title: Fractures and avascular necrosis before and after orthotopic liver transplantation: long-term follow-up and predictive factors.
abstract: With early posttransplant bone loss, orthotopic liver transplantation (OLT) recipients experience a high rate of fracturing and some avascular necrosis (AVN), but little is known about the incidence of and predictive factors for these skeletal complications. We studied 360 consecutive patients who underwent transplantation for primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC) and assessed both vertebral and nonvertebral (rib, pelvic, and femur) fractures in a protocolized fashion. Before OLT, 20% of the patients had experienced fracturing, and 1.4% of the patients had experienced AVN. Following OLT, there was a sharp increase in fracturing, with a 30% cumulative incidence of fractures at 1 year and 46% at 8 years after transplantation. In contrast to previous studies, there was a similar incidence of posttransplant vertebral and nonvertebral fractures. The greatest risk factors for posttransplant fracturing were pretransplant fracturing and the severity of osteopenia and posttransplant glucocorticoids. Nine percent of the liver recipients experienced AVN after OLT, and this correlated with pretransplant and posttransplant lipid metabolism, bone disease (bone mineral density and fracturing), and posttransplant glucocorticoids. A novel association between cholestasis and AVN was also identified, the mechanism for which is not known.
  
  
  CONCLUSIONS
  Fortunately, recent years have seen an increase in the bone mass of liver recipients and, along with this, less fracturing and less AVN. Nonetheless, 25% of patients undergoing OLT for chronic cholestatic liver disease still develop de novo fractures after OLT; this situation demands an ongoing search for effective therapeutic agents for these patients.
authors.affiliation: Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA.
authors.forename: Maureen M J
authors.initials: MM
authors.lastname: Guichelaar
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Schmoll
authors.forename: Michael
authors.initials: M
authors.lastname: Malinchoc
authors.forename: J Eileen
authors.initials: JE
authors.lastname: Hay
mesh_terms: D000328:Adult; D001851:Bone Diseases, Metabolic / Q000150:complications / Q000209:etiology / Q000503:physiopathology; D015209:Cholangitis, Sclerosing / Q000150:complications* / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D050723:Fractures, Bone / Q000209:etiology* / Q000503:physiopathology; D005938:Glucocorticoids / Q000009:adverse effects / Q000627:therapeutic use; D006801:Humans; D015994:Incidence; D008105:Liver Cirrhosis, Biliary / Q000150:complications* / Q000601:surgery; D016031:Liver Transplantation / Q000009:adverse effects*; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010020:Osteonecrosis / Q000209:etiology* / Q000503:physiopathology; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D012307:Risk Factors
chemical_list: D005938:Glucocorticoids