Clinical insights into the association between chronic liver disease and osteoporosis

Osteoporosis is a common complication among children with chronic liver disease (CLD) and cholestasis. This condition is multifactorial, as many different liver dysfunction-related mechanisms contribute to bone loss. The overall prevalence of osteoporosis in patients with advanced CLD ranges from 12% to more than 55%. Patients with CLD have a 2- to 4-fold higher risk of hip, vertebral, and nonvertebral fractures than do matched healthy individuals. Vertebral fractures are particularly common, often occurring in 20% to 30% of cirrhotic patients, even in those whose bone mineral density scores do not strictly meet the osteoporosis threshold. Research in this field has focused primarily on bone health in patients with chronic cholestatic liver diseases, particularly primary biliary cholangitis, before and after liver transplantation. However, studies on bone and mineral disorders associated with other liver diseases, such as viral hepatitis, nonalcoholic fatty liver disease, hemochromatosis, Wilson's disease, and alcoholic liver disease, are rare. Many factors, including impaired bone formation, increased bone resorption, vitamin D deficiency, sex hormone deficiency, nutritional deficiency, and alcohol toxicity contribute to the accurate diagnosis of bone disorders, most commonly osteomalacia and osteoporosis, but they also result in management dilemmas. The management of bone complications in patients with cholestatic and advanced forms of liver disease can be challenging because treatment requires establishing the underlying cause and promoting bone health by increasing bone formation. In many clinics, physicians encounter challenging cases of vertebral fractures because approximately one-third of vertebral fractures are asymptomatic. Therefore, identifying the cause of unknown bone complications in children with CLD is challenging. Thus, this review discusses the association between chronic liver disease and osteoporosis in children.