Hepatic osteodystrophy is common in patients with noncholestatic liver disease

Advancements in the pathogenesis of hepatic osteodystrophy and the potential therapeutic of mesenchymal stromal cells

Hepatic osteodystrophy (HOD) is a metabolically associated bone disease mainly manifested as osteoporosis with the characteristic of bone loss induced by chronic liver disease (CLD). Due to its high incidence in CLD patients and increased risk of fracture, the research on HOD has received considerable interest. The specific pathogenesis of HOD has not been fully revealed. While it is widely believed that disturbance of hormone level, abnormal secretion of cytokines and damage of intestinal barrier caused by CLD might jointly affect the bone metabolic balance of bone formation and bone absorption. At present, the treatment of HOD is mainly to alleviate the bone loss by drug treatment, but the efficacy and safety are not satisfactory. Mesenchymal stromal cells (MSCs) are cells with multidirectional differentiation potential, cell transplantation therapy based on MSCs is an emerging therapeutic approach. This review mainly summarized the pathogenesis and treatment of HOD, reviewed the research progress of MSCs therapy and the combination of MSCs and scaffolds in the application of osteoporotic bone defects, and discussed the potential and limitations of MSCs therapy, providing theoretical basis for subsequent studies.

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.

Patients With Cirrhosis Have Elevated Bone Turnover but Normal Hepatic Production of Osteoprotegerin

CONTEXT

Severe osteodystrophy is common in patients with liver dysfunction. Markers of bone metabolism may help in early diagnosis of osteodystrophy and in understanding underlying pathophysiological mechanisms.

OBJECTIVE

To elucidate changes in bone metabolism associated with cirrhosis and to determine the route of elimination for the markers.

METHODS

Case-control study at a public university hospital. Fifty-nine patients with cirrhosis (47 alcoholic and 12 nonalcoholic cirrhosis) and 20 controls were included. Participants underwent catheterization of the femoral artery, and the hepatic, renal, and femoral veins with collection of blood from all 4 sites. Regional arteriovenous differences in concentrations of bone metabolism markers were determined: procollagen of type I collagen propeptide (PINP), C-terminal cross-linking telopeptide of type I collagen (CTX), osteocalcin, tartrate-resistant acid phosphatase isoform 5b (TRAcP5b), osteoprotegerin (OPG), and sclerostin and correlated with degree of disease (Child-Pugh classification).

RESULTS

PINP concentration was higher (median: 87.9 µg/L) in patients with cirrhosis than in controls (52.6 µg/L) (P = .001), while hepatic extraction was lower (4.3% vs 14.5%) (P < .001). Both CTX and TRAcP5b were higher in patients with cirrhosis (340 ng/L and 3.20 U/L) than in controls (215 ng/L and 1.60 U/L) (P < .001 and P < .0001). Hepatic sclerostin extraction was lower in patients with cirrhosis (14.6%) than in controls (28.7%) (P < .0001). In both groups OPG showed a hepatic release rate (production) of 6%.

CONCLUSION

Patients with cirrhosis have increased bone resorption, but unaltered bone formation. Sclerostin is eliminated through the liver while OPG is produced in the liver. Bone markers may prove useful in evaluating bone turnover in patients with cirrhosis.

High Prevalence of Hormonal Changes and Hepatic Osteodystrophy in Frail Patients with Cirrhosis-An Observational Study

BACKGROUND/AIM

Hormonal changes and hepatic osteodystrophy are less often studied complications of cirrhosis. This study describes the variance in hormones and osteodystrophy between Frail and Not frail patients with cirrhosis.

METHODS

116 outpatients with cirrhosis were prospectively enrolled in this study. Frailty assessment was done using Liver Frailty Index (LFI). Sociodemographic assessment, anthropometry, nutritional assessment, hormone profile, and dual-energy X-ray absorptiometry scan were done in all patients.

RESULTS

116 patients, predominantly males (100 (86.2%) with mean age of 50.16 years (95% CI, 48.43-51.89) were included. Malnutrition was more common in Frail group as compared to Not frail group. Subjective global assessment (SGA) class-B patients were significantly more in Frail group (37 (74%) vs 3 (4.5%), P = 0.001). The prevalence of lower parathyroid hormone (PTH) (14 (28%) vs 2 (3%)), testosterone (33 (66%) vs 15 (22.7%)), vitamin D3 (44 (88%) vs 39 (59.1%)), and cortisol (37 (74%) vs 37 (56.1) levels was higher in Frail group (P < 0.05). The number of patients diagnosed with osteodystrophy (34 (68%) vs 21 (31.8%), P = 0.001) was significantly higher in Frail group. The marker of osteoclastic activity, β-cross laps, was significantly elevated in the Frail group both in males (736 (655-818) vs 380 (329-432), P = 0.001) and (females 619 (479-758) vs 313 (83-543), P = 0.02). Bone mineral density (BMD) at lumbar spine (LS) and neck of femur (NF) had significant correlation with LFI (ρ = 0.60, P = 0.001 for LS and ρ = 0.59, P = 0.001 for NF), serum testosterone (ρ = 0.58, P = 0.001 for LS and ρ = 0.53, P = 0.001 for NF), β-cross laps (ρ = 0.38, P = 0.001for LS and ρ = 0.35, P = 0.000 for NF), vitamin D3 (ρ = 0.23, P = 0.04 for LS and ρ = 0.25, P = 0.01 for NF), PTH (ρ = 0.52, P = 0.001 for LS and ρ = 0.48. P = 0.001 for NF), and cortisol (ρ = 0.50, P = 0.001 for LS and ρ = 0.45, P = 0.001 for NF) levels.

CONCLUSION

This is the first study that highlights the high prevalence of hormonal changes and hepatic osteodystrophy in frail patients with cirrhosis and opens a new dimension for research and target of therapy in this field.

Common musculoskeletal disorders in chronic liver disease patients

Chronic liver disease (CLD) is the commonest ailment affecting the hepatobiliary system. Six significant pathologies related to CLD include hepatic osteodystrophy (HO), increased infection susceptibility, sarcopenia, osteonecrosis of the femoral head (OFH), increased risk of periprosthetic complications and fracture. Hepatic osteodystrophy, which comprises osteopenia, osteoporosis, and osteomalacia, refers to alterations in bone mineral metabolism found in patients with CLD. The HO prevalence ranges from 13 to 95%. Low complement levels, poor opsonization capacity, portosystemic shunting, decreased albumin levels, and impaired reticuloendothelial system make the cirrhotic patients more susceptible to developing infectious diseases. Septic arthritis, osteomyelitis, prosthetic joint infection, and cellulitis were common types of CLD-associated infectious conditions. The incidence of septic arthritis is 1.5 to 2-fold higher in patients with cirrhosis. Sarcopenia, also known as muscle wasting, is one of the frequently overlooked manifestations of CLD. Sarcopenia has been shown to be independent predictor of longer mechanical ventilation, hospital stay, and 12-month mortality of post-transplantation. Alcohol and steroid abuse commonly associated with CLD are the two most important contributory factors for non-traumatic osteonecrosis. However, many studies have identified cirrhosis alone to be an independent cause of atraumatic osteonecrosis. The risk of developing OFH in cirrhosis patients increases by 2.4 folds and the need for total hip arthroplasty increases by 10 folds. Liver disease has been associated with worse outcomes and higher costs after arthroplasty. Cirrhosis is a risk factor for arthroplasty complications and is associated with a prolonged hospital stay, higher costs, readmission rates, and increased mortality after arthroplasty. Greater physician awareness of risk factors associated with musculoskeletal complications of CLD patients would yield earlier interventions, lower healthcare costs, and better overall clinical outcomes for this group of patients.

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.

Nutrition in Chronic Liver Disease: Consensus Statement of the Indian National Association for Study of the Liver

Malnutrition and sarcopenia are common in patients with chronic liver disease and are associated with increased risk of decompensation, infections, wait-list mortality and poorer outcomes after liver transplantation. Assessment of nutritional status and management of malnutrition are therefore essential to improve outcomes in patients with chronic liver disease. This consensus statement of the Indian National Association for Study of the Liver provides a comprehensive review of nutrition in chronic liver disease and gives recommendations for nutritional screening and treatment in specific clinical scenarios of malnutrition in cirrhosis in adults as well as children with chronic liver disease and metabolic disorders.

Long-term Management of the Adult Liver Transplantation Recipients

The survival of liver transplantation (LT) recipients has been improved remarkably in short-term. The major causes of mortality in long-term include nonimmunological causes such as cardiovascular, de novo malignancy, chronic kidney disease, and recurrence of primary disease. Rejection-related mortality is rare in the long-term after LT. We discuss nonrejection causes of long-term morbidity/mortality, risk factors, and management strategies in LT recipients. In addition, we discuss osteoporosis, contraception, and pregnancy in LT recipients.

Prevalence and Trends in Low Bone Density, Osteopenia and Osteoporosis in U.S. Adults With Non-Alcoholic Fatty Liver Disease, 2005-2014

BACKGROUND & AIMS

Non-alcoholic fatty liver disease (NAFLD) is suggested to be associated with bone mineral density (BMD) alterations; however, this has not been ascertained. The current study aimed to investigate the changes in BMD and the prevalence of osteopenia/osteoporosis in US adults with or without NAFLD and to evaluate their association.

METHODS

The study was conducted based on data collected from the U.S. National Health and Nutrition Examination Survey (NHANES) during the period 2005-2014. A total of 13 837 and 6 177 participants aged > 20 years were eligible for conducting the Hepatic Steatosis Index (HSI) and the US Fatty Liver Index (USFLI) analysis, respectively.

RESULTS

From 2005-2014, a downward trend in femoral neck BMD was observed in subjects with NAFLD aged ≥ 40. After adjustment for potential confounders, an upward shift occurred in the prevalence of osteopenia/osteoporosis at the femoral neck in adults aged ≥ 40, particularly in women ≥ 60 years old and men below the age of 60. Moreover, a negative association was found between BMD and NAFLD markers (USFLI, HSI), whereas NAFLD with advanced fibrosis was positively associated with the prevalence of spine fractures.

CONCLUSIONS

There was a trend toward lower BMD and higher prevalence of osteopenia/osteoporosis at the femoral neck in US adults with NAFLD aged ≥ 40 years during the period of 2005-2014. NAFLD with advanced fibrosis was positively associated with a higher risk of spine fracture. More research is required to fully investigate the mechanism and consequence of poor bone health in NAFLD patients and consider optimum management of osteopenia/osteoporosis for this population.

Hepatic osteodystrophy in cirrhosis due to alcohol-related liver disease

INTRODUCTION

hepatic osteodystrophy, including osteoporosis, is an abnormal bone metabolism related with chronic liver diseases. Osteoporosis is associated with an increased risk of bone fractures, with a significant impact on morbidity, mortality and healthcare costs. Nevertheless, bone disorders tend to be undervalued in cirrhosis due to alcohol-related liver disease (ALD cirrhosis). This study aimed to assess the prevalence of hepatic osteodystrophy and osteoporosis in ALD cirrhosis.

METHODS

a prospective observational study was performed that included patients with ALD cirrhosis, between September 2017 and December 2018. Bone mineral density was determined by dual energy X-ray absorptiometry at the lumbar spine and the femoral neck. Hepatic osteodystrophy was defined as a T-score below -1 SD and osteoporosis as a T-score below -2.5 SD.

RESULTS

ninety-four patients were included; 24.5 % (n = 23) had prior fragility fractures and ten patients suffered new osteoporotic fractures during the study period. Hepatic osteodystrophy was diagnosed in 79.8 % (n = 75) and osteoporosis in 21.3 % (n = 20) of cases. Patients with hepatic osteodystrophy presented significantly worse Child-Turcotte-Pugh (p < 0.05) and Model for End-Stage Liver Disease (MELD-sodium) scores (p = 0.01). According to the multivariate analysis, lower body mass index (BMI) (OR = 0.787, 95 % CI: 0.688-0.901, p = 0.001) and vitamin D deficiency (OR = 6.798, 95 % CI: 1.775-26.038, p = 0.005) were significantly and independently associated with hepatic osteodystrophy. Patients with osteoporosis also had a lower BMI (p = 0.01). Female patients and those with prior fragility fractures were more likely to suffer from osteoporosis (p < 0.05).

CONCLUSION

our study revealed a high prevalence of hepatic osteodystrophy and osteoporosis in patients with ALD cirrhosis (particularly in those with a lower BMI) and a concerning high rate of fragility fractures. Bone mineral density should be assessed in order to allow for an early diagnosis and the implementation of preventive measures.

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.

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.

Vitamin D and Chronic Diseases

Vitamin D is one of the essential nutrients to sustain the human health. As a member of the steroid hormone family, it has a classic role in regulating metabolism of calcium and a non-classic role in affecting cell proliferation and differentiation. Epidemiological studies have shown that 25OHD deficiency is closely associated with common chronic diseases such as bone metabolic disorders, tumors, cardiovascular diseases, and diabetes. 25OHD deficiency is also a risk factor for neuropsychiatric disorders and autoimmune diseases. 25OHD deficiency is highly prevalent in the world. It is therefore necessary to know the adverse health effects of 25OHD deficiency, and to design interventions and early treatments for those who are likely to have low levels of 25OHD.

Vitamin D status in patients with cirrhosis of the liver and their relatives-A case control study from North India

BACKGROUND AND AIM

Liver diseases interfere with the production of the metabolites of vitamin D required for activation, thus resulting in abnormal calcium and bone metabolism. Previous studies show inconsistent results of vitamin D level in non-cholestatic liver diseases. Our aim was to determine the prevalence of vitamin D insufficiency in cirrhosis as compared to apparently normal relatives and its relationship with etiology and severity.

METHODS

One hundred and sixty cirrhotic patients attending the Department of Gastroenterology and Hepatology, M L N Medical College, Allahabad, were enrolled, and 25-hydroxy vitamin D [25(OH)D] and calcium levels assessed. Vitamin D status was graded as insufficiency (20-30 ng/mL), deficiency (<20 ng/mL), and severe deficiency (<7 ng/mL). 25(OH)D levels of patients were compared with those of their healthy family members.

RESULTS

Forty-six percent of the normal population had 25(OH)D inadequacy, whereas 51.85% of patients with cirrhosis had 25(OH)D deficiency, and 28.12% had insufficiency. Thus, 80% of patients with cirrhosis of the liver had some form of vitamin D inadequacy. 12.5% of cirrhotics had severe vitamin D deficiency. Serum calcium (Ca⁺⁺) was not significantly different between the patients and control group. The etiology of cirrhosis had no relation with vitamin D levels. Prevalence of deficiency and insufficiency increased with increasing age and mean Child-Turcotte-Pugh and model for end-stage liver disease scores.

CONCLUSION

Vitamin D insufficiency is highly prevalent in patients with cirrhosis irrespective of etiology and significantly more common than their healthy relatives. Measurement of 25(OH) vitamin D and replacement may be considered as part of the overall management of patients with cirrhosis of the liver as well as apparently healthy individuals.

Study of Hepatic Osteodystrophy in Patients with Chronic Liver Disease

INTRODUCTION

Chronic Liver Disease (CLD) is a major cause of morbidity and mortality worldwide. It involves haemodynamic and metabolic complications. Hepatic Osteodystrophy is a metabolic bone disease that may occur in individuals with chronic liver disease. It can significantly affect morbidity and quality of life of these patients. Fractures are also associated with an excess mortality. It has been an under recognized and inadequately studied complication among Indian population. An early diagnosis is essential to correct reversible risk factors which predispose to bone mass loss.

AIM

To assess the prevalence of metabolic bone disease and identify the risk factors associated with hepatic osteodystrophy in patients with cirrhosis.

MATERIALS AND METHODS

This was an observational, cross-sectional, hospital based study conducted at a medical college hospital. All patients more than 20-year-old, diagnosed with chronic liver disease/Cirrhosis were enrolled. They were subjected to haematological, biochemical investigations, evaluation of Vitamin D and other hormonal parameters. Bone Mineral Density (BMD) was estimated by Dual Energy X-ray Absorptiometry (DEXA).

RESULTS

A total of 72 patients with mean age 50.04±11.24 years were included in the study. Amongst causes of chronic liver disease were alcoholic liver disease 22 (30.6%), CLD due to hepatitis B 24 (33.3%) and chronic hepatitis C 26 (36.1%). Twenty one (29.2%) patients had normal BMD while 51 (70.8%) had a low BMD. Out of these 51 patients, 36 (70.6%) were diagnosed of osteopenia and 15 (29.4%) others were found to have osteoporosis. Vitamin D levels and severity of liver disease had correlation with low BMD.

CONCLUSION

Low BMD is highly prevalent in patients with chronic liver disease of variable aetiologies. We advocate more randomised and prospective studies to be conducted on homogeneous groups with chronic liver disease in its various stages. In view of numerous therapeutic options available both for liver disease and bone disease, it is prudent to characterize this condition in order to give these patients a better chance of survival with good quality of life.

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.

Liver Transplantation for Alcohol-Related Liver Disease

Alcoholic liver disease (ALD) is a common indication for liver transplantation. It is a much debated indication for deceased donor liver transplantation due to organ shortage and potential of alcohol relapse after liver transplantation. A six-month abstinence before liver transplantation is required at most centers to decrease chances of alcohol relapse after liver transplantation. However, this rule is not relevant for patients with severe alcoholic hepatitis or severely decompensated patients who are unlikely to survive till 6 months. Long-term care of these patients after liver transplantation includes assessment of relapse, smoking, and surveillance of de novo malignancies. Current review discusses role of abstinence, factors affecting alcohol relapse, liver transplantation for alcoholic hepatitis, role of living donor liver transplantation, and long-term care of ALD patients who undergo liver transplantation.

Lower relapse rates with good post-transplant outcome in alcoholic liver disease: Experience from a living donor liver transplant center

INTRODUCTION

Post-transplant relapse is a major factor influencing the long-term outcome in alcoholic liver disease (ALD) patients.

AIMS

The aim of this study was to evaluate the relapse rates following living donor liver transplantation (LDLT) in patients with ALD in the Indian context with strong family support.

METHODS

Of 458 patients who underwent LDLT for ALD, 408 were included in the study. Post-transplant relapse was determined by information provided by the patient and/or family by means of outpatient and e-mail questionnaire, supported by clinical/biochemical parameters/liver histopathology.

RESULTS

All except one were males, with a mean age of 46.9 ± 8.5 years. The overall rate of relapse was 9.5 % at 34.7 months (interquartile range (IQR) 15-57.6), lower than that reported in the literature from the West. The relapse rate was higher in patients with a shorter duration of pre-transplant abstinence (17.4 % and 15.4 % for recipients with pre-transplant abstinence of <3 and <6 months, respectively, p < 0.05). The overall survival was 88.5 % at 3 years. Of 39 patients with relapse, 16 (41 %) were occasional drinkers, 14 (35.8 %) were moderate drinkers, and 9 (23 %) were heavy drinkers. All the heavy drinkers presented with features of graft dysfunction.

CONCLUSIONS

Good results can be obtained following LDLT for ALD, with significantly lower relapse rates in our setup as compared to the West.

Nonalcoholic fatty liver disease and decreased bone mineral density: is there a link?

PURPOSE

Liver diseases are associated with decreased bone mineral density (BMD) and evidence suggests that nonalcoholic fatty liver disease (NAFLD) affects several extra-hepatic organs, interacting with the regulation of multiple endocrine and metabolic pathways. This review focuses on the rapidly expanding body of evidence that supports a strong association between NAFLD and the risk of decreased BMD, expression of low bone mass (osteoporosis), or reduced mineralization (osteomalacia).

METHODS

We identified studies by searching PubMed for original articles published in English through March 2015 using the keywords "nonalcoholic fatty liver disease" or "fatty liver" combined with "bone mineral density", "osteoporosis", or "osteomalacia".

RESULTS

Recent cross-sectional and case-control studies involving both adults and children have consistently shown that patients with NAFLD exhibit a greater prevalence of decreased BMD compared with age-, sex-, and body mass index-matched healthy controls. Accumulating clinical and experimental evidence suggests that NAFLD may contribute to the pathophysiology of low BMD, possibly through the direct contribution of NAFLD to whole-body and hepatic insulin resistance and/or the systemic release of multiple pro-inflammatory, pro-coagulant, and pro-fibrogenic mediators.

CONCLUSIONS

Although more research is needed before firm conclusions can be drawn, it appears that there is a non-chance, statistical association between NAFLD and low BMD. This finding argues for more careful monitoring and evaluation of BMD among patients with NAFLD. The potential contribution of NAFLD itself to the development and progression of decreased BMD warrants further study.

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.

Prospective study of profile of hepatic osteodystrophy in patients with non-choleastatic liver cirrhosis and impact of bisphosphonate supplementation

BACKGROUND AND OBJECTIVES

Patients with liver cirrhosis are more prone to develop reduced bone mineral density (BMD), i.e. hepatic osteodystrophy (HOD). There are few data on the prevalence of HOD in the Indian population and its treatment. We aimed to determine the prevalence of HOD, factors associated with it and the impact of bisphosphonates on BMD in patients with liver cirrhosis.

PATIENTS AND METHODS

Consecutive patients with liver cirrhosis admitted at Sir Ganga Ram Hospital, New Delhi, between August 2012 and July 2013 were enrolled. Patients with chronic kidney disease, hyperparathyroidism and those on steroids were excluded. BMD was measured by dual-energy X-ray absorptiometry (DEXA) at the lumbar spine and femoral neck. Osteopenia and osteoporosis were defined according to WHO criteria. Ibandronic acid 150 mg per day orally for six months was given to patients with osteoporosis and DEXA scan repeated.

RESULTS

A total of 215 patients (males 179, 83%) with a mean age of 50.9 ± 11 years were enrolled in this study. Prevalence of HOD was found to be 66% (142/215). On multivariate analysis BMI, TLC, total serum bilirubin and transient elastography values were found to be independently associated with HOD. All the patients with osteoporosis (n = 47) were treated with ibandronic acid as per protocol. Treated patients had significant improvement in DEXA scans after six months as compared to baseline.

CONCLUSIONS

HOD was seen in two-thirds of patients with liver cirrhosis. Higher liver stiffness as determined by transient elastography is significantly associated with HOD. Severity scores of liver disease (CTP and MELD) and etiology of liver cirrhosis did not determine HOD. Ibandronic acid is a safe drug that showed significant improvement in BMD in patients with liver disease along with osteoporosis.

Osteoporosis and bone fractures in alcoholic liver disease: A meta-analysis

AIM: To evaluate the association between alcoholic liver disease (ALD) and bone fractures or osteoporosis.

METHODS: Non-randomized studies were identified from databases (PubMed, EMBASE, and the Cochrane Library). The search was conducted using Boolean operators and keywords, which included “alcoholic liver diseases”, “osteoporosis”, or “bone fractures”. The prevalence of any fractures or osteoporosis, and bone mineral density (BMD) were extracted and analyzed using risk ratios and standardized mean difference (SMD). A random effects model was applied.

RESULTS: In total, 15 studies were identified and analyzed. Overall, ALD demonstrated a RR of 1.944 (95%CI: 1.354-2.791) for the development of bone fractures. However, ALD showed a RR of 0.849 (95%CI: 0.523-1.380) for the development of osteoporosis. BMD was not significantly different between the ALD and control groups, although there was a trend toward lower BMD in patients with ALD (SMD in femur-BMD: -0.172, 95%CI: -0.453-0.110; SMD in spine-BMD: -0.169, 95%CI: -0.476-0.138). Sensitivity analyses showed consistent results.

CONCLUSION: Current publications indicate significant associations between bone fractures and ALD, independent of BMD or the presence of osteoporosis.

Vitamin D status and viral response to therapy in hepatitis C infected children

AIM: To study the frequency of vitamin D deficiency in patients with hepatitis C virus (HCV) infection and to evaluate the role of vitamin D supplementation in improving antiviral therapy.

METHODS: Sixty-six children aged from 7-14 years (mean ± SD, 11.17 ± 2.293) diagnosed with HCV infection were matched to 28 healthy controls. Serum levels of 25 (OH) D3, calcium, phosphorus, alkaline phosphatase and plasma level of parathormone were measured. Quantitative PCR for HCV was performed Bone density was determined by dual energy X-ray absorptiometry. All cases received conventional therapy, and only 33 patients received vitamin D supplementation.

RESULTS: Children with HCV showed significantly increased levels of HCV RNA (P < 0.001), parathormone (P < 0.01) and decreased vitamin D levels (P < 0.05) (33.3% deficient and 43.3% insufficient) compared with controls. Abnormal bone status (Z score -1.98 ± 0.75) was found in ribs, L-spine, pelvis and total body. Cases treated with vitamin D showed significant higher early (P < 0.04) and sustained (P < 0.05) virological response. There was a high frequency of vitamin D deficiency among the Egyptian HCV children, with significant decrease in bone density. The vitamin D level should be assessed before the start of antiviral treatment with the correction of any detected deficiency.

CONCLUSION: Adding vitamin D to conventional Peg/RBV therapy significantly improved the virological response and helped to prevent the risk of emerging bone fragility.

Vitamin D deficiency in chronic liver disease

Vitamin D is an important secosteroid hormone with known effect on calcium homeostasis, but recently there is increasing recognition that vitamin D also is involved in cell proliferation and differentiation, has immunomodulatory and anti-inflammatory properties. Vitamin D deficiency has been frequently reported in many causes of chronic liver disease and has been associated with the development and evolution of non-alcoholic fatty liver disease (NAFLD) and chronic hepatitis C (CHC) virus infection. The role of vitamin D in the pathogenesis of NAFLD and CHC is not completely known, but it seems that the involvement of vitamin D in the activation and regulation of both innate and adaptive immune systems and its antiproliferative effect may explain its importance in these liver diseases. Published studies provide evidence for routine screening for hypovitaminosis D in patients with liver disease. Further prospectives studies demonstrating the impact of vitamin D replacement in NAFLD and CHC are required.

Chronic CCl4 intoxication causes liver and bone damage similar to the human pathology of hepatic osteodystrophy: a mouse model to analyse the liver-bone axis

Patients with chronic liver diseases frequently exhibit decreased bone mineral densities (BMD), which is defined as hepatic osteodystrophy (HOD). HOD is a multifactorial disease whose regulatory mechanisms are barely understood. Thus, an early diagnosis and therapy is hardly possible. Therefore, the aim of our study consisted in characterizing a mouse model reflecting the human pathomechanism. Serum samples were collected from patients with chronic liver diseases and 12-week old C57Bl6/N mice after 6-week treatment with carbon tetrachloride (CCl4). Repetitive injections of CCl4 induced liver damage in mice, resembling liver fibrosis in patients, as assessed by serum analysis and histological staining. Although CCl4 did not affect primary osteoblast cultures, μCT analysis revealed significantly decreased BMD, bone volume, trabecular number and thickness in CCl4-treated mice. In both HOD patients and CCl4-treated mice, an altered vitamin D metabolism with decreased CYP27A1, CYP2R1, vitamin D-binding protein GC and increased 7-dehydrocholesterol reductase hepatic gene expression, results in decreased 25-OH vitamin D serum levels. Moreover, both groups exhibit excessively high active transforming growth factor-beta (TGF-β) serum levels, inhibiting osteoblast function in vitro. Summarizing, our mouse model presents possible mediators of HOD, e.g. altered vitamin D metabolism and increased active TGF-β. Liver damage and significant changes in bone structure and mineralization are already visible by μCT analysis after 6 weeks of CCl4 treatment. This fast response and easy transferability makes it an ideal model to investigate specific gene functions in HOD.

Increased bone mineral density in patients with non-alcoholic steatohepatitis

AIM: To determine the relationship between non-alcoholic steatohepatitis (NASH) and bone mineral density (BMD).

METHODS: A total of 38 patients (25 males) with a diagnosis of histologically proven NASH and 42 healthy controls (24 males) were enrolled in the study. Demographic features, clinical findings, complete blood count and routine biochemical analysis, as well as adrenal, thyroid and gonadal functions, were recorded. Additionally, intact parathormone, 25-OH-vitamin-D3, tumor necrosis factor-α, interleukin-6, interleukin-1, insulin-like growth factor-1 and insulin-like growth factor binding protein-3 levels were measured in both groups. Furthermore, lumbar spine and femoral neck BMD of both groups were measured by the dual-energy X-ray absorptiometry (DXA) method.

RESULTS: The mean age was 41 ± 12 years in the NASH group and 43 ± 11 years in the control group. Among demographic features, waist circumference was significantly larger in the NASH group compared to the control group (P < 0.019). Among laboratory parameters, serum triglyceride (P < 0.008), alanine transaminase (P < 0.0001), aspartate transaminase (P < 0.001), alkaline phosphatase (P < 0.016), gamma glutamyl transferase (P < 0.0001), ferritin (P < 0.001) and 25-OH-vitamin-D3 levels (P < 0.0001) were significantly higher in the NASH group compared to the control group. Lumbar BMD was significantly higher in the NASH group compared to the control group (1.057 ± 0.119 g/cm²vs 0.941 ± 0.133 g/cm²; P < 0.001, respectively). In the NASH group, there was no significant relationship between BMD and fibrosis stage in liver biopsy.

CONCLUSION: NASH increases BMD and may be related to an elevated serum 25-OH-vitamin D3 level.

Osteoporosis in chronic liver disease

Osteoporosis is a common skeletal complication seen in patients with chronic liver disease. Osteoporosis is usually asymptomatic and, if untreated, can result in fractures and impaired quality of life. For this review, we performed a systematic search of the PubMed database, and all recent peer-reviewed articles regarding the prevalence, pathophysiology, diagnosis, and management of osteoporosis in chronic liver disease were included. The prevalence of osteoporosis varies between 11% and 58% in patients with chronic liver disease and in transplant recipients. The etiology of osteoporosis is multifactorial and only partially understood. Various factors linked to the pathogenesis of bone loss are vitamin D, calcium, insulin growth factor-1, receptor activation of nuclear factor-κB ligand (RANKL), bilirubin, fibronectin, leptin, proinflammatory cytokines, and genetic polymorphisms. Management of osteoporosis involves early diagnosis, identifying and minimizing risk factors, general supportive care, nutrition therapy, and pharmacotherapy. Osteoporosis is diagnosed based on the bone mineral density (BMD) assessment using dual-energy X-ray absorptiometry scan. Measurement of BMD should be considered in all patients with advanced liver disease and in transplant recipients. Vitamin D and calcium supplementation is recommended for all patients with osteoporosis. Specific agents used for treatment of osteoporosis include bisphosphonates, calcitonin, hormonal therapy, and raloxifene. Bisphosphonates have become the mainstay of therapy for osteoporosis prevention and treatment. Prolonged suppression of bone remodeling resulting in atypical fractures has emerged as a significant complication with long-term use of bisphosphonates. Newer treatment agents and better fracture prevention strategies are necessary to prevent and treat osteoporosis.

The option of HBIG-free prophylaxis against recurrent HBV

Since the early 1990's, hepatitis B immune globulin (HBIG) has been central to the prevention of hepatitis B virus (HBV) recurrence after liver transplantation. When used in combination with oral nucleos(t)ide analogues, HBIG prevents reinfection with HBV in ⩾90% of transplant recipients. While HBIG is highly efficacious, its use is undermined by its high cost. Because of this limitation, there have been many studies of alternative regimens seeking to minimize the dose or duration of HBIG without sacrificing low HBV recurrence rates. Toward that goal, lower dose intramuscular HBIG in combination with oral nucleos(t)ide analogues has been shown to be highly efficacious in preventing disease recurrence and represents a significant cost savings when compared with high dose intravenous administration. The withdrawal of HBIG after a defined course of combination HBIG and oral antivirals has also been shown to be effective, particularly if combination antiviral therapy is used. The ability to achieve undetectable HBV DNA levels pre-transplantation in the majority of patients may contribute to the high efficacy of these HBIG "light" regimens. Additionally, the success of antiviral rescue therapy for those patients who fail prophylaxis and develop recurrent HBV infection post-transplant has provided the impetus to move increasingly towards HBIG-free approaches. New techniques to detect occult HBV in hepatic and extrahepatic sites may allow clinicians to define a subgroup of patients in whom withdrawal of HBIG or all prophylaxis may be applicable.

Review article: the extra-skeletal effects of vitamin D in chronic hepatitis C infection

BACKGROUND

Recent interest has focused on the extra-skeletal effects of vitamin D, in particular, in patients with chronic hepatitis C.

AIMS

To review data in the literature regarding the extra-skeletal effects of vitamin D in patients with chronic hepatitis C, with and without liver transplantation.

METHODS

A Medline search was performed for relevant studies up to August 2011 using the terms 'vitamin D' 'chronic liver disease' and 'hepatitis C'.

RESULTS

Vitamin D deficiency is very frequent before liver transplantation ranging between 51% and 92%, whereas, in the liver transplantation setting, the prevalence of vitamin D deficiency is also high. Severe liver disease may increase the risk of vitamin D deficiency and vice versa, as there may be a relationship between vitamin D deficiency and fibrosis. In patients with chronic hepatitis C and those with recurrent of hepatitis C after liver transplantation, recent clinical data shows that a higher serum vitamin D level is an independent predictor of sustained virological response (SVR) following anti-viral therapy, and that a higher SVR is achieved with vitamin D supplementation.

CONCLUSIONS

Larger randomised clinical studies with adequate statistical power are needed to confirm these potentially very important nonskeletal effects of vitamin D in patients with chronic hepatitis C.

Spontaneus bilateral pedicle fracture 30 years after Harrington Instrumentation for idiopathic scoliosis: a case report

Introduction

Spontaneous fractures of the spine are a common entity. They usually occur in older people with osteoporosis. This case is presented on account of its rarity. To the best of the authors' knowledge only one case of an osteoporotic pedicle fracture after Harrington Instrumentation has been described before.

Case presentation

We report the case of a 46-year-old Caucasian woman who underwent surgery due to idiopathic scoliosis with a Harrington Instrumentation (T4 to L3) 30 years ago. During the operation she was infected with hepatitis C while receiving erythrocyte concentrates and has suffered from liver cirrhosis since then. She presented with a sudden pain in her lower back and paraesthesia in both her legs but no other neurological symptoms. A computed tomography scan showed a bilateral pedicle fracture of L3 and an additional compression fracture of L4. In the first session we performed a dorsal stabilization with massive intraoperative bleeding and a postoperative failure of liver synthesis. In a second session an additional ventral augmentation was done. After the second operation she developed a hepatorenal syndrome. Both operations left the patient in a very critical state which led to a prolonged stay in the intensive care and rehabilitation unit. At her 12-month follow-up visit, she was free of complaints.

Conclusion

The un-physiological load of the spine after Harrington Instrumentation can lead to osteoporosis due to inactivity even in younger patients. Although these implants are not used anymore one should keep this possibility in mind when dealing with patients who have received Harrington rods in surgical procedures.

Classical and emerging roles of vitamin D in hepatitis C virus infection

According to the Institute of Medicine, the risk of clinically significant vitamin D deficiency increases at 25-hydroxyvitamin D levels below 20 ng/mL. By this standard, most cirrhotic hepatitis C virus- (HCV-) positive patients and many noncirrhotic patients are vitamin D-deficient. The high prevalence of vitamin D deficiency among HCV patients is a cause for concern for several specific reasons. Classic studies established the importance of vitamin D and calcium in maintaining bone. Vitamin D's beneficial effects on bone are likely to be vital for HCV-infected patients because these individuals have a high prevalence of low bone mineral density. Many pharmaceutical agents reduce bone density and exposure to these drugs may increase bone disease in HCV-positive patients. Bone loss occurs following liver transplantation and bone density is often low in patients with HIV/HCV co-infection who are on combination antiretroviral therapy. Some evidence suggests that ribavirin reduces bone density, underscoring the special need to monitor vitamin D in patients receiving HCV treatment and to prescribe supplements, as appropriate. In addition to its role in calcium metabolism, vitamin D is also an immune modulator that reduces inflammation while enhancing protective immune responses. Higher vitamin D levels are associated with less liver fibrosis and less inflammation in HCV patients. Recent studies show that low vitamin D levels are associated with treatment failure among HCV-infected patients receiving pegylated-interferon and ribavirin. If confirmed, these findings will provide an additional reason to ensure adequate levels of vitamin D. Information about how to monitor vitamin D status and how to use vitamin D supplements most effectively in HCV-infected patients is provided.