Baseline Bone Metabolism in Patients with Hepatitis B Related Liver Disease

Background: Osteoporosis is common with cholestatic liver disease. However, in hepatitis B patients, bone loss occurs due to TNF mediated mechanisms and tenofovir worsens this. Knowledge of the baseline bone parameters will help us to correct these abnormalities before treatment. Aims: To assess the bone parameters calcium, vitamin D, parathyroid hormone and bone mineral density in patients with Hepatitis B related chronic liver disease. Methods: Consecutive Hepatitis B patients to be started on treatment based on the AASLD criteria were eligible. Study period was June 2012 to December 2013. After informed consent, serum calcium, phosphorus, Vitamin D, parathormone and DXA scan were performed. Mean T and Z scores at forearm, spine and hip and fracture risk according to WHO classification was calculated. Patients with Childs C cirrhosis, hepatocellular carcinoma, previous fracture, postmenopausal, significant alcohol, hypogonadism, corticosteroids, hyperthyroidism and sepsis were excluded. Results: One hundred and twenty-seven patients were included. There were 108 males. Mean age was 39.68 ± 11.8. Majority were from Eastern India (56); 24 patients from North India, 14 from South and 33 from Outside India (Bangladesh and Nepal). The patients included were chronic hepatitis B–59 (46.5%), Childs A cirrhosis-47 (37%) and 21 (16.5%) Childs B cirrhosis. Eighty-four (66.1%) patients were not on any treatment for hepatitis B. The ‘e’ Antigen was negative in 86 (67.7%). HBV DNA ranged between 10–4000000000 IU/ml. The bone parameters were as follows: mean calcium was 8.79 ± 0.69 (range 7–11); mean phosphate - 3.36 ± 0.69 (1–5); mean parathormone - 55.88 ± 35.3 (3–165) and mean Vitamin D-23.88 ± 12.95 (3–82). Bone Mineral Density was done in 109 patients. At forearm, 59 (46.5%) patients had normal BMD with no fracture risk, 40 (31.5%) had osteopenia with increased fracture risk and 10 (7.9%) had osteoporosis with very high fracture risk. At spine, BMD was normal in 44 (34.6%), osteopenia in 45 (35.4%) and osteoporosis in 20 (15.7%) patients respectively. Hip parameters were normal in 62 (48.8%); osteopenia in 41 (32.3%) and osteoporosis in 6 (4.7%) patients respectively. Conclusions: Majority of patients with hepatitis B who needs antivirals have low baseline Vitamin D, parathormone and abnormal bone densitometry with highest risk of fracture at the spine. Therefore, we suggest considering baseline bone mineral parameters during evaluation and correct it prior to starting treatment with antivirals which can worsen the bone mineral density.