Hepatic osteodystrophy: An underrecognized metabolic bone disease.

Hepatic osteodystrophy (HO) is a common and frequently untreated complication, manifested as osteoporosis or osteopenia, encountered in the evolution of chronic liver diseases (CLD). In addition to patients with chronic cholestasis and cirrhosis, patients with CLD from other etiologies may be affected. Several studies have reported an increased prevalence of osteoporosis/osteopenia in patients with CLD. The pathogenesis varies according to etiology and is multifactorial, involving genetic factors, vitamin deficiencies, proinflammatory cytokines, hypogonadism, hyperbilirubinemia, antiviral therapy, corticosteroids, and lifestyle factors. The approach to management should include individualized assessment for fracture risk factors and bone mineral density. Prevention of osteoporosis in CLD relies on the mitigation of risk factors, treatment of underlying hypogonadism, and encouraging a healthy diet and weight-bearing exercise. Treatment trials specific to HO are small, and the primary medical intervention for the treatment of osteoporosis in CLD remains bisphosphonates although the benefit in fracture reduction has not consistently been shown. Further research is necessary to better define the management and specific treatment of HO for the prevention of fragility fractures and to improve the quality of life. This article provides an updated review of HO covering all these aspects.