Epidemiology

Increased risk of fractures seen in patients with cirrhosis

Last Updated: 2013-01-01 10:00:26 -0400 (Reuters Health)

By Will Boggs, MD

NEW YORK (Reuters Health) - Patients with cirrhosis face an increased risk of orthopedic fracture, researchers from Taiwan report.

"Health providers (not limited to physicians) who take care of cirrhotic patients and even family members of the patients should be aware and cautious of the increased risk of fracture among cirrhotic patients," Dr. Ching-Liang Lu from Taipei Veterans General Hospital and National Yang-Ming University told Reuters Health by email. "Every effort should be tried to prevent the fall and subsequent potential fractures."

Earlier studies of fracture risks in cirrhotic patients suggested a two-fold increased risk, but these studies were mostly small-scale case-control studies lacking details, according to the new report, online December 11 in The Journal of Hepatology.

Dr. Lu and colleagues used Taiwan's National Health Insurance database to examine the incidence of fractures and medical costs in patients with hepatic encephalopathy (HE) and compared them with cirrhotics without HE and patients without cirrhosis.

They included more than 3,700 patients with newly diagnosed HE, each matched with one cirrhotic patient without HE and one non-cirrhotic patient of like age, sex, and comorbidity.

The fracture incidence was significantly higher in the HE group (34.4/1,000 person-years) and in the cirrhosis without HE group (43.8/1,000 person-years) than in the control (without cirrhosis) group (29.6/1,000 person-years).

"No difference in the incidence rate was observed between cirrhotic patients with and without HE," the researchers note. "This result was somewhat unexpected, and the underlying cause is debatable."

After adjusting for alcoholism, the incidence of fractures was 32% higher (p=0.03) in the HE group and 63% higher (p=0.001) in the cirrhosis without HE group than in the control group.

In subanalyses, patients with HE had a significantly higher incidence of skull fractures, and patients with cirrhosis without HE had a significantly higher incidence of fractures of the spine and trunk and upper limbs.

Medical costs during 18 months of follow-up were highest in the HE group, followed by the cirrhosis without HE group and the controls. In multiple linear progression analysis, medical costs were significantly associated with fractures and HE diagnosis.

Significant independent risk fractures in the HE group included heart failure, cerebrovascular disease, and alcoholism.

Dr. Lu said the mechanism underlying the higher fracture risk among cirrhotic patients with or without HE is still unclear, but might involve a higher prevalence of osteoporosis in cirrhosis or a higher rate of falls and accidents in the patients with minimal HE.

"Though the evidence to support the intervention is still lacking, it is rational to take actions to decrease the fracture incidence," Dr. Lu said. "We suggest that all physicians who take care of the cirrhotic patients should first know this potential extra-hepatic complication and consider the potential contributing factors. Second, fall prevention and osteoporosis screening with calcium and vitamin D supplement may benefit this group of patients. Identification and subsequent treatment of the cirrhotic patients with minimal hepatic encephalopathy may also help to avoid fracture."

SOURCE: http://bit.ly/106j3u6

J Hepatol 2012.