Prevalence of hepatic osteodystrophy and vitamin D deficiency in cirrhosis

BACKGROUND

Hepatic osteodystrophy (HO) is a major complication of cirrhosis. However, the prevalence of HO in a general cirrhotic patient population is not well defined as previous studies were in single aetiology or pre-liver transplant patients.

AIMS

The aims of this study were to investigate the prevalence of HO and vitamin D deficiency in patients with cirrhosis of mixed aetiology and disease severity and to determine the risk factors for HO.

METHODS

This is a single-centre cross-sectional study of all patients newly diagnosed with cirrhosis between September 2009 and December 2012. All patients underwent bone mineral density assessment using dual energy X-ray absorptiometry within 3 months of diagnosis. Demographic and biochemical factors, severity of underlying liver disease, previous fragility fractures, smoking status and alcohol use were collected on diagnosis. Logistic regression analysis was used to assess risk factors for HO.

RESULTS

Among the 406 patients (67% males), the median (range) age was 56 years (21-85) and most (84%) were Childs-Pugh A or B with a median (range) model for end-stage liver disease score of 11 (5-40). Alcohol (41%) was the most common underlying aetiology. The prevalence of HO and vitamin D deficiency (≤50 nmol/L) was 56% and 54%, respectively, and previous fragility fractures had occurred in 3%. Increasing age (odds ratio (95% confidence interval): 1.49 per 10 years (1.02-2.18), P = 0.04), excessive alcohol intake (2.34 (1.03-5.32), P = 0.04) and lower body mass index (0.92 per kg/m2 (0.87-0.98), P = 0.009) were independent risk factors for HO.

CONCLUSION

There is a high prevalence of HO and vitamin D deficiency in patients with cirrhosis at presentation irrespective of disease severity or underlying aetiology.

Life and death on the waiting list for coronary bypass surgery

AIM

To assess the baseline characteristics of patients referred for isolated coronary bypass surgery (CABG), waiting times for coronary bypass surgery and clinical events while waiting for coronary bypass surgery. To compare the New Zealand priority scoring system with a previously validated Ontario urgency score.

METHODS

Outcomes in a consecutive case series of 88 patients referred from Christchurch Hospital for coronary bypass surgery between July 1 and December 31 1993 were compared with a previous Christchurch case series and a contemporary Canadian case series. Patients were stratified according to both Ontario and New Zealand priority scores.

RESULTS

Of 88 patients, one patient died prior to surgery, 79 had undergone coronary bypass surgery (with three deaths), and eight were still waiting as at December 31 1995. Twenty five percent of patients had left main disease, another 60% had multivessel disease that included the proximal left anterior descending coronary artery and 64% had angina at rest or on minimal exertion. The median waiting time was 92 days (inter-quartile range 20-234), 8 (6-12) days in the 23 patients who underwent surgery as in-hospital cases, and 181 (83-295) in those who waited at home. Patients with left main disease waited a median of 41 (11-205) days. While waiting at home one patient died, one patient suffered a myocardial infarction, and 17 patients were readmitted with unstable angina. Readmissions were not predicted by New Zealand or Ontario priority scores, nor by clinical variables.

CONCLUSIONS

Thresholds for referral are very similar, but waiting times for coronary bypass surgery are far longer in New Zealand than Canada. The long waiting times are a considerable cost to both patients and government. Priority scores facilitate comparison between countries but they may not predict readmission to hospital while on a long waiting list.