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World J Gastroenterol. Jul 28, 2009; 15(28): 3516-3522
Published online Jul 28, 2009. doi: 10.3748/wjg.15.3516
Bone mineral density and disorders of mineral metabolism in chronic liver disease
Joe George, Hosahithlu K Ganesh, Shrikrishna Acharya, Tushar R Bandgar, Vyankatesh Shivane, Anjana Karvat, Shobna J Bhatia, Samir Shah, Padmavathy S Menon, Nalini Shah
Joe George, Hosahithlu K Ganesh, Shrikrishna Acharya, Anjana Karvat, Padmavathy S Menon, Nalini Shah, Tushar R Bandgar Vyankatesh Shivane, Department of Endocrinology, Seth G.S. Medical College and KEM Hospital, Mumbai 400012, India
Shobna J Bhatia, Department of Gastroenterology, Seth G.S. Medical College and KEM Hospital, Mumbai 400012, India
Samir Shah, Department of Gastroenterology, Jaslok Hospital, Mumbai 400026, India
Author contributions: George J, Ganesh HK and Acharya S performed the research; Shivane V and Karvat A contributed acquisition and analysis of data; George J, Bandgar TR, Bhatia SJ, Shah S, Menon PS and Shah N contributed to the conception, design and review of the final version of this paper; George J and Bandgar TR wrote the paper.
Correspondence to: Tushar R Bandgar, MD, DM, Associate Professor, Department of Endocrinology, KEM Hospital, Parel, Mumbai 400012, India.
Telephone: +91-98-20025037
Fax: +91-22-24162883
Received: April 9, 2009
Revised: June 19, 2009
Accepted: June 26, 2009
Published online: July 28, 2009

AIM: To estimate the prevalence and identify the risk factors for metabolic bone disease in patients with cirrhosis.

METHODS: The study was performed on 72 Indian patients with cirrhosis (63 male, nine female; aged < 50 years). Etiology of cirrhosis was alcoholism (n = 37), hepatitis B (n = 25) and hepatitis C (n = 10). Twenty-three patients belonged to Child class A, while 39 were in class B and 10 in class C. Secondary causes for metabolic bone disease and osteoporosis were ruled out. Sunlight exposure, physical activity and dietary constituents were calculated. Complete metabolic profiles were derived, and bone mineral density (BMD) was measured using dual energy X ray absorptiometry. Low BMD was defined as a Z score below -2.

RESULTS: Low BMD was found in 68% of patients. Lumbar spine was the most frequently and severely affected site. Risk factors for low BMD included low physical activity, decreased sunlight exposure, and low lean body mass. Calcium intake was adequate, with unfavorable calcium: protein ratio and calcium: phosphorus ratio. Vitamin D deficiency was highly prevalent (92%). There was a high incidence of hypogonadism (41%). Serum estradiol level was elevated significantly in patients with normal BMD. Insulin-like growth factor (IGF) 1 and IGF binding protein 3 levels were below the age-related normal range in both groups. IGF-1 was significantly lower in patients with low BMD. Serum osteocalcin level was low (68%) and urinary deoxypyridinoline to creatinine ratio was high (79%), which demonstrated low bone formation with high resorption.

CONCLUSION: Patients with cirrhosis have low BMD. Contributory factors are reduced physical activity, low lean body mass, vitamin D deficiency and hypogonadism and low IGF-1 level.

Keywords: Bone mineral density, Liver disease, Chronic disease, Cirrhosis, Bone mineral metabolism, Hepatic osteodystrophy