Liver Diseases Cause Bone Disease

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John A. Donovan, MD
Keck School of Medicine
University of Southern California

Persons with chronic liver disease are at risk to develop more premature and more clinically significant loss of bone density. Chronic liver diseases of all types can cause " metabolic bone disease", weakened bone, and osteoporosis. Care of the patient with chronic liver disease includes careful assessment of bone health and may include the prescription of therapies to improve bone strength.


Bones enable us to stand erect, ambulate, and function within our environment. Good bone health depends upon a dynamic process of bone remodeling. This life-long remodeling process bone resorption and bone formation. Bone resorption and formation are caused by the action of specialized bone cells known as osteoclasts (resorption) and osteoblasts (formation). As a body develops and grows, bone formation exceeds resorption and bones and skeletons are strengthened. Aging beyond the fourth decade shifts the balance of remodeling towards bone resorption. Diminished exercise, smoking and alcohol use accelerate the progressive loss of bone density with advancing age. Severity of bone density loss can be quantitatively assessed by bone densiometry. Weakened bones are fragile and more likely to fracture.


Medical recommendations to slow the progression of metabolic bone disease and loss of bone density usually include increased exercise, smoking cessation, avoidance of excessive alcohol use, use of calcium supplements, and hormone replacement therapy (HRT) for post-menopausal women without contraindications to hormone prescription.


All types of chronic liver disease and cirrhosis predispose individuals of all ages and both sexes to the effects of metabolic bone disease. Individuals with cholestatic liver diseases (primary biliary cirrhosis or primary sclerosing cholangitis) are at particular risk because of an associated impairment of vitamin D absorption that causes a decrease in the uptake of dietary calcium. Prednisone therapy for autoimmune hepatitis is cause for accelerated bone density loss that is an indication to preemptively initiate "steroid sparing" immunosupression treatment.


Liver transplantation may eventually, but not immediately, restore the bone lost because of earlier chronic liver disease. Loss of bone density continues in the first months after liver replacement and be related to prescribed anti-rejection regimens using higher immunosupression and steroid doses. Delayed recovery of bone density usually occurs by the end of the first year following liver transplantation.


Medical care of patients with chronic liver disease should usually include assessment of bone health. Bone densiometry is the most often used diagnostic tool. Bone density can be initially evaluated and later testing can be used to determine response to prescribed therapies.


Depending on the severity of the bone density loss, prescribed therapies may include recommendations for increased exercise, smoking cessation, calcium and vitamin D supplementation, calcitonin, and biphosphonates. In general, hepatologists do not consider most chronic liver diseases or cirrhosis to be a contraindication to the prescription of hormone replacement therapy so long as liver function is closely monitored and there are no other contraindications to HRT.


Ask your doctor to help take care of your bones.