Bone disease in primary biliary cirrhosis: independent indicators and rate of progression☆
Introduction
Osteopenic bone disease with its predisposition to pain and fracturing is a common complication in primary biliary cirrhosis (PBC) [1], [2], [3], [4]. Bone loss in patients with PBC increases, sometimes dramatically in the first 3–6 months after liver transplantation. During the first post-transplant year fractures may occur and are seen almost exclusively in those patients who are already osteopenic at the time of transplantation [5], [6]. Hence, the identification of patients with PBC at risk for osteoporosis may lead to a better selection of potential candidates for studies of new therapies aimed at preventing or improving bone mass before liver transplantation.
The reported prevalence of bone disease in PBC in earlier studies varied from 9 to 83% due to different diagnostic criteria as well as different patient populations studied [1], [2], [3], [4], [7], [8], [9]. With the use of dual-energy X-ray absorptiometry, a sensitive non-invasive method for quantification of bone mass, osteoporosis was found in less than a third of ambulatory patients with PBC [9], [10] and in a half of patients undergoing evaluation for liver transplantation [6], [11]. This may suggest a correlation between the severity of liver disease and bone disease. However, since most reports have been limited by the small sample size, no factors that predict the presence and severity of bone disease in patients with PBC have yet been identified. Therefore, bone density measurement is recommended in all patients for diagnostic and prognostic purposes. Furthermore, since most reports are cross-sectional studies with patients studied at a single point in time, progression of bone disease over time has remained largely unstudied and recommendations for subsequent bone density measurements have been essentially empirical.
To deal with these issues, we reviewed our experience with a large population of patients with PBC followed up for up to 7 years at the Mayo Clinic. This study was aimed: (i) to determine the prevalence of bone disease in a large cohort of patients with PBC with all stages of disease; (ii) to identify independent indicators of osteoporosis; and (iii) to determine the rate of bone loss over time.
Section snippets
Patient population
One-hundred and seventy-six patients with PBC seen at the Mayo Clinic in Rochester, MN were identified from our computerized master diagnosis index. All patients had bone mineral density (BMD) of the lumbar spine L2–L4 measured at the time of the first visit at Mayo, from 1/1/91 to 12/31/94, as part of the standard care of patients with chronic cholestatic liver disease. BMD of the hip was also measured in 82 patients. The date of 1/1/91 was chosen because it was the date when the current
Results
Demographic, clinical, biochemical and histological features of the patient population are summarized in Table 1. The mean age for the entire group was 53±0.6 years (range 29–72). There were 147 females (mean age 53±0.8 years, range 29–72) and 29 males (mean age 56±1.8 years, range 33–72). Forty-five percent (66/147) of the females were post-menopausal.
Osteoporosis of either lumbar spine or hip (t-score below −2.5) occurred 32.1 times (95% CI 4.8–213.6) more frequently in patients with PBC than
Discussion
In this large series, we found that 20% of patients with PBC have established osteoporosis at the time of their first visit to our institution with more than a 30-fold increased risk of osteoporosis than expected. Bone mass in patients with PBC with early disease, however, was similar to the expected in normal population, but significantly lower in those patients with more advanced disease. Patients with PBC with histologic stage 3 or 4 had more than a 5-fold increased risk of osteoporosis
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Cited by (0)
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Presented in part during the Annual Meeting of the American Gastroenterological Association, Orlando, FL, May, 1999.