Hepatic osteodystrophy: An underrecognized metabolic bone disease

Figure 1 Outline of pathogenesis of hepatic osteodystrophy: Reduced osteoblast function, activated functions of osteoclasts and other factors. IGF-1: Insulin-like growth factor 1; OPG: Osteoprotegerin; RANKL: Receptor activator of nuclear factor kappa-B ligand.

Figure 2 Role of inflammatory cytokines and hormonal factors in the pathogenesis of hepatic osteodystrophy (Solid arrows display known pathways, while interrupted arrows suggest pathways with little evidence). IGF-1: Insulin-like growth factor 1; OPG: Osteoprotegerin; PTH: Parathyroid hormone; TNF: Tumor necrosis factor.

Figure 3 Diagnosis and treatment of bone disorders among patients with chronic liver disease[80]. ¹According to the severity of liver disease and cholestasis, and in patients taking steroids; ²Calcium (1000–1500 mg/day) and vitamin D (400–800 IU/day) are necessary to maintain normal levels; ³Depending on additional risk factors. DXA: Dual energy X-ray absorptiometry.

Figure 4 Schematic diagram of contributing factors to the development of osteoporosis in chronic liver disease, preventive interventions, and treatment of osteoporosis[1]. PBC: Primary biliary cholangitis; PSC: Primary sclerosing cholangitis; NASH: Non-alcoholic steatohepatitis.