Osteoporosis is common in patients with chronic cholestatic
liver disease, and atraumatic
spinal fracture is a recognized complication after orthotopic
liver transplantation.
Bisphosphonates are potent inhibitors of osteoclast
bone resorption and have been successfully used to treat
postmenopausal osteoporosis. We examined whether preoperative bone mineral density can predict the risk of fracture after orthotopic
liver transplantation and whether intravenous
bisphosphonate can prevent fractures in high-risk patients. Beginning in February 1993, standard bone mineral density measurements of the lumbar spine were performed as part of routine pretransplantation assessment. On the basis of a preliminary analysis from January 1995, patients with a lumbar spine bone mineral density of <0.84 g/cm2, or <84% of the predicted value (age/sex), were treated with intravenous
bisphosphonate (
pamidronate disodium) every 3 months before and for 9 months after
liver transplantation. Bone mineral density measurements were available in 90 of 136 consecutive first transplants performed in our unit from February 1993 to September 1996. Before the use of
pamidronate, 7 patients sustained symptomatic vertebral fractures. Their mean spine bone mineral density was lower than in the 38 patients with no clinical evidence of fracture (81.8% +/- 12.3% v 94.2% +/- 10.2%; P = .006). Since the introduction of
pamidronate, no symptomatic vertebral fractures have occurred. Of 29 surviving patients with bone mineral density <0.84 g/cm2 before
transplantation, 38% who did not receive treatment with
pamidronate suffered
spontaneous fracture, whereas 0 of 13 who received treatment suffered such a complication. A low lumbar spine bone mineral density is associated with a high risk of symptomatic vertebral fracture after
liver transplantation. These results suggest that this risk is considerably reduced by the administration of intravenous
bisphosphonate before and after
transplantation.