Copyright: ©Author(s) 2026. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution-NonCommercial (CC BY-NC 4.0) license. No commercial re-use. See permissions. Published by Baishideng Publishing Group Inc.
World J Hepatol. Aug 27, 2026; 18(8): 120697
Published online Aug 27, 2026. doi: 10.4254/wjh.120697
Examination of bone mineral density in patients with varied liver diseases - a cross-sectional study
Oliver Rohland, Lysann Schwarzer, Laura Schwenk, Nicola Pollmann, Aladdin Ali Deeb, Utz Settmacher, Falk Rauchfuss, Felix Dondorf, Karin Amrein, Roland Kocijan, Michael Ardelt
Oliver Rohland, Lysann Schwarzer, Laura Schwenk, Nicola Pollmann, Aladdin Ali Deeb, Utz Settmacher, Falk Rauchfuss, Felix Dondorf, Michael Ardelt, Department of General, Visceral and Vascular Surgery, University Hospital Jena, Jena 07747, Thuringia, Germany
Karin Amrein, Department of Internal Medicine, Medical University of Graz, Graz 8036, Austria
Roland Kocijan, Medical Faculty of Bone Diseases, Sigmund Freud University, Vienna 1020, Wien, Austria
Roland Kocijan, Ludwig Boltzmann Institute of Osteology, Hanusch Hospital of OEGK and AUVA, Vienna 1140, Wien, Austria
Co-first authors: Oliver Rohland and Lysann Schwarzer.
Author contributions: Rohland O and Schwarzer L contributed to this work and performed the majority of the study, including study design, data collection, data analysis, and manuscript preparation, they contributed equally to this article, they are the co-first authors of this manuscript; Amrein K and Kocijan R contributed to data acquisition, data analysis, and the scientific concept of the study; Schwenk L, Pollmann N, Ali Deeb A, Settmacher U, Rauchfuss F, and Dondorf F contributed to literature research and critical revision of the manuscript; Ardelt M contributed to the scientific concept, literature review, and critical revision of the manuscript; and all authors approved the final version of the manuscript.
AI contribution statement: ChatGPT (OpenAI) was used exclusively for language-related assistance during the preparation of this manuscript. Specifically, it was employed to support the translation of selected text passages into English and for proofreading to improve grammar, spelling, clarity, and readability. All scientific content, data analysis, interpretation of results, and conclusions were developed, verified, and approved by the authors, who take full responsibility for the final manuscript.
Institutional review board statement: This study was approved by the Medical Ethics Committee of University Hospital Jena, approval No. 2025-3947-BO-D.
Informed consent statement: Informed consent was obtained from all the subjects involved in the study.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: The data presented in this study are available on request from the corresponding author.
Corresponding author: Oliver Rohland, MD, Department of General, Visceral and Vascular Surgery, University Hospital Jena, Am Klinikum 1, Jena 07747, Thuringia, Germany.
oliver.rohland@med.uni-jena.de
Received: March 6, 2026
Revised: April 14, 2026
Accepted: July 29, 2026
Published online: August 27, 2026
Processing time: 165 Days and 19.1 Hours
BACKGROUND
Chronic liver disease is associated with profound alterations in bone metabolism, predisposing patients to secondary osteoporosis and fragility fractures - a condition commonly termed hepatic osteodystrophy. The pathogenesis of bone loss in chronic liver disease is multifactorial, involving increased osteoclastic activity, impaired osteoblast function, chronic inflammation, malnutrition, and deficiencies of vitamin D and K. Among these, cholestatic liver diseases such as primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC) are particularly prone to severe bone loss, whereas viral hepatitis and autoimmune hepatitis (AIH) may contribute through inflammatory and steroid-mediated mechanisms. Despite this, comparative data on bone mineral density (BMD) across different etiologies of end-stage liver disease remain limited, particularly in patients awaiting liver transplantation.
AIM
To compare BMD and bone turnover markers among patients with different etiologies of end-stage liver disease listed for liver transplantation.
METHODS
This retrospective, cross-sectional study included 82 patients with end-stage liver disease: AIH, hepatitis C virus infection, PBC, PSC, and polycystic liver disease. Areal BMD at the lumbar spine and femoral neck was measured using dual-energy X-ray absorptiometry. Standard hepatic parameters (bilirubin, international normalized ratio, creatinine, albumin), and bone turnover and micronutrient markers (25-hydroxyvitamin D, parathyroid hormone, osteocalcin, phosphate, calcium, magnesium, ferritin, zinc, and copper.) were analyzed from clinical laboratory data. The Model of End-stage Liver Disease-score and Child-Pugh scores were analyzed. Data on current or prior use of bisphosphonates and glucocorticoids were extracted from patient records.
RESULTS
All liver disease groups showed significantly reduced lumbar spine BMD compared to controls (P < 0.01), with the lowest lumbar spine T-scores in PBC (-2.5) and PSC (-2.1). Femoral BMD was less affected but still reduced in several groups. Elevated osteocalcin and parathormone levels were most pronounced in patients with hepatic cysts. AIH patients exhibited less severe bone loss, despite glucocorticoid exposure in some cases.
CONCLUSION
Reduced BMD is prevalent across hepatic disease entities in liver transplant candidates, particularly in cholestatic and cystic liver disease. Early screening and targeted bone-protective strategies are essential to mitigate fracture risk in this population.
Core Tip: Patients with end-stage liver disease are at high risk of reduced bone mineral density, particularly in cholestatic liver diseases such as primary biliary cholangitis and primary sclerosing cholangitis. This study demonstrates that bone loss varies according to the underlying liver disease etiology. Given the high prevalence of osteoporosis in this population, early assessment using dual-energy X-ray absorptiometry should be considered in clinical routine to identify patients at risk and guide preventive strategies.
