitamin D deficiency, whereas 35.1% had mild deficiency. Vitamin D positively correlated with bone mineral density Z-score, whereas it negatively correlated with total joint score. Positive correlation between bone mineral density and age was also found. Serum levels of urea, urinary calcium creatinine ratio, and parathormone were found to be higher in cases than in control. Also, serum calcium level was found to be lower in patients than in controls. We concluded that vitamin D deficiency is an essential cause of decreased bone mineral density in hemophilic children. Hemophilic arthropathy with consecutive immobilization plays an important role in vitamin D deficiency and decreased bone mineral density.

Diagnosis and Management of Cirrhosis-Related Osteoporosis

Management of cirrhosis complications has greatly improved, increasing survival and quality of life of the patients. Despite that, some of these complications are still overlooked and scarcely treated, particularly those that are not related to the liver. This is the case of osteoporosis, the only cirrhosis complication that is not solved after liver transplantation, because bone loss often increases after immunosuppressant therapy. In this review, the definitions of bone conditions in cirrhotic patients are analyzed, focusing on the more common ones and on those that have the largest impact on this population. Risk factors, physiopathology, diagnosis, screening strategies, and treatment of osteoporosis in cirrhotic patients are discussed, presenting the more striking data on this issue. Therapies used for particular conditions, such as primary biliary cirrhosis and liver transplantation, are also presented.

Prevalence of hepatic osteodystrophy and vitamin D deficiency in cirrhosis

BACKGROUND

Hepatic osteodystrophy (HO) is a major complication of cirrhosis. However, the prevalence of HO in a general cirrhotic patient population is not well defined as previous studies were in single aetiology or pre-liver transplant patients.

AIMS

The aims of this study were to investigate the prevalence of HO and vitamin D deficiency in patients with cirrhosis of mixed aetiology and disease severity and to determine the risk factors for HO.

METHODS

This is a single-centre cross-sectional study of all patients newly diagnosed with cirrhosis between September 2009 and December 2012. All patients underwent bone mineral density assessment using dual energy X-ray absorptiometry within 3 months of diagnosis. Demographic and biochemical factors, severity of underlying liver disease, previous fragility fractures, smoking status and alcohol use were collected on diagnosis. Logistic regression analysis was used to assess risk factors for HO.

RESULTS

Among the 406 patients (67% males), the median (range) age was 56 years (21-85) and most (84%) were Childs-Pugh A or B with a median (range) model for end-stage liver disease score of 11 (5-40). Alcohol (41%) was the most common underlying aetiology. The prevalence of HO and vitamin D deficiency (≤50 nmol/L) was 56% and 54%, respectively, and previous fragility fractures had occurred in 3%. Increasing age (odds ratio (95% confidence interval): 1.49 per 10 years (1.02-2.18), P = 0.04), excessive alcohol intake (2.34 (1.03-5.32), P = 0.04) and lower body mass index (0.92 per kg/m2 (0.87-0.98), P = 0.009) were independent risk factors for HO.

CONCLUSION

There is a high prevalence of HO and vitamin D deficiency in patients with cirrhosis at presentation irrespective of disease severity or underlying aetiology.

Osteoporosis in liver disease: pathogenesis and management

Osteoporosis affects a substantial proportion of patients with chronic liver disease. Pathologic fracture in osteoporosis significantly affects quality of life and life expectancy. By some estimates, 40% of patients with chronic liver disease may experience osteoporotic fracture. In this study we review the pathogenesis, diagnosis and treatment of specific liver disease entities and their relation to osteoporosis.

Crucial Role of Vitamin D in the Musculoskeletal System

Vitamin D is well known to exert multiple functions in bone biology, autoimmune diseases, cell growth, inflammation or neuromuscular and other immune functions. It is a fat-soluble vitamin present in many foods. It can be endogenously produced by ultraviolet rays from sunlight when the skin is exposed to initiate vitamin D synthesis. However, since vitamin D is biologically inert when obtained from sun exposure or diet, it must first be activated in human beings before functioning. The kidney and the liver play here a crucial role by hydroxylation of vitamin D to 25-hydroxyvitamin D in the liver and to 1,25-dihydroxyvitamin D in the kidney. In the past decades, it has been proven that vitamin D deficiency is involved in many diseases. Due to vitamin D’s central role in the musculoskeletal system and consequently the strong negative impact on bone health in cases of vitamin D deficiency, our aim was to underline its importance in bone physiology by summarizing recent findings on the correlation of vitamin D status and rickets, osteomalacia, osteopenia, primary and secondary osteoporosis as well as sarcopenia and musculoskeletal pain. While these diseases all positively correlate with a vitamin D deficiency, there is a great controversy regarding the appropriate vitamin D supplementation as both positive and negative effects on bone mineral density, musculoskeletal pain and incidence of falls are reported.

The risk of osteoporosis in patients with liver cirrhosis: a meta-analysis of literature studies

OBJECTIVE

Data about the association between cirrhosis and osteoporosis are contrasting. Thus, we have performed a meta-analysis of literature studies on this topic.

DESIGN

MEDLINE, Cochrane library, EMBASE, Scopus and Web of Science databases have been searched to retrieve all articles of interest. Data on prevalence of osteoporosis, bone mineral density (BMD) and bone turnover laboratory parameters were compared among cirrhotic patients and control subjects without cirrhosis.

PATIENTS

Studies on patients with liver cirrhosis screened for the presence of osteoporosis were included.

RESULTS

Six case-control studies (372 cirrhotic patients and 1579 controls) were included. The prevalence of osteoporosis was higher in cirrhotic patients than in controls (34·7% vs 12·8%, OR: 2·52, 95%CI: 1·11, 5·69; P = 0·03, I(2) = 81%; P = 0·005). Accordingly, a reduced lumbar spine BMD (MD: -0·13, 95%CI: -0·24, -0·02; P = 0·02, I(2) = 93%; P < 0·00001) and z-score (MD: -1·06, 95%CI: -1·79, -0·34; P = 0·004, I(2) = 95%; P < 0·00001) were found in cirrhotic patients as compared with controls. In contrast, no significant differences were reported in femoral neck BMD and z-score. Interestingly, bone turnover laboratory parameters widely confirmed these results showing higher levels of ALP and D-Pyr, accompanied by reduced levels of IGF-1, PTH and 25-OH-D in cirrhotic patients as compared with controls.

CONCLUSIONS

Despite the high heterogeneity among studies, data showed an increased prevalence of osteoporosis in patients with cirrhosis. This information suggests the need of an accurate screening of bone mineral density in patients with liver cirrhosis to plan an adequate osteoporosis management.

Total 25(OH) vitamin D, free 25(OH) vitamin D and markers of bone turnover in cirrhotics with and without synthetic dysfunction

BACKGROUND & AIMS

Current clinical assays for total 25-hydroxy (OH) vitamin D measure vitamin D bound to vitamin D-binding protein (DBP) and albumin plus unbound ('free') D. We investigated the relationship between total and free 25(OH)D with bone metabolism markers in normal (>3.5 g/dl) vs. low (≤3.5 g/dl) albumin cirrhotics.

METHODS

Eighty-two cirrhotics underwent measurement of free and total 25(OH)D by immunoassay, DBP and markers of bone metabolism [intact parathyroid hormone (iPTH), C-telopeptide (CTX), bone-specific alkaline phosphatase (BSAP), osteocalcin, amino-terminal pro-peptide of type 1-collagen (P1NP)]. Pearson's coefficients assessed relevant associations.

RESULTS

Cirrhotics with low (n = 54) vs. normal (n = 28) albumin had lower total 25(OH)D (12.1 vs. 21.7 ng/ml), free 25(OH)D (6.2vs.8.6 pg/ml) and DBP(91.4 vs. 140.3 μg/ml) [P < 0.01 for each]. iPTH was similar in low and normal albumin groups (33 vs. 28 pg/ml; P = 0.38), although serum CTX(0.46vs.0.28 ng/ml) and BSAP(31.7 vs. 24.8 μg/L) were increased (P < 0.01). An inverse relationship was observed between total 25(OH)D and iPTH in normal (r = -0.47, P = 0.01) but not low albumin cirrhotics (r = 0.07, P = 0.62). Similar associations were seen between free 25(OH)D and iPTH(Normal: r = -0.46, P = 0.01; Low: r = -0.03, P = 0.84). BSAP, osteocalcin and P1NP were elevated above the normal range in all cirrhotics but not consistently associated with total or free 25(OH)D.

CONCLUSIONS

Cirrhotics with low vs. normal albumin have lower levels of DBP, total and free 25(OH)D. The expected relationship between total or free 25(OH)D with iPTH was observed in normal but not in low albumin cirrhotics, demonstrating that total 25(OH)D is not an accurate marker of bioactive vitamin D status in cirrhotics with synthetic dysfunction. Additional investigation into the role of vitamin D supplementation and its impact on bone mineral homoeostasis in this population is needed.

Bone Mineral Density, Bone Turnover, and Systemic Inflammation in Non-cirrhotics with Chronic Hepatitis C

BACKGROUND

Whether chronic HCV, a disease characterized by systemic inflammation, impacts bone mineral density (BMD) independent of cirrhosis is unknown.

AIM

We aimed to evaluate the association between BMD, systemic inflammation, and markers of bone turnover in chronic HCV without cirrhosis.

METHODS

Non-cirrhotics, 40-60 years old, with chronic HCV underwent measurement of: (1) BMD by dual-energy X-ray absorptiometry scan and (2) serum markers of systemic inflammation and bone turnover. By Chi-squared or t test, we compared those with normal versus low BMD.

RESULTS

Of the 60 non-cirrhotics, 53 % were female and 53 % Caucasian. Mean (SD) age was 53.3 years (5.7), total bilirubin 0.7 mg/dL (0.3), creatinine 0.8 mg/dL (0.2), and body mass index 28.4 kg/m(2) (6.5). Low BMD was observed in 42 %: 30 % had osteopenia, 12 % had osteoporosis. Elevated tumor necrosis factor α, interleukin-6, and C-reactive protein levels were found in 26, 32, and 5 %, respectively, but did not differ by BMD group (p > 0.05). Patients with low BMD had higher serum phosphorus (4.1 vs. 3.5 mg/dL) and pro-peptide of type 1 collagen (P1NP; 73.1 vs. 47.5 ng/mL) [p < 0.05], but similar bone-specific alkaline phosphatase, serum C-telopeptide, and parathyroid hormone levels.

CONCLUSIONS

Low BMD is prevalent in 40- to 60-year-old non-cirrhotics with chronic HCV, but not associated with systemic inflammatory markers. Elevated P1NP levels may help to identify those at increased risk of bone complications in this population. Chronic HCV should be considered a risk factor for bone loss, prompting earlier BMD assessments in both men and women.

Association between nutritional screening via the Controlling Nutritional Status index and bone mineral density in chronic liver disease of various etiologies

AIM

Bone density disorders are prevalent in patients with chronic liver disease (CLD), who commonly present with hepatic osteodystrophy. However, the relationship between nutritional status and bone mineral density (BMD) has been scarcely studied in CLD.

METHODS

This single-center, cross-sectional study included outpatients consecutively diagnosed with CLD during a 1.5-year period. The nutritional status was assessed with the Controlling Nutritional Status (CONUT) index; dual-energy X-ray absorptiometry scans and parameters of bone mineral metabolism were carried out. Bone fracture risk was estimated with the World Health Organization FRAX tool.

RESULTS

Among the 126 patients recruited (58.7% male), osteopenia and osteoporosis were present in 31.1% and 10.7%, respectively. The 10-year fracture risk was significantly higher among women. Malnutrition estimated with the CONUT index was present in 29.9% of patients and was significantly more frequent in cirrhotic patients, 63.4% of whom were malnourished. Malnutrition stage directly correlated with hepatic function as expressed by the Model for End-Stage Liver Disease index. A non-significant relationship between CONUT-assessed nutritional status and BMD was documented. 25-Hydroxyvitamin-D3 (25[OH]-D3) and fracture risk correlated positively with the CONUT stage, and total cholesterol had an inverse relationship with BMD.

CONCLUSION

Malnutrition assessed by the CONUT was very frequent in patients with liver cirrhosis. The CONUT score inversely correlated with liver function, while malnutrition stage directly correlated with BMD, fracture risk and 25(OH)-D3. Total cholesterol showed a negative association with BMD in this population.

Pros and cons of fatty acids in bone biology

Despite the growing interest in deciphering the causes and consequences of obesity-related disorders, the mechanisms linking fat intake to bone behaviour remain unclear. Since bone fractures are widely associated with increased morbidity and mortality, most notably in elderly and obese people, bone health has become a major social and economic issue. Consistently, public health system guidelines have encouraged low-fat diets in order to reduce associated complications. However, from a bone point of view, mechanisms linking fat intake to bone alteration remain quite controversial. Thus, after more than a decade of dedicated studies, this timely review offers a comprehensive overview of the relationships between bone and fatty acids. Using clinical evidences as a starting-point to more complex molecular elucidation, this work highlights the complexity of the system and reveals that bone alteration that cannot be solved simply by taking ω-3 pills. Fatty acid effects on bone metabolism can be both direct and indirect and require integrated investigations. Furthermore, even at the level of a single cell, one fatty acid is able to trigger several different independent pathways (receptors, metabolites…) which may all have a say in the final cellular metabolic response.

Effect of calcitriol supplementation and tail suspension on serum biomarkers of bone formation in rats

BACKGROUND

Calcitriol is documented to cause significant increase in bone mass densitometry counteracting osteoporosis. Promising results of calcitriol supplementation in studies aiming space flight induced osteoporosis is little and the effect of this hormone on biomarkers of bone metabolism is not examined yet in space flight models of osteoporosis in rats.

METHODS

This was an interventional animal study being performed in a 1-month period. We included 21 Sprague Dawley strain rats (>200 gr, >6 week) who were randomly assigned to receive daily supplementation of oral 0.03μgr calcitriol and to be submitted to tail suspension model. Rats were followed for 1 month and were tested for serum osteocalcin (OC), alkaline phosphatase (ALP) and serum calcium at the beginning and the end of the study period. The results were analyzed and compared between groups.

RESULTS

Although serum levels of osteocalcin and alkaline phosphatase biomarkers and total serum calcium were not significantly different within and between study groups, their levels were increased in tail suspension model compared to control group. The levels of these biomarkers were lower in those who were submitted to tail suspension model and received calcitriol supplementation compared to those who were only submitted to tail suspension (60.14 ± 11.73 ng/mL vs. 58.29 ± 2.69 ng/mL; p = 0.696 for osteocalcin and 381.86 ± 99.16 mU/mL vs. 362.57 ± 27.41 ng/mL; p = 0.635 for alkaline phosphatase).

CONCLUSION

Supplementation of daily diet with calcitriol in rats under weightlessness conditions may results in lower values for bone metabolic biomarkers of alkaline phosphatase and osteocalcin and serum calcium. This pattern of change in biomarkers of bone formation, may point to the capacity of calcitriol supplementation in preventing cellular process of osteoporosis. Thus calcitriol supplementation could be an available, economic and effective strategy for preventing bone metabolic changes related to weightlessness commonly encountered in space flight. The outcome of this study needs to be further studied in future trying to find more definite results.