Association between chronic hepatitis C virus infection and bone mineral density

Abnormal Trabecular and Cortical Bone Microarchitecture in Chronic Hepatitis C Infection and Associations With Select Inflammatory Cytokines

Background

Hepatitis C virus (HCV) infection is associated with reduced bone mineral density (BMD) and increased fracture risk. The structural underpinnings for skeletal fragility with HCV and contributions of inflammatory cytokines remain unknown. We used high-resolution peripheral quantitative computed tomography (HR-pQCT) to compare skeletal parameters by chronic HCV.

Methods

We conducted a cross-sectional study among 58 participants with chronic HCV and 58 participants without HCV. Volumetric BMD and cortical dimensions of the radius and tibia were determined by HR-pQCT; visceral fat area and appendicular lean mass were assessed by whole body dual-energy x-ray absorptiometry; serum levels of tumor necrosis factor α (TNF-α), interleukin 6, and interleukin 18 were measured. Multivariable linear regression was used to estimate group differences in bone measurements and cytokines.

Results

Participants with chronic HCV had lower radius trabecular volumetric BMD (-24.2 mg hydroxyapatite [HA]/cm3) and lower tibia trabecular volumetric BMD (-20.5 mg HA/cm3), cortical area (-20.9 mm2), and cortical thickness (-0.47 mm) than participants without HCV (all P < .05), independent of age, sex, visceral fat area, appendicular lean mass, and smoking. Mean log TNF-α was higher with chronic HCV (+0.1-log pg/mL; P < .001), but no differences in mean log interleukin 6 or interleukin 18 were observed. Higher log TNF-α was associated with lower radius trabecular volumetric BMD (-99.7 mg HA/cm3), lower tibia cortical volumetric BMD (-91.6 mg HA/cm3), and higher tibia cortical porosity (+1.39%) by HR-pQCT (all P < .05).

Conclusions

Patients with chronic HCV had decreased trabecular volumetric BMD and cortical dimensions and higher TNF-α than individuals without infection, suggesting that HCV-associated inflammation might contribute to bone deficits.

Association of chronic liver disease with bone diseases and muscle weakness

The liver is a vital organ involved in nutrient metabolism, hormone regulation, immunity, cytokine production, and gut homeostasis. Impairment in liver function can result in malnutrition, chronic inflammation, decreased anabolic hormone levels, and dysbiosis. These conditions eventually cause an imbalance in osteoblast and osteoclast activities, resulting in bone loss. Osteoporosis is a frequent complication of chronic liver disease (CLD) that adversely affects quality of life and increases early mortality. Sarcopenia is another common complication of CLD characterized by progressive loss of skeletal muscle mass and function. Assessment criteria for sarcopenia specific to liver disease have been established, and sarcopenia has been reported to be associated with an increase in the risk of liver disease-related events and mortality in patients with CLD. Owing to their similar risk factors and underlying pathophysiological mechanisms, osteoporosis and sarcopenia often coexist (termed osteosarcopenia), progress in parallel, and further exacerbate the conditions mentioned above. Therefore, comprehensive management of these musculoskeletal disorders is imperative. This review summarizes the clinical implications and characteristics of osteoporosis, extending to sarcopenia and osteosarcopenia, in patients with CLD caused by different etiologies.

Seropositive for hepatitis B and C viruses is associated with the risk of decreased bone mineral density in adults: An analysis of studies from the NHANES database

Background

Some studies had reported that patients with viral hepatitis are at increased risk of reduced bone mineral density and even osteoporosis. However, the interaction between reduced bone mineral density (BMD) and viral hepatitis remains inconclusive. Therefore, our study collected hepatitis test results and bone mineral density from respondents in the NHANES database. The aim of this study was to investigate whether there is an association between hepatitis and a decrease in bone mineral density.

Methods

The respondents with both hepatitis- and BMD-related indicators from the NHANES database in the United States from 2005-2010, 2013-2014, to 2017-2020 were collected for this study. BMD were compared between respondents who were positive and negative for respondents related to hepatitis B and C. BMD was measured using dual-energy X-ray absorptiometry of the femur and lumbar spine. Finally, multiple regression analysis was performed between hepatitis B surface antigen (HBsAg) and hepatitis C RNA (HCV-RNA) and BMD in the respondents.

Results

A total of 15,642 respondents were included in the hepatitis B surface antigen-related survey. Of these, 1,217 respondents were positive for hepatitis B surface antigen. A total of 5111 hepatitis C RNA-related responders were included. Hepatitis C RNA-positive had 268 respondents. According to the results of the multiple regression analysis, the femoral BMD was significantly lower in HBsAg (+) respondents compared to HBsAg (-) respondents: -0.018 (-0.026, -0.009) (P < 0.01). Moreover, spinal BMD was significantly lower in HBsAg (+) respondents compared to HBsAg (-) respondents: -0.020 (-0.030, -0.010) (P < 0.01). According to the results of multiple regression analysis for hepatitis C RNA, HCV-RNA (+) respondents had significantly lower BMD compared to HCV-RNA (-) respondents: -0.043 (-0.059, -0.026) (P < 0.01).

Conclusion

During the analysis of respondents in the NHANES database in the United States, positive tests for hepatitis B surface antigen and hepatitis C RNA were found to be associated with a reduction in BMD. Positive serology for these hepatitis indicators may increase the risk of reduced BMD. Of course, this conclusion still needs to be further confirmed by more large clinical trials.

Unravelling hip-spine bone mineral density discordance in people living with HIV

INTRODUCTION

In people living with HIV (PLWH), bone mineral density (BMD) discordance between the lumbar spine (LS) and femoral neck (FN) could be frequent given the high frequency of secondary osteoporosis, including HIV-related factors for bone disease.

MATERIALS AND METHODS

Retrospective cohort of PLWH with a dual X-ray absorptiometry scan. Hip-spine BMD discordance was defined as different T-score or Z-scores categories at LS and FN.

RESULTS

Overall, 865 individuals (mean 49.5 years, female 27%) were included. Osteoporosis diagnosis was four-to-seven times lower when both skeletal sites were affected than when considering the lowest T-score at any site (overall, 21% vs 4%). Hip-spine BMD discordance was observed in 381 (44%) individuals, it increased with age (from 43 to 52%, P = 0.032), and it was mainly due to lower LS-BMD. A lower FN-BMD was associated with older age, lower BMI (P < 0.01), and HIV-related factors, such as low CD4 + T-cell counts, duration of HIV infection, and time on antiretroviral therapy (ART). In a multivariate regression analysis, sex male (Odds Ratio, OR 4.901), hyperparathyroidism (OR, 2.364), and time on ART (OR 1.005 per month) were independently associated with discordance. A higher estimated fracture risk by FRAX equation was observed in individuals with BMD discordance due to lower FN-BMD compared to those with lower LS-BMD (+ 36% for major osteoporotic fracture, P = 0.04; + 135% for hip fracture, P < 0.01).

CONCLUSION

Hip-spine BMD discordance is highly prevalent in PLWH and it is associated with classical and HIV-related risk factors, modifying the rate of osteoporosis and fracture risk estimation.

Relationships Between Vitamin D Status and Cytokine: Results from Interferon-Based Therapy in Non-Cirrhotic, Treatment-Naïve Patients with Chronic Hepatitis C Infection

Background

Vitamin D contributes to bone health and extra-skeletal effects. The mechanisms underlying vitamin D metabolism have not been extensively evaluated. The relationships between vitamin D and inflammatory cytokines are debated. Our objective was to investigate whether supplemental interferons are associated with longitudinal change of vitamin D status in humans.

Methods

A total of 48 patients with 24 or 48 weeks of pegylated interferon-α plus ribavirin therapy were examined for serum 25-hydroxyvitamin D (25[OH]D) level before treatment, at the end of treatment, and 24 weeks after treatment. In addition, we analyzed publicly available RNA sequencing data from accession GSE42697 and GSE7123 in the Gene Expression Omnibus.

Findings

The overall sustained virologic response (SVR) rate was 62.5%. There was no statistically significant association between baseline 25(OH)D concentrations and liver fibrosis. In patients with SVR, serum 25(OH)D increased markedly at end-of-treatment and decreased markedly by the end of the 24-week follow-up period. In the non-SVR group, this treatment-dependent change was lost. In gene expression analysis, the vitamin D biosynthesis process was activated in subjects with SVR, but not in patients without SVR. Furthermore, vitamin D receptor (VDR) signaling in peripheral blood mononuclear cells (PBMCs) was triggered in marked responders but not in poor responders.

Conclusion

In the aggregate, these data suggest that interferons have a regulatory influence on vitamin D status that can contribute to VDR signaling in PBMCs.

Evaluation of the fracture risk assessment tool for determining bone disease and the impact of secondary causes of osteoporosis in people living with HIV

BACKGROUND

Among HIV-infected individuals, screening for bone disease is encouraged to assess reversible risk factors and plan therapeutic interventions.

OBJECTIVE

We assessed the usefulness of Fracture Risk Assessment (FRAX) tool to identify candidates for dual X-ray absorptiometry (DXA) scan, or individuals with bone loss progression. We further explored how secondary causes of osteoporosis are reflected on FRAX.

METHODS

Longitudinal study of 217 consecutive individuals (mean, 45.8 years, 24% females) included after DXA scan. FRAX was calculated without/with femoral neck bone mineral density (BMD), checking the box of "secondary osteoporosis" for all the individuals.

RESULTS

Low BMD was observed in 133/217 (61%) individuals, of whom 98.5% had not been selected as candidates for DXA by current FRAX thresholds. Specifically, 23% of individuals aged <50 had low BMD but none was candidate for DXA. Adding BMD data, FRAX results increased by 50-100%, with 2/217 individuals (1%) above the thresholds. Classical and HIV-related secondary causes of osteoporosis (observed in 98% overall) correlated with low BMD, modifying significantly FRAX results (HCV coinfection, +124%; longer time of HIV infection, +93%; longer time on antiretroviral therapy, +147%; tenofovir exposure +36%). Individuals with lower BMD and higher FRAX results at inclusion had less bone decline in a follow-up DXA after a median of 3.5 years.

CONCLUSIONS

Currently recommended FRAX thresholds are not useful to select candidates for DXA scan, which could delay its performance in a population with a high prevalence of secondary factors for low BMD. Classical and HIV-related factors alter BMD and fracture risk estimation.

Bone mineral density and trabecular bone score in treatment-naïve patients with non-cirrhotic hepatitis C virus infection

We studied 112 treatment-naïve chronic HCV patients without cirrhosis, and we found that, especially HCV+ postmenopausal women, they had lower TBS and BMD values than healthy controls. This suggests that HCV infection is an independent risk factor for osteoporosis, and therefore, screening for osteoporosis in postmenopausal HCV+ women should be considered.

PURPOSE

To know whether patients in earlier stages of chronic HCV infection are at increased risk of developing low bone mass and bone microarchitectural changes and whether there is an association between bone metabolism and the severity of the liver disease.

METHODS

We studied 112 treatment-naïve chronic HCV outpatients and 233 healthy age- and sex-matched controls. Bone mineral density (BMD) and trabecular bone score (TBS) were assessed by DXA. Serum 25(OH)D, PTH, P1NP, and CTX were determined by electrochemiluminescence.

RESULTS

TBS values were significantly lower in HCV patients than in controls, both considering the population as a whole (1.337 ± 0.119 vs. 1.377 ± 0.122; p < 0.005) and after stratifying by sex (1.347 ± 0.12 vs. 1.381 ± 0.13 in men and 1.314 ± 0.10 vs. 1.369 ± 0.11 in women). The difference remained significant (p < 0.0001 in all cases) after adjusting for confounders. BMD was also lower in HCV patients (lumbar spine, 0.935 ± 0.151 vs. 0.991 ± 0.143 g/cm², p 0.001; femoral neck, 0.764 ± 0.123 vs. 0.818 ± 0.123 g/cm², p 0.0001; total hip, 0.926 ± 0.148 vs. 0.963 ± 0.132 g/cm², p 0.02), although, after adjustment, differences kept a clear trend towards statistical significance in women at the lumbar spine and femoral neck. However, in men and at the total hip in women, differences were no longer significant. We find no relationship between these parameters and the severity of the disease. No significant difference was observed in PTH and 25OHD status after adjustment. Finally, serum P1NP, but not CTX, was higher in HCV patients.

CONCLUSIONS

Our findings suggest that HCV infection is an independent risk factor for osteoporosis, especially among postmenopausal women. Therefore, the appropriateness of screening for osteoporosis in postmenopausal HCV-positive women should be considered.

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.

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.

The association between hepatitis and osteoporosis: a nested case-control study using a national sample cohort

The prevalence of hepatitis B was higher in osteoporosis patients than the control group, especially in females. However, the prevalence of hepatitis C was not different. The matching for various factors improved to have same conditions between osteoporosis patients and the control group.

PURPOSE

Although chronic liver disease, including hepatitis B and hepatitis C, has been associated with osteoporosis in previous studies, the evidence was insufficient, and some findings were inconsistent. The aim of this study was to evaluate the relationship between hepatitis B or hepatitis C and osteoporosis.

METHODS

We used the Korean National Health Insurance Service-National Sample Cohort with ≥ 50-year-old participants from 2002 to 2013. Age was determined at osteoporosis diagnosis. We extracted 68,492 osteoporosis patients (ICD-10 codes E7001-E7004, HC341-HC345) with a 68,492-member control group at a ratio of 1:1 by age, sex, income, region of residence, hypertension, diabetes, and dyslipidemia. We analyzed previous histories of hepatitis B (ICD-10 codes B18.0-B18.1) and hepatitis C (ICD-10 code B18.2) in the osteoporosis patients and control groups. The logistic regression with the crude and adjusted model was analyzed. Additionally, subgroup analyses divided by age and sex were performed.

RESULTS

The adjusted odds ratios for hepatitis B and hepatitis C were 1.19 (95% confidence interval (CI) = 1.11-1.28, P < 0.001) and 1.04 (95% CI = 0.90-1.19, P > 0.05), respectively, in osteoporosis patients. Subgroup analyses showed that the risk of hepatitis B was higher in osteoporosis patients in female groups but not in male groups.

CONCLUSION

Hepatitis B virus infection might be a risk factor for osteoporosis.

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.

Hepatitis C virus infection and risk of osteoporotic fracture: A systematic review and meta-analysis

BACKGROUND/OBJECTIVES

Hepatitis C virus (HCV) infection is one of the most common causes of chronic liver disease. Several epidemiologic studies have suggested that patients with HCV infection might have a higher risk of osteoporotic fracture. However, the data are inconclusive. This systematic review and meta-analysis was conducted with the aims to summarize all available evidence.

METHODS

A literature search was performed using MEDLINE and EMBASE database from inception to June 2016. Studies that reported relative risks, odd ratios, or hazard ratios comparing the risk of osteoporotic fracture among HCV-infected patients versus subjects without HCV infection were included. Pooled risk ratio (RR) and 95% confidence interval (CI) were calculated using a random-effect, generic inverse variance method.

RESULTS

Three studies with 362,285 participants met our eligibility criteria and were included in analysis. We found a significantly higher risk of osteoporotic fracture among patients with HCV infection with RR of 1.53 (95% CI 1.09 to 2.14).

CONCLUSIONS

Our study demonstrated an increased risk of osteoporotic fracture among HCV-infected patients. Further studies are required to clarify how this risk should be addressed in clinical practice.

Other Extrahepatic Manifestations of Hepatitis C Virus Infection (Pulmonary, Idiopathic Thrombocytopenic Purpura, Nondiabetes Endocrine Disorders)

Extrahepatic manifestations of hepatitis C virus (HCV) infection are a rare but serious condition. This article summarizes the current literature on the association between HCV and endocrine and pulmonary manifestations, as well as idiopathic thrombocytopenic purpura (ITP). HCV may directly infect extrahepatic tissues and interact with the immune system predisposing for obstructive and interstitial lung disease, ITP, autoimmune thyroiditis, infertility, growth hormone and adrenal deficiencies, osteoporosis, and potentially lung and thyroid cancers. However, in many cases, the current evidence is divergent and cannot sufficiently confirm a true association, which emphasizes the need for future targeted projects in this field.

Bone health in HIV and hepatitis B or C infections

Chronic infections with human immunodeficiency virus (HIV), hepatitis B virus (HBV) or hepatitis C virus (HCV) add to age-dependent bone loss and may contribute to lower bone strength in the elderly. In this review, we report recent highlights on the epidemiology of bone fragility in chronic viral infections with HIV, HCV and HBV, its physiopathology and discuss the interference of antiviral therapies with bone metabolism. Chronic infections influence bone through the interactions between risk factors for bone fragility and falls (which are highly prevalent in infected patients), virus activity and antiviral drugs. HIV-infected patients are at increased risk of fracture and the risk is higher in cases of co-infection with HIV and untreated chronic viral hepatitis. In HIV patients, the majority of bone loss occurs during virus activity and at initiation of antiretroviral therapy (ART). However, long-term elderly HIV-infected patients on successful ART display bone microstructure alterations only partially captured by dual energy X-ray absorptiometry (DXA). Bone loss is associated with an increase of bone resorption, reflecting the upregulation of the receptor activator of nuclear factor-kappaB ligand (RANKL) and osteoprotegerin (OPG) pathways via a crosstalk between virus activity, inflammation and the immune system. The use of some antiviral drugs, such as tenofovir (controlling both HBV and HIV infections) or protease inhibitors, may be associated with higher bone toxicity. The reduction of tenofovir plasma concentrations with the implementation of tenofovir alafenamide (TAF) attenuates bone mineral density (BMD) loss but it remains unknown whether it will contribute to reducing fracture risk in long-term HIV-treated patients. Moreover, to what extent the new direct-acting agents for treatment of HCV, including nucleotide inhibitors and protease inhibitors, may affect bone health similarly as ART in HIV should be investigated.

Hepatitis C virus infection and risk of osteoporosis: A meta-analysis

BACKGROUND/AIMS

Hepatitis C virus (HCV) infection is one of the most common infections worldwide. Several epidemiologic studies have suggested that patients with HCV infection might be at an increased risk of osteoporosis. However, the data on this relationship remains inconclusive. This meta-analysis was conducted with the aim to summarize all available evidence.

MATERIALS AND METHODS

A literature search was performed using MEDLINE and EMBASE databases from inception to June 2016. Studies that reported relative risks, odd ratios (OR), or hazard ratios comparing the risk of osteoporosis among HCV-infected patients versus those without HCV infection were included. Pooled OR and 95% confidence interval (CI) were calculated using a random-effect, generic inverse variance method.

RESULTS

Four studies met our eligibility criteria and were included in the analysis. We found a higher risk of osteoporosis among patients with chronic HCV with OR of 1.65 (95% CI: 0.98-2.77). Sensitivity analysis including only studies with higher quality yielded a higher OR, and the result was statistically significant (OR: 2.47; 95% CI: 1.03-5.93).

CONCLUSIONS

Our study demonstrated a higher risk of osteoporosis among HCV-infected patients. Further studies are required to clarify how this risk should be addressed in clinical practice.

Relation Between Hepatitis C Virus Exposure and Risk of Osteoporosis: A Nationwide Population-Based Study

The effect of hepatitis C virus (HCV) exposure on bone mineral density without advanced liver disease remains debated. Thus, we assessed the relation between HCV exposure and the risk of osteoporosis.From 2000 to 2011, patients aged >20 years with HCV exposure were identified from the Longitudinal Health Insurance Database 2000. Of the 51,535 sampled patients, 41,228 and 10,307 patients were categorized as the comparison and the HCV exposure cohorts, respectively.The overall incidence of osteoporosis in the HCV exposure cohort was higher than in the comparison cohort (8.27 vs 6.19 per 1000 person-years; crude hazard ratio = 1.33, 95% confidence interval = 1.20-1.47). The incidence of osteoporosis, higher in women than in men, increased with age and comorbidity of hypertension, hyperlipidemia, and heart failure. The risk of developing osteoporosis was significantly higher in the HCV exposure cohort than in the comparison cohort after adjusting for age, sex, diabetes, hypertension, hyperlipidemia, heart failure, stroke, and cirrhosis. However, the risk of osteoporosis contributed by HCV decreased with age and the presence of comorbidity. Furthermore, the risk of osteoporotic fracture did not differ significantly between patients exposed to HCV and the comparison cohorts.HCV increases the risk of osteoporosis, but no detrimental effect on osteoporotic fracture was observed in this study. Furthermore, HCV may be less influential than other risk factors, such as hypertension, hyperlipidemia, and heart failure, in contributing to the development of osteoporosis.

Bone alterations associated with HIV

HIV infection and initiation of antiretroviral therapy (ART) have been consistently associated with decreased bone mineral density (BMD), with growing evidence linking HIV to an increased risk of fracture. This is especially concerning with the expanding number of older persons living with HIV. Interestingly, recent data suggest that HIV-infected children and youth fail to achieve peak BMD, possibly increasing their lifetime risk of fracture. Elucidating the causes of the bone changes in HIV-positive persons is challenging because of the multifactorial nature of bone disease in HIV, including contribution of the virus, immunosuppression, ART toxicity, and traditional osteoporosis risk factors, such as age, lower weight, tobacco, and alcohol use. Thus, practitioners must recognize the risk of low BMD and fractures and appropriately screen patients for osteoporosis if risk factors exist. If fractures do occur or elevated fracture risk is detected through screening, treatment with bisphosphonate medications appears safe and effective in the HIV+population.

Inflammatory co-morbidities in HIV+ individuals: learning lessons from healthy ageing

Increased life expectancy due to improved efficacy of cART has uncovered an increased risk of age-related morbidities in HIV+ individuals and catalyzed significant research into mechanisms driving these diseases. HIV infection increases the risk of non-communicable diseases common in the aged, including cardiovascular disease, neurocognitive decline, non-AIDS malignancies, osteoporosis, and frailty. These observations suggest that HIV accelerates immunological ageing, and there are many immunological similarities with the aged, including shortened telomeres, accumulation of senescent T cells and altered monocyte phenotype/function. However, the most critical similarity between HIV+ individuals and the elderly, which most likely underpins the heightened risk of non-communicable diseases, is chronic inflammation and associated immune activation. Here, we review the similarities between HIV+ individuals and the aged regarding the pathogenesis of inflammatory diseases, the current evidence for mechanisms driving these processes and discuss current and potential therapeutic strategies for addressing inflammatory co-morbidity in HIV+ infection.

Osteoporosis and fractures in HIV/hepatitis C virus coinfection: a systematic review and meta-analysis

OBJECTIVE

There is growing evidence that fracture risk is increased in individuals with HIV and/or hepatitis C virus (HCV) infection. We systematically reviewed the literature to determine whether prevalence of osteoporosis and incidence of fracture is increased in HIV/HCV-coinfected individuals.

DESIGN

A systematic review and meta-analysis.

METHODS

A search was performed of Medline, Scopus and the Cochrane Library databases, as well as of abstracts from annual retroviral, liver and bone meetings (up to 2013) for studies with bone mineral density (BMD) or bone fracture data for HIV/ HCV-coinfected individuals. Osteoporosis odds ratios (ORs) and fracture incidence rate ratios (IRRs) were estimated from studies with data on HIV-monoinfected or HIV/HCV uninfected comparison groups.

RESULTS

Of 15 included studies, nine reported BMD data and six reported fracture data. For HIV/HCV-coinfected, the estimated osteoporosis prevalence was 22% [95% confidence interval (95% CI) 12–31] and the crude OR for osteoporosis compared with HIV-monoinfected was 1.63 (95% CI 1.27-2.11). The pooled IRR of overall fracture risk for HIV/HCV-coinfected individuals was 1.77 (95% CI 1.44-2.18) compared with HIV-monoinfected and 2.95 (95% CI 2.17-4.01) compared with uninfected individuals. In addition to HIV/HCV-coinfection, older age, lower BMI, smoking, alcohol and substance use were significant predictors of osteoporosis and fractures across studies.

CONCLUSION

HIV/HCV coinfection is associated with a greater risk of osteoporosis and fracture than HIV monoinfection; fracture risk is even greater than uninfected controls. These data suggest that HIV/HCV-coinfected individuals should be targeted for fracture prevention through risk factor modification at all ages and DXA screening at age 50.

Areal bone mineral density in pediatric patients with chronic hepatitis B or chronic hepatitis C

Decreased bone mineral density (BMD) is a known complication of chronic liver disease in adults. Data on bone mass, an important factor for the development of osteoporosis in adult life, in young patients with chronic hepatitis B (HBV) and C virus (HCV) infections are scarce. We measured BMD at the lumbar spine and whole skeleton by dual-energy X-ray absorptiometry in 11 HBV- and 21 HCV-vertically infected untreated youths (3.9-21.1 years). BMD measurements were compared to those of 202 healthy subjects (3.0-21.9 years). The median BMD Z-score of the lumbar spine of HBV-infected patients was -0.3, ranging from -1.6 to 0.6, while the median whole skeleton BMD Z-score was 0.1 (-0.8 to 0.6). HBV-infected patients showed a median Z-score of the lumbar spine of 0.6 (-1.6 to 1.9), and a median whole skeleton BMD Z-score of 0.6, ranging from -1.5 to 1.4. Multivariate analyses have been performed to correct for differences in sex, age, and anthropometric measurements. Lumbar spine BMD values of HBV and HCV-infected patients were not significantly different from those of controls. Similarly, no differences were found between groups in total body BMD measurements. Our data suggest that, unlikely adult patients, untreated young patients with chronic HBV and HCV infection may not have impaired bone mass measurements.

Fracture risk in hepatitis C virus infected persons: results from the DANVIR cohort study

BACKGROUND & AIMS

The association between Hepatitis C virus (HCV)-infection and fracture risk is not well characterized. We compared fracture risk between HCV-seropositive (HCV-exposed) patients and the general population and between patients with cleared and chronic HCV-infection.

METHODS

Outcome measures were time to first fracture at any site, time to first low-energy and first non-low-energy (other) fracture in 12,013 HCV-exposed patients from the DANVIR cohort compared with a general population control cohort (n=60,065) matched by sex and age. Within DANVIR, 4500 patients with chronic HCV-infection and 2656 patients with cleared HCV-infection were studied.

RESULTS

Compared with population controls, HCV-exposed patients had increased overall risk of fracture [adjusted incidence rate ratio (aIRR) 2.15, 95% Confidence Interval (CI) 2.03-2.28], increased risk of low-energy fracture (aIRR 2.13, 95% CI: 1.93-2.35) and of other fracture (aIRR 2.18, 95% CI: 2.02-2.34). Compared with cleared HCV-infection, chronic HCV-infection was not associated with increased risk of fracture at any site (aIRR 1.08, 95% CI: 0.97-1.20), or other fracture (aIRR 1.04, 95% CI: 0.91-1.19). The aIRR for low-energy fracture was 1.20 (95% CI: 0.99-1.44).

CONCLUSIONS

HCV-exposed patients had increased risk of all fracture types. In contrast, overall risk of fracture did not differ between patients with chronic vs. cleared HCV-infection, although chronic HCV-infection might be associated with a small excess risk of low-energy fractures. Our study suggests that fracture risk in HCV-infected patients is multi-factorial and mainly determined by lifestyle-related factors associated with HCV-exposure.

Bone mineral density and bone turnover in non-cirrhotic patients with chronic hepatitis C and sustained virological response to antiviral therapy with peginterferon-alfa and ribavirin

Patients with chronic hepatitis C have low bone mineral density and increased bone resorption related to serum transaminase levels. Elevated serum soluble tumor necrosis factor (sTNFR-55) receptor levels may play a role in the bone mass loss in these patients. Bone mass is improved and bone turnover normalized in patients who respond to antiviral therapy with interferon and ribavirin.

INTRODUCTION

Low bone mineral density (BMD) has been described in patients with chronic hepatitis C (HCV). The study objective was to evaluate the effect of antiviral therapy on BMD and bone metabolism in non-cirrhotic HCV patients with sustained virological response.

METHODS

We conducted a prospective study in 36 consecutive outpatients from the general community with non-cirrhotic HCV and an early and sustained virological response to peginterferon-alfa and ribavirin therapy. Determinations of BMD (dual X-ray absorptiometry at lumbar spine and femoral neck) and biochemical measurements of bone metabolism and sTNFR-55 were made at baseline, after 24 and 48 weeks of antiviral therapy, and at 48 weeks after the end of treatment.

RESULTS

Patients had a significantly reduced BMD, which significantly increased during the follow-up. Serum levels of sTNFR-55 and bone turnover markers were increased at baseline and significantly reduced at all subsequent time points. We found an inverse correlation between BMD and both serum aminotransferase levels and urine deoxypyridinoline (D-pyr) and a positive correlation between serum aminotransferases and both urine D-Pyr and serum sTNFR-55.

CONCLUSIONS

Patients with chronic hepatitis C have low bone mass associated with increased bone resorption, and some relationship can be expected between serum aminotransferase levels and the degree of bone mass loss. Bone mass may be improved and bone turnover normalized in patients who respond to antiviral therapy. Elevated serum sTRFR-55 levels may play a role in the bone mass loss of these patients.

Prevalence of causes of secondary osteoporosis and contribution to lower bone mineral density in HIV-infected patients

SUMMARY

Eighty-one percent of human immunodeficiency virus (HIV)-infected patients had one or more of seven evaluated causes of secondary osteoporosis, and this rate increases with age. The type and number of causes were associated with a lower bone mineral density (BMD), and with an increased rate of osteopenia/osteoporosis, regardless of age and body mass index.

INTRODUCTION

The objective of this study was to determine whether factors of secondary osteoporosis were associated with lower BMD in HIV.

METHODS

This was a cross-sectional study of 285 HIV-infected patients (25 % females) evaluating the impact of seven different factors of reduced BMD: hyperthyroidism, diabetes, chronic viral hepatitis, chronic kidney disease (CKD), hypovitaminosis D, secondary hyperparathyroidism, and hypogonadism. Dual-energy X-ray absorptiometry scan of the femoral neck was obtained at the clinical visit.

RESULTS

Mean age was 45.7 years; osteopenia and osteoporosis were diagnosed in 38 and 6 %, respectively. Overall, 230 patients (81 %) had secondary factors; 107 (38 %) had only 1 cause, 94 (33 %) had 2, and 28 (10 %) had 3 or more, predominantly vitamin D deficiency in 61 %, hepatitis C virus coinfection in 45 %, and secondary hyperparathyroidism in 27 %. The number of secondary factors was closely related to a lower BMD, which is statistically significant for patients having ≥2 causes (0.77 vs 0.73 g/cm(2), p = 0.02). The rate of osteopenia ranged from 36 % without any cause to 57 % with three or more, osteoporosis from 0 to 19 %, and Z-score <-2 SD from 0 to 27 %, respectively. In a multivariate linear regression, adjusting by age, body mass index, and HIV-related factors, the number of secondary factors was independently associated with a lower BMD (ß coefficient -0.134; p = 0.02), mainly due to patients with hepatitis C virus (HCV) coinfection, secondary hyperparathyroidism, and CKD.

CONCLUSIONS

A high prevalence of secondary causes of osteoporosis is observed in HIV-infected patients, and its type and cumulative number determine a lower BMD, after adjusting by age and body mass index.

Per oral substitution with 300000 IU vitamin D (Cholecalciferol) reduces bone turnover markers in HIV-infected patients

Background

Osteoporosis and bone fractures seem to be higher in HIV-infected Patients compared to the general populations. Moreover, bone turnover markers are increased in patients on antiretroviral therapy and vitamin D deficiency is prevalent in HIV-infected patients. However, the influence of per oral cholecalciferol on bone metabolism in HIV infected patients is not well understood.

Methods

We measured the bone turnover markers in 96 HIV-infected patients: Bone specific alkaline phosphatase (BSAP), Pyridinoline (PYR), Desoxypyridinoline (DPD) and 25-OH vitamin D. If 25-OH vitamin D was below 75 nnol/L (87/96 patients), 300000 IU cholecalciferol was given per os. 25OH-vitamin D and bone turn over markers were determinded 3 month later. 25 OH-vitamin D was corrected for circannual rythm y'=y+17.875*sin2π365*day+2.06, whereas bone turnover markers were not corrected. The paired students t-Test was used to compare the two periods. No calcium supplementation or biphosphonate therapy was given.

Results

Corrected 25OH-vitamin D levels increased significantly after supplementation (42.7 ± 26.61 vs. 52.85 ± 21.8 nmol/L, p < 0.001). After supplementation, bone turnover markers were significantly lower. The values decreased for BSAP from 21.31 ± 14.32 to 17.53 ± 8.17 μg/L (p < 0.001), PYR from 74.57 ± 36.83 to 54.82 ± 21.43 nmol/mmol creatinine (p < 0.001) and DPD from 15.17 ± 8.34 to 12.61 ± 5.02 nmol/mmol creatinine (p = 0.01).

Conclusions

After per oral substitution with cholecalciferol, bone formation as well as bone resorption markers decreased significant. We postulate a protective effect on bone structure with cholecalciferol supplementation.

Bone disease in patients awaiting liver transplantation. Has the situation improved in the last two decades?

In recent years, there has been speculation about the possibility of a reduction in the incidence of fractures after liver transplantation (LT) because of changes in the characteristics of candidates and the use of different immunosuppressive therapies. We analyzed the characteristics of LT candidates (CTC) and compared them with historical data from a group of LT candidate patients (HTC). Data from 60 CTC patients consecutively included in a screening program of metabolic bone disease were compared with data from 60 HTC patients prospectively evaluated between 1992 and 1993. In all patients, we analyzed the clinical and laboratory characteristics, bone mineral density (BMD) dual-energy X-ray absorptiometry, and skeletal fractures. Patients in the CTC group were older than patients in the HTC group. The CTC group had lower femoral neck T scores. No differences were observed between groups in the proportion of patients with osteoporosis (22 vs. 30 %, p = ns) or fractures (36 vs. 33 %, p = ns). The percentage of patients with normal BMD decreased from 38 to 20 %. 25(OH)D values were low in both groups. Only 7.5 % of the CTC patients received calcium and/or vitamin D supplementation. The prevalence of fractures among CTC patients was similar to that seen two decades ago. At present, candidates for LT are older and have lower femoral bone mass. Vitamin D deficiency remains frequent; however, calcium and/or vitamin D supplementation is uncommon.