Bone Disease in Patients with Cirrhosis

Abstract

Osteoporosis resulting in a high fracture risk is a frequent complication in patients with liver disease, particularly in those with chronic cholestasis and end-stage cirrhosis. Osteomalacia is, however, exceptional and only presents when associated with persistent vitamin D deficiency in subjects with deep cholestasis. The pathogenesis of bone loss in these patients mainly results from low bone formation as a consequence of cholestasis or the harmful effects of alcohol or iron on osteoblasts. The management of bone disease in cirrhosis is addressed to reduce or avoid the risk factors for osteoporosis and fracture. Bisphosphonates associated with supplements of calcium and vitamin D are safe and effective for increasing bone mass in patients with chronic cholestasis and in cirrhotics after liver transplantation, though no clear achievements in decreasing the incidence of fractures have been described. Randomized studies assessing bisphosphonates in larger series of patients and the development of new drugs for osteoporosis may change future management. Clinicians must be aware of this frequent and detrimental complication in patients with cirrhosis.