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Jadzic J, Djonic D. Bone loss in chronic liver diseases: Could healthy liver be a requirement for good bone health? World J Gastroenterol 2023; 29:825-833. [PMID: 36816627 PMCID: PMC9932432 DOI: 10.3748/wjg.v29.i5.825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 10/29/2022] [Accepted: 01/12/2023] [Indexed: 02/06/2023] Open
Abstract
Given that the liver is involved in many metabolic mechanisms, it is not surprising that chronic liver disease (CLD) could have numerous complications. Secondary osteoporosis and increased bone fragility are frequently overlooked complications in CLD patients. Previous studies implied that up to one-third of these individuals meet diagnostic criteria for osteopenia or osteoporosis. Recent publications indicated that CLD-induced bone fragility depends on the etiology, duration, and stage of liver disease. Therefore, the increased fracture risk in CLD patients puts a severe socioeconomic burden on the health system and urgently requires more effective prevention, diagnosis, and treatment measures. The pathogenesis of CLD-induced bone loss is multifactorial and still insufficiently understood, especially considering the relative impact of increased bone resorption and reduced bone formation in these individuals. It is essential to note that inconsistent findings regarding bone mineral density measurement were previously reported in these individuals. Bone mineral density is widely used as the “golden standard” in the clinical assessment of bone fragility although it is not adequate to predict individual fracture risk. Therefore, microscale bone alterations (bone microstructure, mechanical properties, and cellular indices) were analyzed in CLD individuals. These studies further support the thesis that bone strength could be compromised in CLD individuals, implying that an individualized approach to fracture risk assessment and subsequent therapy is necessary for CLD patients. However, more well-designed studies are required to solve the bone fragility puzzle in CLD patients.
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Affiliation(s)
- Jelena Jadzic
- Center of Bone Biology, Faculty of Medicine, University of Belgrade, Belgrade 11000, Serbia
| | - Danijela Djonic
- Center of Bone Biology, Faculty of Medicine, University of Belgrade, Belgrade 11000, Serbia
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Jadzic J, Djonic D. Bone loss in chronic liver diseases: Could healthy liver be a requirement for good bone health? World J Gastroenterol 2023; 29:825-833. [DOI: https:/doi.org/10.3748/wjg.v29.i5.825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/10/2024] Open
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Chazouilleres O, Beuers U, Bergquist A, Karlsen TH, Levy C, Samyn M, Schramm C, Trauner M. EASL Clinical Practice Guidelines on sclerosing cholangitis. J Hepatol 2022; 77:761-806. [PMID: 35738507 DOI: 10.1016/j.jhep.2022.05.011] [Citation(s) in RCA: 94] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 05/16/2022] [Indexed: 02/07/2023]
Abstract
Management of primary or secondary sclerosing cholangitis is challenging. These Clinical Practice Guidelines have been developed to provide practical guidance on debated topics including diagnostic methods, prognostic assessment, early detection of complications, optimal care pathways and therapeutic (pharmacological, endoscopic or surgical) options both in adults and children.
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A Systematic Review and Meta-Analysis on Metabolic Bone Disease in Patients with Primary Sclerosing Cholangitis. J Clin Med 2022; 11:jcm11133807. [PMID: 35807091 PMCID: PMC9267321 DOI: 10.3390/jcm11133807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 06/25/2022] [Accepted: 06/28/2022] [Indexed: 12/26/2022] Open
Abstract
Data about the association between primary sclerosing cholangitis (PSC) and metabolic bone disease are still unclear. PSC is a chronic cholestatic liver disease (CCLD) which affects the biliary tract, and it has a highly variable natural history. We systematically searched until 28 February 2022 MEDLINE, Cochrane Central Register of Controlled Trials, the ISI Web of Science, and SCOPUS, for studies in patients with PSC. We identified 343 references to potential studies. After screening them, we included eight studies (893 PSC patients, 398 primary biliary cirrhosis (PBC) patients, and 673 healthy controls) for the present meta-analysis. Pooled analyses found no difference in BMD-LS (Z = 0.02, p-value = 0.98) between PSC patients and healthy controls. BMD-LS was statistically lower in PBC patients than in PSC patients (Mean Difference, MD, 0.06, 95% CI 0.03 to 0.09, p-value = 0.0007). The lumbar spine T-score was higher in the PSC patients compared with PBC patients (MD 0.23, 95% CI 0.04 to 0.42, p-value = 0.02). Given the limited literature available, better designed, and larger scale primary studies will be required to confirm our conclusion.
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Pugliese N, Arcari I, Aghemo A, Lania AG, Lleo A, Mazziotti G. Osteosarcopenia in autoimmune cholestatic liver diseases: Causes, management, and challenges. World J Gastroenterol 2022; 28:1430-1443. [PMID: 35582674 PMCID: PMC9048470 DOI: 10.3748/wjg.v28.i14.1430] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 12/05/2021] [Accepted: 03/07/2022] [Indexed: 02/06/2023] Open
Abstract
Primary biliary cholangitis and primary sclerosing cholangitis (PSC) are the most common cholestatic liver diseases (CLD) in adults and are both characterized by an immune pathogenesis. While primary biliary cholangitis is a model autoimmune disease, with over 90% of patients presenting very specific autoantibodies against mitochondrial antigens, PSC is considered an immune mediated disease. Osteoporosis is the most common bone disease in CLD, resulting in frequent fractures and leading to significant morbidity. Further, sarcopenia is emerging as a frequent complication of chronic liver diseases with a significant prognostic impact and severe implications on the quality of life of patients. The mechanisms underlying osteoporosis and sarcopenia in CLD are still largely unknown and the association between these clinical conditions remains to be dissected. Although timely diagnosis, prevention, and management of osteosarcopenia are crucial to limit the consequences, there are no specific guidelines for management of osteoporosis and sarcopenia in patients with CLD. International guidelines recommend screening for bone disease at the time of diagnosis of CLD. However, the optimal monitoring strategies and treatments have not been defined yet and vary among centers. We herein aim to comprehensively outline the pathogenic mechanisms and clinical implications of osteosarcopenia in CLD, and to summarize expert recommendations for appropriate diagnostic and therapeutic approaches.
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Affiliation(s)
- Nicola Pugliese
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele 20090, Milan, Italy
- Division of Internal Medicine and Hepatology, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano 20089, MI, Italy
| | - Ivan Arcari
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele 20090, Milan, Italy
- Division of Internal Medicine and Hepatology, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano 20089, MI, Italy
| | - Alessio Aghemo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele 20090, Milan, Italy
- Division of Internal Medicine and Hepatology, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano 20089, MI, Italy
| | - Andrea G Lania
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele 20090, Milan, Italy
- Department of Endocrinology, Diabetology and Medical Andrology Unit, IRCCS Humanitas Research Hospital, Rozzano 20089, MI, Italy
| | - Ana Lleo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele 20090, Milan, Italy
- Division of Internal Medicine and Hepatology, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano 20089, MI, Italy
| | - Gherardo Mazziotti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele 20090, Milan, Italy
- Department of Endocrinology, Diabetology and Medical Andrology Unit, IRCCS Humanitas Research Hospital, Rozzano 20089, MI, Italy
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Jadzic J, Cvetkovic D, Tomanovic N, Zivkovic V, Nikolic S, Milovanovic P, Djuric M, Djonic D. The severity of hepatic disorder is related to vertebral microstructure deterioration in cadaveric donors with liver cirrhosis. Microsc Res Tech 2020; 84:840-849. [PMID: 33170963 DOI: 10.1002/jemt.23642] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 09/26/2020] [Accepted: 10/29/2020] [Indexed: 02/06/2023]
Abstract
Patients with liver cirrhosis (LC) commonly suffer from osteoporosis and vertebral fracture, but data about their vertebral micro-architectural changes are still limited. This study aimed to evaluate the potential differences in trabecular micro-architecture of lumbar vertebrae between male LC patients and healthy controls, in relation to etiology and pathohistological scoring of the liver disorder. After pathohistological examination of liver tissue, micro-computed tomography was performed on the vertebral samples included into: alcoholic liver cirrhosis group (ALC; n = 16; age: 59 ± 8 years), non-alcoholic liver cirrhosis group (non-ALC; n = 15; age: 69 ± 10 years) and control group (n = 16; age: 58 ± 6 years). Our data showed significant impairment of the trabecular microstructure in the lumbar vertebrae from LC donors, regardless of the alcoholic/non-alcoholic origin of liver disorder, as illustrated by lower BV/TV, Tb.Th, and Tb.N compared with controls (p < .05). Moreover, depredation in trabecular micro-architecture was inversely associated with pathohistological scores (p < .05), indicating that severity of liver disorder could be an important predictor of reduced vertebral strength in LC. We noticed significant micro-architectural deterioration in the trabecular compartment of the lumbar vertebrae of male individuals with alcoholic and non-alcoholic LC, which was associated with the severity of the liver disease. Thus, clinical assessment of fracture risk should be advised for all LC patients, regardless of the alcoholic origin of liver cirrhosis. Additionally, adequate and timely treatment of liver disorder may decelerate the progression of bone impairment in LC patients.
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Affiliation(s)
- Jelena Jadzic
- Laboratory for Anthropology and Skeletal biology, Institute for Anatomy, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Danica Cvetkovic
- Institute of Forensic Medicine, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Nada Tomanovic
- Institute of Pathology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Vladimir Zivkovic
- Institute of Forensic Medicine, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Slobodan Nikolic
- Institute of Forensic Medicine, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Petar Milovanovic
- Laboratory for Anthropology and Skeletal biology, Institute for Anatomy, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marija Djuric
- Laboratory for Anthropology and Skeletal biology, Institute for Anatomy, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Danijela Djonic
- Laboratory for Anthropology and Skeletal biology, Institute for Anatomy, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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7
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Jadžić J, Đonić D. Compromised bone strength in patients with alcoholic liver cirrhosis. MEDICINSKI PODMLADAK 2020. [DOI: 10.5937/mp71-27443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Osteoporosis and/or osteopenia are frequently observed complications in alcoholic liver disease patients, especially in its irreversible stage (alcoholic liver cirrhosis - ALC). Current literature review regarding osteoporosis incidence increased fracture risk, bone mineral density changes, micro-structural alteration and pathogenetic mechanisms leading to ALC - induced decrease in bone quality is presented. It has been reported that osteoporosis is influenceing significant number of ALC patients, with particular accent on lumbar spine, as most commonly affected skeletal site. Several risk factors and ethio-pathogenic mechanisms have been associated with the loss of bone mineral density, in patients with ALC and other cirrhosis. Certain authors claim that dominant mechanism in ALC-induced bone loss is decrease in bone formation and osteoblastic function, while other results suggest increased bone remodeling as underlying cause of increased bone fragility in ALC patients. Increased bone fragility and susceptibility to osteoporotic fractures significantly affect life expectancy and quality of life in patients with ALC. Thus, osteological screening and individual fracture risk assessment are highly recommended for all patients with alcoholic liver cirrhosis.
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Chapman MH, Thorburn D, Hirschfield GM, Webster GGJ, Rushbrook SM, Alexander G, Collier J, Dyson JK, Jones DE, Patanwala I, Thain C, Walmsley M, Pereira SP. British Society of Gastroenterology and UK-PSC guidelines for the diagnosis and management of primary sclerosing cholangitis. Gut 2019; 68:1356-1378. [PMID: 31154395 PMCID: PMC6691863 DOI: 10.1136/gutjnl-2018-317993] [Citation(s) in RCA: 138] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 02/21/2019] [Accepted: 03/24/2019] [Indexed: 12/11/2022]
Abstract
These guidelines on the management of primary sclerosing cholangitis (PSC) were commissioned by the British Society of Gastroenterology liver section. The guideline writing committee included medical representatives from hepatology and gastroenterology groups as well as patient representatives from PSC Support. The guidelines aim to support general physicians, gastroenterologists and surgeons in managing adults with PSC or those presenting with similar cholangiopathies which may mimic PSC, such as IgG4 sclerosing cholangitis. It also acts as a reference for patients with PSC to help them understand their own management. Quality of evidence is presented using the AGREE II format. Guidance is meant to be used as a reference rather than for rigid protocol-based care as we understand that management of patients often requires individual patient-centred considerations.
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Affiliation(s)
- Michael Huw Chapman
- GI Division, UCL Hospitals NHS Foundation Trust, London, UK
- Liver Unit, Royal Free London NHS Foundation Trust, London, UK
| | | | - Gideon M Hirschfield
- Toronto Centre for Liver Disease, University Health Network and University of Toronto, Toronto, Canada
| | | | - Simon M Rushbrook
- Department of Hepatology, Norfolk and Norwich University Hospitals NHS Trust, Norwich, UK
| | | | | | - Jessica K Dyson
- Hepatology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle, UK
| | - David Ej Jones
- Institute of Cellular Medicine, Newcastle University, Newcastle, UK
| | - Imran Patanwala
- Gastroenterology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
- University of Liverpool, Liverpool, UK
| | | | | | - Stephen P Pereira
- GI Division, UCL Hospitals NHS Foundation Trust, London, UK
- Institute for Liver & Digestive Health, University College London, London, UK
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Schmidt T, Schwinge D, Rolvien T, Jeschke A, Schmidt C, Neven M, Butscheidt S, Kriz M, Kunzmann L, Mussawy H, Hubert J, Hawellek T, Rüther W, Oheim R, Barvencik F, Lohse AW, Schramm C, Schinke T, Amling M. Th17 cell frequency is associated with low bone mass in primary sclerosing cholangitis. J Hepatol 2019; 70:941-953. [PMID: 30641095 DOI: 10.1016/j.jhep.2018.12.035] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 12/19/2018] [Accepted: 12/26/2018] [Indexed: 01/18/2023]
Abstract
BACKGROUND & AIMS Osteoporotic fractures are a major cause of morbidity and reduced quality of life in patients with primary sclerosing cholangitis (PSC), a progressive bile duct disease of unknown origin. Although it is generally assumed that this pathology is a consequence of impaired calcium homeostasis and malabsorption, the cellular and molecular causes of PSC-associated osteoporosis are unknown. METHODS We determined bone mineral density by dual-X-ray absorptiometry and assessed bone microstructure by high-resolution peripheral quantitative computed tomography in patients with PSC. Laboratory markers of liver and bone metabolism were measured, and liver stiffness was assessed by FibroScan. We determined the frequency of Th17 cells by the ex vivo stimulation of peripheral blood mononuclear cells in a subgroup of 40 patients with PSC. To investigate the potential involvement of IL-17 in PSC-associated bone loss, we analyzed the skeletal phenotype of mice lacking Abcb4 and/or Il-17. RESULTS Unlike in patients with primary biliary cholangitis, bone loss in patients with PSC was not associated with disease duration or liver fibrosis. However, we observed a significant negative correlation between the bone resorption biomarker deoxypyridinoline and bone mineral density in the PSC cohort, indicating increased bone resorption. Importantly, the frequency of Th17 cells in peripheral blood was positively correlated with the urinary deoxypyridinoline level and negatively correlated with bone mass. We observed that Abcb4-deficient mice displayed a low-bone-mass phenotype, which was corrected by an additional Il-17 deficiency or anti-IL-17 treatment, whereas the liver pathology was unaffected. CONCLUSIONS Our findings demonstrate that an increased frequency of Th17 cells is associated with bone resorption in PSC. Whether antibody-based IL-17 blockade is beneficial against bone loss in patients with PSC should be addressed in future studies. LAY SUMMARY Primary sclerosing cholangitis (PSC) is a cholestatic liver disease characterized by progressive bile duct destruction. One serious complication of PSC is reduced bone mass resulting in increased fracture risk. Herein, we demonstrate that Th17 cells mediate bone loss in PSC by inducing bone resorption, which suggests that antibody-based IL-17 blockade might be beneficial for the treatment of bone loss in affected patients.
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Affiliation(s)
- Tobias Schmidt
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany; Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Dorothee Schwinge
- First Department of Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Tim Rolvien
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany; Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Anke Jeschke
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Constantin Schmidt
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Mona Neven
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Sebastian Butscheidt
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Marvin Kriz
- First Department of Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Lilly Kunzmann
- First Department of Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Haider Mussawy
- Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Jan Hubert
- Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Thelonius Hawellek
- Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Wolfgang Rüther
- Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Ralf Oheim
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany; Martin Zeitz Center for Rare Diseases, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Florian Barvencik
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany; Martin Zeitz Center for Rare Diseases, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Ansgar W Lohse
- First Department of Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany; Martin Zeitz Center for Rare Diseases, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Christoph Schramm
- First Department of Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany; Martin Zeitz Center for Rare Diseases, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Thorsten Schinke
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Michael Amling
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany; Martin Zeitz Center for Rare Diseases, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany.
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Keller S, Ittrich H, Schramm C, Lohse AW, Amling M, Adam G, Yamamura J. Diffusion-weighted MRI for detection of hepatic osteodystrophy in primary sclerosing cholangitis: a comparison study with dual-energy X-ray absorptiometry. Jpn J Radiol 2016; 34:677-683. [PMID: 27492220 DOI: 10.1007/s11604-016-0573-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 07/27/2016] [Indexed: 12/19/2022]
Abstract
PURPOSE Osteodystrophy is a frequent complication in primary sclerosing cholangitis (PSC). The aim was to test the feasibility of vertebral bone diffusion-weighted imaging (DWI) in routine liver MRI for detection of osteoporosis using dual-energy X-ray absorptiometry (DXA) as gold standard. MATERIALS AND METHODS Forty PSC patients (50 ± 12.6 years) and ten controls (49.5 ± 13.0 years) were scanned using a DWI spin echo echo-planar sequence (b-factors 0-800 s/mm2) on a 3-T MRI system and DXA (76 kVp). The apparent diffusion coefficient (ADC) and T-score were correlated to laboratory and clinical details using Pearson correlation. RESULTS In DXA-diagnosed osteoporosis (n = 3) and osteopenia (n = 12), the mean ADC was decreased (0.26 ± 0.03 and 0.30 ± 0.07 × 10-3 mm2/s) compared to patients with normal DXA scan results (n = 25; 0.32 ± 0.06 × 10-3 mm2/s). No significant correlation of the ADC and T-score (r = 0.24; p = 0.13) was found, but the T-score correlated significantly to disease duration (r = -0.33; p = 0.04). In patients with prednisolone therapy (n = 7), the DXA T-score was significantly lower (-1.46 ± 0.49 vs. -0.16 ± 0.23; p = 0.03). CONCLUSION Diffusion-weighted MRI of the vertebral spine is a feasible technic to detect diffusion alterations caused by osteoporosis but lacks diagnostic capacities for diagnosing minor reductions of the bone mineral density detected by DXA.
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Affiliation(s)
- Sarah Keller
- Department of Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf (UKE), Martinistr. 52, 20246, Hamburg, Germany.
| | - Harald Ittrich
- Department of Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf (UKE), Martinistr. 52, 20246, Hamburg, Germany
| | - Christoph Schramm
- Department of Internal Medicine, University Medical Center Hamburg-Eppendorf (UKE), Martinistr. 52, 20246, Hamburg, Germany
| | - Ansgar W Lohse
- Department of Internal Medicine, University Medical Center Hamburg-Eppendorf (UKE), Martinistr. 52, 20246, Hamburg, Germany
| | - Michael Amling
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf (UKE), Martinistr. 52, 20246, Hamburg, Germany
| | - Gerhard Adam
- Department of Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf (UKE), Martinistr. 52, 20246, Hamburg, Germany
| | - Jin Yamamura
- Department of Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf (UKE), Martinistr. 52, 20246, Hamburg, Germany
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Kumar A, Wheatley D, Puttanna A. Primary Sclerosing Cholangitis: Therapeutic Options and Surveillance Management. CLINICAL MEDICINE INSIGHTS. GASTROENTEROLOGY 2016; 9:25-9. [PMID: 27330336 PMCID: PMC4902039 DOI: 10.4137/cgast.s38451] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 05/01/2016] [Accepted: 05/03/2016] [Indexed: 02/07/2023]
Abstract
Primary sclerosing cholangitis is a chronic immune-mediated liver disease. Though rare, it poses several clinical concerns for the managing physician. There are currently limited therapeutic options in the management of the condition and weak evidence base behind them. Endoscopic intervention is limited to those patients with obstructing stricture-related disease, and even liver transplantation has a risk of disease recurrence. Surveillance for inflammatory bowel disorders, metabolic bone disease, and malignancy is paramount when managing such patients. This article provides an overview of the condition with further focus on current therapeutic options and guidance on surveillance management.
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Affiliation(s)
| | | | - Amar Puttanna
- University Hospital North Midlands, Stoke-on-Trent, England, UK
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Raszeja-Wyszomirska J, Kucharski R, Zygmunt M, Safranow K, Miazgowski T. The impact of fragility fractures on health-related quality of life in patients with primary sclerosing cholangitis. HEPATITIS MONTHLY 2015; 15:e25539. [PMID: 25972904 PMCID: PMC4426354 DOI: 10.5812/hepatmon.25539] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Revised: 01/23/2015] [Accepted: 02/04/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Osteoporosis occurs frequently in patients with chronic cholestatic liver diseases, yet data are scarce regarding the prevalence of osteoporosis and fragility fractures and their impact on Health-Related Quality of Life (HRQoL) in Primary Sclerosing Cholangitis (PSC). OBJECTIVES We aimed to assess Bone Mineral Density (BMD), physical activity and incidence of fragility fractures in patients with PSC. We also sought associations between prior fractures and HRQoL. PATIENTS AND METHODS The study was performed on 33 patients (11 females, 22 males) aged 35.3 ± 13 years. HRQoL was assessed by Short Form (SF)-36, Primary Biliary Cirrhosis (PBC)-40 and PBC-27 questionnaires. BMD was measured by densitometry in the lumbar spine and hip. Physical activity was assessed by questionnaire. RESULTS In 32% of patients, BMD measured in the hip or spine was below 1.0 Standard Deviation. A history of fragility fractures (distal forearm and ribs) was reported in six patients (18%). In SF-36 assessment, patients with fractures had lower scores in the role functioning, general health and vitality domains and Physical Component Summary (PCS) than those without fractures. Prior fractures adjusted for gender and PSC duration were associated with lower PCS and Mental Component Summary (MCS) scores. Symptoms and fatigue (assessed by PBC) and prior fractures were inversely associated with MCS (P = 0.007). CONCLUSIONS In middle-aged subjects with PSC, we found a high rate of non-vertebral fractures and a moderately decreased BMD in lumbar spine and hip. Fragility fractures had an impact on physical and mental aspects of HRQoL.
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Affiliation(s)
- Joanna Raszeja-Wyszomirska
- Hepatology and Internal Medicine Unit, Department of General Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Robert Kucharski
- Liver Research Laboratories, Pomeranian Medical University, Szczecin, Poland
| | - Marta Zygmunt
- Hepatology and Internal Medicine Unit, Department of General Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Krzysztof Safranow
- Department of Biochemistry and Chemistry, Pomeranian Medical University, Szczecin, Poland
| | - Tomasz Miazgowski
- Department of Hypertension and Internal Medicine, Pomeranian Medical University, Szczecin, Poland
- Corresponding Author: Tomasz Miazgowski, Department of Hypertension and Internal Medicine, Pomeranian Medical University, Szczecin, Poland. Tel: +48-91425 3550, Fax: +48-914253552, E-mail:
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Culafić D, Djonic D, Culafic-Vojinovic V, Ignjatovic S, Soldatovic I, Vasic J, Beck TJ, Djuric M. Evidence of degraded BMD and geometry at the proximal femora in male patients with alcoholic liver cirrhosis. Osteoporos Int 2015; 26:253-9. [PMID: 25172381 DOI: 10.1007/s00198-014-2849-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 08/10/2014] [Indexed: 02/06/2023]
Abstract
UNLABELLED We examined the association of alcoholic cirrhosis in 33 patients with areal bone mineral density (BMD) and the assessed bone geometric strength of their proximal femora. Lower areal BMD, cross-sectional area and section modulus, thinner cortex, and higher buckling ratio suggest that the alcoholic liver cirrhosis is associated with lower measures of bone strength. INTRODUCTION Hepatic bone disease is an important complication of chronic liver disease and is associated with significant morbidity through fractures resulting in pain, deformity, and immobility. In this study, we examined the association of alcoholic cirrhosis and liver insufficiency stage with areal bone mineral density (aBMD) and additionally employed hip structure analysis (HSA) as an advanced method to assess bone geometric strength of the proximal femur in men with alcoholic liver cirrhosis. METHODS The study included 33 male patients with alcoholic liver cirrhosis and a control group of 36 healthy patients. Laboratory testing included the following biochemical markers of bone turnover: serum levels of osteocalcin and C-telopeptide of type 1 collagen. Areal BMD was measured by dual x-ray absorptiometry on the proximal femora. Structural parameters were then derived from these scans using hip structure analysis software. RESULTS After adjusting for age, body height, and weight, we found lower cross-sectional area (p = 0.005) and section modulus (p = 0.005), thinner cortex (p = 0.012), and higher buckling ratio (p = 0.043) in the neck region among patients with cirrhosis. The findings suggest that alcoholic liver cirrhosis is associated with lower measures of bone strength. These findings were consistent with decreased osteocalcin values and increased C-telopeptide of type 1 collagen in patients with cirrhosis, indicating reduction in bone formation and increased bone resorption. CONCLUSION Our results emphasize that HSA-derived structural indices of proximal femoral structure may be an important index of greater fragility in patients with alcoholic cirrhosis.
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Affiliation(s)
- Dj Culafić
- Clinic of Gastroenterology, Clinical Center of Serbia, School of Medicine, University of Belgrade, Belgrade, Serbia
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Abstract
Primary sclerosing cholangitis (PSC) is a chronic, cholestatic liver disease caused by diffuse inflammation and fibrosis that can involve the entire biliary tree. It is a progressive disorder which can ultimately lead to biliary cirrhosis, portal hypertension and hepatic failure. PSC is a complex genetic disorder with male predominance. Environmental predisposing factors include non-smoking. It is closely associated with inflammatory bowel disease (IBD), particularly ulcerative colitis, which occurs in about two thirds of PSC cases. Recent studies have suggested that PSC-IBD is a separate disease entity from IBD alone with distinctive genetic and phenotypic characteristics. Most PSC patients are asymptomatic at presentation; clinical symptoms include fatigue, jaundice, weight loss, right upper quadrant pain and pruritis. Serum biochemical tests indicate cholestasis, and diagnosis is usually established by cholangiography. In symptomatic patients, median survival from presentation to death or liver transplantation is about 12 years. It is a premalignant condition, and the majority of deaths are from malignancy, particularly cholangiocarcinoma or colonic cancer. PSC has no curative treatment. Medical treatment with ursodeoxycholic acid may slow progression of the disease and reduce colonic dysplasia, though trials lack statistical significance. Liver transplantation is the only option in young patients with PSC and advanced liver disease.
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Bang UC, Benfield T, Bendtsen F, Hyldstrup L, Beck Jensen JE. The risk of fractures among patients with cirrhosis or chronic pancreatitis. Clin Gastroenterol Hepatol 2014; 12:320-6. [PMID: 23644391 DOI: 10.1016/j.cgh.2013.04.031] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Revised: 03/18/2013] [Accepted: 04/08/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Cirrhosis and chronic pancreatitis (CP) are accompanied by inflammation and malnutrition. Both conditions can have negative effects on bone metabolism and promote fractures. We evaluated the risk of fractures among patients with CP or cirrhosis and determined the effect of fat malabsorption on fracture risk among patients with CP. METHODS We performed a retrospective cohort study using the Danish National Patient Register to identify patients diagnosed with CP or cirrhosis. We analyzed data collected from January 1, 1995, to December 31, 2010, on 20,769 patients (35.5% women with cirrhosis and 11,972 patients (33.5% women) with CP. Each patient was compared with 10 age- and sex-matched controls. We also assessed the risk of fractures among patients with CP who received pancreatic enzyme substitution (PES) for fat malabsorption. RESULTS During the study period, bone fractures occurred in 3954 patients with cirrhosis and 2594 patients with CP. The adjusted hazard ratio (HR) for any fracture was 2.4 in patients with cirrhosis (95% confidence interval [CI], 2.2-2.5) and 1.7 in patients with CP (95% CI, 1.6-1.8). The relative risk of low-trauma fractures was highest among individuals younger than 50 years old. Alcohol as an etiology was associated with an increased risk of fracture compared with patients with nonalcoholic cirrhosis (HR, 2.4 vs 1.5; P < .0001) and CP (HR, 2.0 vs 1.5; P < .0001). Patients with CP receiving PES for fat malabsorption had a lower risk of fractures than other CP patients (HR, 0.8; 95% CI, 0.7-0.9). However, increasing the duration of treatment with PES was associated with an increased risk of fracture. CONCLUSIONS Patients, especially younger patients, with cirrhosis or CP have an increased risk of fractures of all types.
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Affiliation(s)
| | - Thomas Benfield
- Department of Infectious Diseases, University Hospital of Hvidovre, Hvidovre, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Flemming Bendtsen
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Gastroenterology, University Hospital of Hvidovre, Hvidovre, Denmark
| | - Lars Hyldstrup
- Department of Endocrinology, University Hospital of Hvidovre, Hvidovre, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jens-Erik Beck Jensen
- Department of Endocrinology, University Hospital of Hvidovre, Hvidovre, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Mitchell R, McDermid J, Ma MM, Chik CL. MELD score, insulin-like growth factor 1 and cytokines on bone density in end-stage liver disease. World J Hepatol 2011; 3:157-63. [PMID: 21860675 PMCID: PMC3159496 DOI: 10.4254/wjh.v3.i6.157] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Revised: 05/20/2011] [Accepted: 05/27/2011] [Indexed: 02/06/2023] Open
Abstract
AIM To determine the contributions of insulin-like growth factor 1 (IGF-1), cytokines and liver disease severity to bone mineral density in patients pre-transplantation. METHODS Serum IGF-1, tumor necrosis factor-α (TNFα) and interleukin 6 (IL-6) were measured and the Model for End-Stage Liver Disease (MELD) score calculated in 121 adult patients referred to a single centre for liver transplantation. Bone mineral density (BMD) of the lumbar spine and femoral neck were assessed via dual energy X-ray absorptiometry. Demographics, liver disease etiology, medication use and relevant biochemistry were recorded. RESULTS A total of 117 subjects were included, with low BMD seen in 68.6%, irrespective of disease etiology. In multivariable analysis, low body mass index (BMI), increased bone turnover and low IGF-1 were independent predictors of low spinal bone density. At the hip, BMI, IGF-1 and vitamin D status were predictive. Despite prevalent elevations of TNFα and IL-6, levels did not correlate with degree of bone loss. The MELD score failed to predict low BMD in this pre-transplant population. CONCLUSION Osteopenia/osteoporosis is common in advanced liver disease. Low serum IGF-1 is weakly predictive but serum cytokine and MELD score fail to predict the severity of bone disease.
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Affiliation(s)
- Rebecca Mitchell
- Rebecca Mitchell, Constance L Chik, Divisions of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 2S2, Alberta, Canada
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17
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Abstract
Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disorder that most commonly affects middle-aged men. PSC is strongly associated with IBD, and in this setting the risk of colorectal cancer is markedly increased. Cholangiocarcinoma, and its devastating consequences, is another well-recognized complication of PSC. This condition tends to progress to end-stage liver disease, and patients with PSC have reduced survival rates compared with the general population. Despite significant research efforts in this field, the pathogenetic mechanisms of PSC are still incompletely understood, although growing evidence supports the role of genetic and immunologic factors. Effective medical therapy is lacking; liver transplantation is the only curative treatment modality, with excellent outcomes in this patient population.
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Affiliation(s)
- Flavia Mendes
- Department of Medicine, University of Miami Miller School of Medicine, Miami VA Medical Center, 1201 NW 16th Street Miami, FL 33125, USA
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18
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Abstract
Primary sclerosing cholangitis is a cholestatic liver disease characterized by inflammation and fibrosis of intra-/extrahepatic bile ducts, leading to multifocal strictures. Primary sclerosing cholangitis exhibits a progressive course resulting in cirrhosis and the need for liver transplantation over a median period of 12 years. The disease is frequently associated with inflammatory bowel disease and carries an increased risk of colorectal cancer and cholangiocarcinoma. Despite extensive research, there is currently no effective medical treatment. Multiple drugs are shown to be ineffective in halting disease progression, including ursodeoxycholic acid, the most widely evaluated drug. High-dose ursodeoxycholic acid (28-30 mg/kg/day) was recently shown to increase the adverse events rate. Endoscopic or radiological dilatation of a 'dominant' stricture may lead to symptomatic and biochemical improvement. However, liver transplantation is the only life-prolonging treatment for patients with end-stage disease. Studies with promising drugs, such as antibiotics, antifibrotic agents and bile acid derivatives, are eagerly awaited.
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Affiliation(s)
- Emmanouil Sinakos
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905, USA
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Chapman R, Fevery J, Kalloo A, Nagorney DM, Boberg KM, Shneider B, Gores GJ. Diagnosis and management of primary sclerosing cholangitis. Hepatology 2010; 51:660-78. [PMID: 20101749 DOI: 10.1002/hep.23294] [Citation(s) in RCA: 803] [Impact Index Per Article: 57.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Abstract
Primary sclerosing cholangitis is a chronic cholestatic liver disease characterized by inflammation and fibrosis of the bile ducts, resulting in cirrhosis and need for liver transplantation and reduced life expectancy. The majority of cases occur in young and middle-aged men, often in association with inflammatory bowel disease. The etiology of primary sclerosing cholangitis includes immune-mediated components and elements of undefined nature. No effective medical therapy has been identified. The multiple complications of primary sclerosing cholangitis include metabolic bone disease, dominant strictures, bacterial cholangitis, and malignancy, particularly cholangiocarcinoma, which is the most lethal complication of primary sclerosing cholangitis. Liver transplantation is currently the only life-extending therapeutic alternative for patients with end-stage disease, although recurrence in the allografted liver has been described. A PSC-like variant attracting attention is cholangitis marked by raised levels of the immunoglobulin G4 subclass, prominence of plasma cells within the lesions, and steroid responsiveness.
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Abstract
PURPOSE OF REVIEW Primary sclerosing cholangitis is a chronic cholestatic liver disease characterized by strictures of the biliary tree complicated by cirrhosis and cholangiocarcinoma. It is immune mediated although the precise etiology remains unknown. RECENT FINDINGS Research into etiopathogenesis, epidemiology, the relationship with inflammatory bowel disease, diagnosis of cholangiocarcinoma, medical therapy, and the outcome of liver transplantation are discussed. SUMMARY It is likely that a number of patients previously diagnosed with primary sclerosing cholangitis have autoimmune pancreatitis in association with primary sclerosing cholangitis, a syndrome with distinct clinicopathological features including steroid responsiveness. Primary sclerosing cholangitis-inflammatory bowel disease probably represents a distinct inflammatory bowel disease phenotype, which has implications for colonoscopic surveillance of these patients. CA19-9 plays no surveillance role for the early detection of cholangiocarcinoma. The best-studied drug in primary sclerosing cholangitis is ursodeoxycholic acid, which, despite a range of potentially valuable actions on the cholestatic liver, has not yet been proved to make a substantial impression on the course of the disease. Orthotopic liver transplantation remains the only established long-term treatment for primary sclerosing cholangitis.
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Affiliation(s)
- George R MacFaul
- Department of Gastroenterology, John Radcliffe Hospital, Oxford, UK
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Charatcharoenwitthaya P, Lindor KD. Primary sclerosing cholangitis: diagnosis and management. Curr Gastroenterol Rep 2006; 8:75-82. [PMID: 16510038 DOI: 10.1007/s11894-006-0067-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease caused by progressive inflammatory destruction of intrahepatic and extrahepatic bile ducts, and ultimately cirrhosis. PSC occurs primarily in patients with underlying ulcerative colitis and affects primarily young to middle-aged men. PSC is believed to be an autoimmune disease mediated by immune dysregulation in patients with genetic susceptibility. One possible mechanism for the development of PSC is the homing of memory lymphocytes to the biliary tract. Cholangiography is the gold standard for diagnosis of PSC. The typical radiologic findings include multifocal strictures and dilation involving the intrahepatic or extrahepatic biliary tract, or both. Although no medical therapy has proved beneficial, a variety of agents have been tested, some of which appear promising and deserve further study. High-dose ursodeoxycholic acid may have benefit in slowing disease progression; a multicenter placebo-controlled trial is ongoing. Liver transplantation is a good option for patients with advanced PSC, although the disease can recur after successful transplantation.
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