Osteoporosis and Bone Health in Chronic Liver Disease

Chronic liver disease encompasses a spectrum of disorders that compromise hepatic function and disrupt skeletal homeostasis. A common extrahepatic complication is hepatic osteodystrophy, characterised by reduced bone mineral density, impaired microarchitecture and heightened fracture risk. Pathophysiological mechanisms include malabsorption of vitamin D and calcium, altered sex hormone metabolism, chronic inflammation with dysregulated cytokine profiles, and impaired growth factor signalling in bone tissue. Nutritional deficiencies, sarcopenia and the effects of medications such as glucocorticoids further exacerbate bone loss. Clinically, osteoporosis in this setting often remains under-recognised until fragility fractures occur, which in turn increase morbidity and mortality. Early screening with dual-energy X-ray absorptiometry and consideration of bone turnover markers are essential in at-risk patients, particularly those awaiting or having undergone liver transplantation. Management strategies combine optimisation of nutritional status, correction of vitamin D deficiency, judicious use of antiresorptive agents and targeted rehabilitation. Given the global burden of chronic liver disease and its rising prevalence, integrating bone health assessment into standard hepatology care pathways is paramount to reduce fracture rates, improve quality of life and mitigate long-term healthcare costs.

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Osteoporosis and Bone Health in Chronic Liver Disease publication trend

The graph below shows the total number of articles in osteoporosis and bone health in chronic liver disease across all publications each year (not limited to Nature Index journals).

Technical terms

Osteoporosis: A systemic skeletal disorder characterised by low bone mass and microarchitectural deterioration, leading to increased fracture susceptibility.

Chronic liver disease (CLD): Progressive hepatic dysfunction resulting from sustained injury, including viral hepatitis, cholestatic disorders and alcohol-related liver damage.

Bone mineral density (BMD): A quantitative measure of mineral content in bone tissue, typically assessed by dual-energy X-ray absorptiometry to evaluate fracture risk.

Fragility fracture: A fracture resulting from low-energy trauma, indicative of compromised bone strength.

Primary biliary cholangitis (PBC): An autoimmune cholestatic liver disease characterised by destruction of intrahepatic bile ducts and associated extrahepatic manifestations including osteoporosis.

Trabecular bone score (TBS): An index derived from imaging that reflects trabecular microarchitecture and provides insight into bone quality beyond BMD.

References

1. Risk of fractures and postfracture mortality in 3980 people with primary biliary cholangitis: A population‐based cohort study. Journal of Internal Medicine (2023).
2. High bone fracture risk in a large modern cohort of liver transplant recipients. Internal and Emergency Medicine (2024).
3. Clinical Indicators of Bone Deterioration in Alcoholic Liver Cirrhosis and Chronic Alcohol Abuse: Looking beyond Bone Fracture Occurrence. Diagnostics (2024).
4. Hepatic Osteodystrophy—Molecular Mechanisms Proposed to Favor Its Development. International Journal of Molecular Sciences (2019).
5. Diagnosis and Management of Cirrhosis‐Related Osteoporosis. BioMed Research International (2016).