Treatment options for osteoporosis in chronic liver disease patients requiring liver transplantation

As patient life expectancy rises after liver transplantation, osteoporosis becomes a significant contributor to morbidity and mortality. Patients who undergo liver transplant have an increased risk of bone fractures secondary to osteoporosis, relative to the general population. Risk factors (pre- and posttransplant) include treatment with steroids, alcohol abuse, smoking, poor nutritional status, immobility, reduced muscle mass, menopause, and hypogonadism. The role of cholestatic liver disease is well recognized, but as of yet, the underlying etiology is unknown. The role of immunosuppressants is also evident, but their exact contribution remains to be established. Currently, there are no established therapies for osteoporosis secondary to liver transplantation. Most of the therapeutic options have been extrapolated from usual treatment options for osteoporosis in the general population. It is reasonable to attempt to lower steroid dosages, especially with the availability of new and more potent immunosuppressants such as mycophenolate mofetil and tacrolimus. Potentially, high-risk patients could be identified early with BMD screening. Preventive measures could be instituted and patients could be monitored more closely for objective signs of osteoporosis, such as decline in BMD and early fractures. Calcium and vitamin D supplementation may be helpful in those with deficiencies or poor nutritional intake, as well as in women older than 25 years. The role of bisphosphonates and hormone replacement therapy remains equivocal as studies in transplant patients are currently lacking. Risk versus benefit must be weighed on an individual basis. Lifestyle measures should be instituted in all patients if possible.