title: Fracture risk calculation tool enhances dual-energy X-ray absorptiometry scan referral pathway in cirrhosis patients.
abstract: OBJECTIVE
  Liver cirrhosis is associated with osteoporosis leading to an increased risk of fractures. We aimed to establish whether a risk stratification strategy using a fracture risk calculation tool (FRAX) to determine which patients should receive a dual-energy X-ray absorptiometry (DXA) scan is effective in reducing scan rates without compromising sensitivity for detecting osteoporosis.
  
  
  METHODS
  A retrospective analysis of 252 patients with liver cirrhosis attending hepatoma surveillance clinics. Receiver operating characteristic analysis was performed to assess sensitivity and specificity at 10-year fracture risk thresholds of 5, 10 and 15%.
  
  
  RESULTS
  DXA scans were performed among 252 patients. Mean age was 61.6±10.2 years, of which 53.2% were male. Cirrhosis aetiology was largely a result of alcohol excess (n=33.3%), chronic hepatitis C virus infection (n=20.2%) and nonalcoholic fatty liver disease (n=15.9%). The majority of patients were in good prognostic groups (87.4% Child-Pugh A, 11.3% Child-Pugh B, 1.3% Child-Pugh C). Osteoporosis was present in 19.0% of those who underwent DXA scanning. The optimum 10-year fracture risk threshold was found to be 10% using the FRAX tool. This retained a high sensitivity of 95.8%, specificity 64.7%, and negative predictive value 98.5%. Introduction of a 10% FRAX threshold would result in a reduction of the DXA scanning rate to 46.8% of the current rate.
  
  
  CONCLUSIONS
  A risk stratification strategy for DXA scanning using a fracture risk assessment tool (FRAX) and a 10-year fracture risk threshold of 10% leads to a significant reduction in scan rates without compromising osteoporosis detection rates.
authors.affiliation: Departments of aGastroenterology bRheumatology, Aberdeen Royal Infirmary, Aberdeen, UK.
authors.forename: Ruairidh
authors.initials: R
authors.lastname: Nicoll
authors.forename: Alison
authors.initials: A
authors.lastname: Black
authors.forename: Lorna
authors.initials: L
authors.lastname: Bailey
authors.forename: Pauline
authors.initials: P
authors.lastname: Dundas
authors.forename: Lindsay
authors.initials: L
authors.lastname: McLeman
authors.forename: Balasubramaniam
authors.initials: B
authors.lastname: Vijayan
authors.forename: Andrew
authors.initials: A
authors.lastname: Fraser
authors.forename: Ashis
authors.initials: A
authors.lastname: Mukhopadhya
mesh_terms: D015502:Absorptiometry, Photon / Q000379:methods; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications*; D008297:Male; D008875:Middle Aged; D010024:Osteoporosis / Q000000981:diagnostic imaging* / Q000209:etiology*; D058866:Osteoporotic Fractures / Q000209:etiology*; D018579:Patient Selection; D012372:ROC Curve; D012017:Referral and Consultation / Q000458:organization & administration; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods; D012307:Risk Factors; D012680:Sensitivity and Specificity