title: Increased incidence of orthopedic fractures in cirrhotic patients: a nationwide population-based study.
abstract: OBJECTIVE
  Hepatic encephalopathy (HE) is a reversible neuropsychiatric disorder in cirrhotic patients. The cognitive dysfunction and increased accidental falls in HE and osteodystrophy in cirrhotic patients may contribute to orthopedic fractures. This study investigated the fracture incidence and risk factors in cirrhotic patients with HE.
  
  
  METHODS
  In total, 3764 cirrhotic patients with HE were identified from the Taiwan National Health Insurance database between 2000 and 2009. The fracture incidence of the HE patients was compared with that of 3764 age-, sex-, and comorbidity-matched cirrhotic patients without HE and non-cirrhotic controls. Cox proportional hazard models were used to estimate the risk of fracture in the HE patients.
  
  
  RESULTS
  Cirrhotic patients with and without HE had comparable increased risks of fracture (p <0.05) and cumulative incidences of fracture than controls (log-rank p <0.001). The estimated fracture rates were 7.09% for the HE group, 7.72% for the cirrhosis without HE group, and 4.05% for the controls, during the 18-month follow-up. The HE group had a higher incidence rate of skull fractures (IRR=2.61, 95% CI 1.04-6.57), but a lower rate of upper limb fractures (IRR=0.45, 95% CI 0.29-0.70) than the cirrhosis without HE group. Alcoholism, heart failure, and cerebrovascular disease were associated with increased risk of fracture in HE patients.
  
  
  CONCLUSIONS
  Cirrhotic patients, with or without HE, are at an increased risk of orthopedic fractures. Skull fractures, rather than fractures in weight-bearing bones, are more frequently observed in HE patients, particularly those with comorbidities.
authors.affiliation: Institute of Brain Science, National Yang-Ming University Schools of Medicine, Taipei, Taiwan.
authors.forename: Chia-Fen
authors.initials: CF
authors.lastname: Tsai
authors.forename: Chia-Jen
authors.initials: CJ
authors.lastname: Liu
authors.forename: Tzeng-Ji
authors.initials: TJ
authors.lastname: Chen
authors.forename: Chi-Jen
authors.initials: CJ
authors.lastname: Chu
authors.forename: Han-Chieh
authors.initials: HC
authors.lastname: Lin
authors.forename: Fa-Yauh
authors.initials: FY
authors.lastname: Lee
authors.forename: Tung-Ping
authors.initials: TP
authors.lastname: Su
authors.forename: Ching-Liang
authors.initials: CL
authors.lastname: Lu
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016022:Case-Control Studies; D015331:Cohort Studies; D005260:Female; D050723:Fractures, Bone / Q000453:epidemiology* / Q000209:etiology*; D006333:Heart Failure / Q000150:complications; D006501:Hepatic Encephalopathy / Q000150:complications; D006801:Humans; D015994:Incidence; D008103:Liver Cirrhosis / Q000150:complications*; D008104:Liver Cirrhosis, Alcoholic / Q000150:complications; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D012307:Risk Factors; D020521:Stroke / Q000150:complications; D013624:Taiwan / Q000453:epidemiology; D055815:Young Adult