Patients with chronic liver disease should be alert to osteoporosis.
Osteoporosis (OP) is a systemic bone disease characterized by low bone mass and destruction of bone microstructure, leading to increased bone fragility and susceptibility to fracture. It is a disease of the skeletal system characterized by decreased bone strength and increased risk of fracture. According to the causes, osteoporosis can be divided into two categories: primary osteoporosis, which is caused by old age or menopause and mainly occurs in elderly people after 70 years old and in women within 5-10 years after menopause; secondary osteoporosis, which is caused by endocrine metabolic diseases, liver and kidney diseases, certain drugs such as hormones, and after organ transplantation.
Osteoporosis a quietly progressive disease.
From 0 to 30 years old, bone formation is greater than bone resorption and bone mass accumulates, reaching a peak at the age of 30; from 30 to 50 years old, bone formation and bone resorption are in dynamic balance; after 50 years old, women lose bone mass rapidly due to menopause, and after 65 to 70 years old, they enter the stage of degenerative bone loss. In addition to age-related bone loss, it is also associated with disease, hormone levels, medications, vitamin D deficiency, insufficient physical exercise, smoking, alcohol abuse, and carbonated beverages.
In the United States, the prevalence of osteoporosis in postmenopausal women is 15%-20%, in the United Kingdom, the prevalence of osteoporosis in women over 50 years old is 23%, and in China, a sample survey shows that the prevalence of osteoporosis in people over 40 years old is about 10%, and the prevalence in people over 60 years old is 14%. The prevalence of osteoporosis in women increases with age: 0.2% for women aged 40-49, 5.2% for women aged 50-59, and 53.3% for women aged 80 or older.
What are the symptoms of osteoporosis? Common symptoms include low back or peripheral pain, spinal deformity, height shortening in severe cases, hunchback, and fractures (thoracic spine, lumbar spine, hip, radius, distal ulna, and proximal humerus are common sites). It is important to note that the symptoms of osteoporosis are non-specific until a fracture occurs and therefore can be easily overlooked.
A serious consequence of osteoporosis is fracture. Having had a fracture, the risk of another fracture is also significantly increased. about 56% of fractures due to osteoporosis occur in women aged 60-65 years and 29% in men; 70% of fractures in people over 65 years can be attributed to osteoporosis. Because 1/4 of fracture patients need home care, long-term bed rest brings bed sores, pneumonia, muscle atrophy, venous thrombosis of the lower limbs, etc., and even leads to disability, and more seriously, the mortality rate of hip fracture within 2 years is 25%.
How to diagnose osteoporosis?
Bone density test is a common method to diagnose osteoporosis. If there is no condition to check bone density, osteoporosis can be diagnosed if there is a shortening of more than 3cm in height, humpback and spine deformation, translucent X-ray, other typical clinical manifestations of osteoporosis and a combination of more than one risk factor within 3 years. Because of osteoporosis, a new concept was also introduced, namely fragility fracture: minor trauma (e.g., fall below height, fall, etc.) or no history of trauma but signs of fracture is called fragility fracture, and the presence of fragility fracture can be diagnosed as osteoporosis regardless of the bone density.
Patients with chronic liver disease are more likely to develop osteoporosis.
Patients with chronic liver disease are more likely to develop osteoporosis secondary to abnormal vitamin D metabolism and calcium malabsorption, among which primary biliary cirrhosis, alcoholic cirrhosis, chronic hepatitis B, and post-hepatitis cirrhosis are the most common. Therefore, chronic liver disease is one of the risk factors for the occurrence of osteoporosis. The comprehensive department of Beijing Ditan Hospital conducted a controlled study on the bone density of 32 patients with cirrhosis and 40 healthy individuals and found that: 23 cases (71.9%) of cirrhosis combined with bone density abnormalities, including 9 cases (28.1%) of osteoporosis and 14 cases (43.8%) of bone loss, while 8 cases (20%) of bone density abnormalities occurred in the control group, including 1 case (2.5%) of osteoporosis and 7 cases (17.5%) of bone loss There was a significant difference between the two groups in terms of osteoporosis and bone loss (P<0.05).
Therefore, it can be concluded that patients with cirrhosis are more likely to have combined bone metabolism abnormalities (bone loss and osteoporosis) than healthy adults, and patients with liver function Child C should be routinely tested for bone mineral density.
How to prevent and treat osteoporosis?
First of all, we should emphasize the basic measures: first, adjust the lifestyle, including the intake of a balanced diet rich in calcium, proper exercise, sunlight exposure, avoidance of smoking, alcohol abuse and careful use of drugs that affect bone metabolism, and prevention of falls, and second, use of basic bone health supplements (calcium, vitamin D), calcium supplementation: 800mg/day for adults, 1000mg/day for postmenopausal women and the elderly. Vitamin D intake: 200 IU/day for adults and 400-800 IU/day for the elderly. Patients with chronic liver disease are recommended to apply active vitamin D3, such as osteopontin 0.25-0.5 μg/d. The drug is not affected by liver or kidney function and blood calcium is monitored regularly during treatment.
Secondly, early detection should be emphasized. Bone density should be tested in patients who have had fragility fractures, postmenopause, need long-term glucocorticoid therapy (>3 months), first diagnosis of PBC, patients with cirrhosis, and patients before liver transplantation, and those with the above risk factors but normal bone density should be reviewed after 2-3 years, and those who apply high-dose glucocorticoids should be reviewed after 1 year.
Thirdly, if osteoporosis is diagnosed, it should be combined with the use of calcium and vitamin D with drugs that inhibit bone resorption (bisphosphonates, calcitonin, selective estrogen receptor modulators SERMs, estrogen) or drugs that promote bone formation (parathyroid hormone), etc. At this time, it is best to seek further consultation with a specialist at the hospital.
For patients with cirrhosis, active treatment of the primary disease can play a role in preventing osteoporosis.
Bone density has been reported to increase in patients with chronic viral hepatitis after the application of antiviral therapy. Some experts investigated and found that 30 patients with genotype 1 chronic hepatitis C treated with pegylated interferon and ribavirin had a significant increase in bone mineral density during antiviral therapy compared to pre-treatment, and the effect could be sustained if a sustained virological response could be obtained. Viral clearance has also been reported to reduce the risk of osteoporotic fractures in postmenopausal women with chronic hepatitis C. However, a decrease in bone mineral density can occur during the use of individual antiviral agents such as tenofovir, and therefore close monitoring should be observed during treatment.
For patients with cholestatic cirrhosis, the use of ursodeoxycholic acid can reduce cholestasis and increase the absorption of vitamin D and calcium; patients with alcoholic liver disease can improve liver function and promote the absorption of calcium and vitamin D by abstaining from alcohol and increasing nutrition, which is beneficial to the prevention of osteoporosis.
Proper understanding and active prevention and treatment of osteoporosis are important to improve the quality of life of patients with chronic liver disease. As a hepatologist, in the diagnosis and follow-up management of patients with chronic hepatitis cirrhosis, we also need to pay attention to the osteoporosis status of patients at the same time, and conduct relevant examinations and treatment in a timely manner to improve the quality of life of patients with chronic liver disease.