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American Journal of  Medical 
Science and Innovation (AJMSI) 

Assessment of  Bone Mineral Density in Cirrhotic Patients at Ibn Sina Hospital
Amjed Mohammed Osman Bashir1*, Hala Ibrahim Abu Alhassan2, Abdel Moneamal Taeb2, Ismat Abdel Rahmansirag2

Volume 4 Issue 1, Year 2025
ISSN: 2836-8509 (Online)

DOI: https://doi.org/10.54536/ajmsi.v4i1.3126
https://journals.e-palli.com/home/index.php/ajmsi

Article Information ABSTRACT

Received: June 01, 2024
Accepted: July 11, 2024
Published: April 23, 2025

Bone diseases are prevalent in patients with liver cirrhosis. Bone mineral density is the most 
reliable method for detecting osteoporosis, osteopenia, and vulnerability to fractures, with an 
average prevalence of  35% worldwide. The study aimed to assess the relationship between 
bone mineral density and liver cirrhosis among Sudanese patients. A cross-sectional study 
was conducted at Ibn-Sina Specialized Hospital among Sudanese patients from June 2019 to 
November 2019. The study population consists of  80 patients suffering from liver cirrhosis 
and reduced bone mineral density. Bone mineral density was measured using DEXA. The 
diagnosis of  osteoporosis and osteopenia was based on the criteria established by the WHO. 
Further, the severity of  liver cirrhosis was assessed using MELD and Child-Pugh Turcott 
Scores. Ethical approval and written informed consent were obtained. However, data were 
analyzed using appropriate statistical tests. The analysis revealed that among 80 patients 
(63.8%) were males and (36.2%) were females, with hepatitis B being the primary cause 
(61.3%), alcohol consumption (8.8%), and hepatitis C (3.8%). The average MELD score 
was 15±6. However, abnormal DEXA values were observed in (63.8%) of  the patients, with 
(55%) showing osteopenia and (8.8%) showing osteoporosis. Patients with encephalopathy 
had a high prevalence of  osteoporosis and osteopenia with a significant p-value (p=0.002). 
Other prominent factors included increased bilirubin (P= 0.000), hypernatremia (p=0.000), 
advanced Child-pugh score (p= 0.041), and high MELD scoring of  liver cirrhosis (p = 
0.000), showed statistical significance among these patients. The study showed that patients 
with liver cirrhosis were more susceptible to reduced bone mineral density, emphasizing the need 
for timely diagnosis and treatment of  bone health issues. However,  further research is required to 
examine the correlation between liver cirrhosis and bone disease in Sudan’s population.

Keywords
Bone Mineral Densitometry,  
Bone Mineral Density, Chronic 
Liver Disease, Cirrhosis, Dual 
Energy X-ray Absorptiometry, 
Elastography, Fragility Fracture 
Risk Assessment, Model for End-
Stage Liver Disease, Osteoporosis, 
Osteopenia

1 Department of  Medicine, Bakht El Ruda University & Sudan Medical Specialization Board Council of  Internal Medicine,
  Al Khurtum, Sudan
2 Ibn Sina Hospital, Mohammed Najeeb St, Khartoum, Sudan
* Corresponding author’s e-mail: amjedmohammed58@outlook.com

INTRODUCTION
The Bone Mineral Density (BMD) test is utilized to 
measure the amount of  calcium and other minerals in 
bones (Ahmadi et al., 2018). Bones with a higher mineral 
content tend to be denser, resulting in increased strength 
and reduced risk of  fractures (Burr, 2019). Aging or 
certain medical conditions can decrease bone density 
(Aspray & Hill, 2019). In addition, BMD is the most 
reliable method for diagnosing osteopenia, osteoporosis, 
and the associated risk of  fractures (Choksi et al., 
2018; Rossini et al., 2016). Osteoporosis is a condition 
characterized by the weakening and fragility of  bones, 
which significantly increases the risk of  fractures. This 
condition can be caused by excessive bone resorption 
(Wilson, 2019). BMD assays are commonly employed for 
the identification and assessment of  osteoporosis (Sözen 
et al., 2017). The BMD is directly affected by the number 
of  bones present in the skeleton, and stronger bones 
are associated with higher BMD (Burr, 2019; Nayak et 
al., 2016). However, genetic factors exert a substantial 
impact, which may occasionally be modified by external 
factors and medications (Nayak et al., 2016). 
Typically, BMD increases during childhood, reaches 
the highest point at the age of  25, and subsequently 
stabilizes for ten years. As people age, both men and 
women typically lose 0.3 to 0.5% of  their BMD after the 
age of  35 years (Nayak et al., 2016). The Dual-Energy 

X-ray Absorptiometry (DEXA) screening method is 
frequently employed to assess BMD in Fragility Fracture 
Risk Assessment (FRAX) (Haseltine et al., 2021). Social 
guidelines delineate the populations that are anticipated to 
benefit from DEXA screening and provide instructions 
on utilizing the FRAX tool to assist with decisions 
regarding osteoporosis treatment strategies (Haseltine 
et al., 2021; Iseri et al., 2020). Additionally, BMD 
problems can arise in people with chronic liver diseases, 
such as autoimmune, post-viral cirrhosis, cholestatic 
disorders, and alcohol consumption (George et al., 2009; 
Mancell, 2020). This condition is known as Hepatic 
Osteodystrophy (HO), which is frequently identified in 
patients with Chronic Liver Disease (CLD) (Ranjan et al., 
2021). The cause of  the disease is not well understood and 
is thought to differ depending on the type, severity, and 
course of  liver disease, as well as other factors, such as the 
ethnicity of  the population (Barbu et al., 2017). However, 
HO can result in the occurrence of  spontaneous low-
trauma fractures, leading to a substantial negative impact 
on morbidity, quality of  life, and even survival (Karoli et 
al., 2016). The main symptoms of  this are discomfort, 
deformity, and immobility (Haseltine et al., 2021).
Cirrhosis, a prevalent global health issue, can arise from 
various factors, including obesity, non-alcoholic fatty liver 
disease, excessive alcohol consumption, nonalcoholic 
steatohepatitis, hepatitis B or C infections, autoimmune 



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disorders, cholestatic conditions, and imbalances in iron 
or copper levels (Ginès et al., 2021; Smith et al., 2019). 
As cirrhosis progresses, there is a prolonged period 
of  inflammation that causes fibrotic and regenerative 
nodules to replace healthy liver tissue, which raises 
the risk of  portal hypertension (Takahara et al., 2019). 
Compensated cirrhosis is an asymptomatic phase of  
the disease that progresses to decompensated cirrhosis 
(Kumar et al., 2023), a symptomatic phase characterized by 
frequent hospitalization, a decline in quality of  life, and an 
increased risk of  death (D’Amico et al., 2022; Zaccherini 
et al., 2021). The primary factors contributing to illness 
outcomes include liver failure, systematic inflammation, 
and increased hypertension (Costa et al., 2021). Treating 
the underlying causes of  liver cirrhosis and controlling 
its side effects are the main goals of  management; in 
some circumstances, Liver Transplantation (LT) may be 
necessary, and it is a gold standard for treatment (Markin 
et al., 2019; Trebicka et al., 2020). As liver transplantation 
becomes more common as the primary treatment of  
end-stage cirrhosis resulting from various causes (Goel 
et al., 2019), bone disease has become a crucial factor 
in determining the patient’s survival and quality of  life 
(D’Oronzo et al., 2019; George et al., 2009). However, 
the diagnosis of  liver cirrhosis can be accomplished by 
the utilization of  elastography, a technique that assesses 
liver stiffness, in addition to a variety of  blood tests that 
measure fibrosis scores (Yoshiji et al., 2021).
CLD prevalence in Sudan is unknown, but it is a 
significant healthcare burden due to diverse etiologies. 
The 2018 Hepahealth survey found that cirrhosis 
and CLD prevalence in Europe ranges from 500 to 
1100 cases per 100,000 individuals (Traub et al., 2021). 
The US experienced a 65% rise in mortality associated 
with cirrhosis between 1999 and 2016, resulting in 
approximately 44,000 deaths in the US  and 2 million 
worldwide (Pimpin, 2018). Moreover, variability in 
patient characteristics may account for differences in the 
reported osteoporosis prevalence among CLD patients 
(Muhsen et al., 2018). There is inconsistent advice on 
when to test for BMD in CLD patients (Danford et 
al., 2020). Latent osteoporosis increases fracture risk, 
leading to higher hospitalization, morbidity, and mortality 
(Muhsen et al., 2018). Thus, early diagnosis is crucial for 
cirrhotic patients to prevent fractures and improve their 
quality of  life (Gokcan et al., 2020). Studies showed that 
bone diseases are common in cirrhosis patients even after 
controlling for confounding factors (CHEN et al., 1996; 
Danford et al., 2020; Lupoli et al., 2016). This occurs due 
to decreased BMD, and the risk of  fractures in cirrhosis 
is twice as high as that of  the general population (Jeong 
& Kim, 2019; Santos & Romeiro, 2016). Studies on BMD 
in Sudanese cirrhosis patients are scarce.
Therefore, the study aimed to assess the relationship 
between bone mineral density and liver cirrhosis among 
Sudanese patients. The present study provides insights 
into the incidence, risk factors, signs, prevention, and 
treatment of  BMD in liver cirrhosis patients, defining 
osteoporosis or osteopenia.

MATERIALS AND METHODS
Study Design and Population
This cross-sectional study was conducted at Ibn-Sina 
Specialized Hospital among Sudanese patients from June 
2019 to November 2019. The study population consists 
of  80 patients suffering from liver cirrhosis.

Ethical Approval
Ethical approval was obtained from the Sudan Medical 
Specialization Board (SMSB) and Ibn Sina Hospital’s 
ethical committee. Written informed consent was also 
obtained from the patients, and the study was carried out 
in conformity with the 1964 Declaration of  Helsinki. The 
STROBE guidelines were followed, and any subsequent 
revisions or with comparable ethical standards.

Inclusion and Exclusion Criteria
The study included a clinically suitable participant cohort. 
The study included patients suffering from liver cirrhosis. 
Conversely, the exclusion criteria included patients 
who had renal dysfunction, thyroid and parathyroid 
disorders, Cushing’s syndrome, and diabetes. Similarly, 
the study excluded patients who had a history of  chronic 
disorders associated with changes in mineral metabolism. 
Furthermore, patients who received calcium, Vitamin 
D, and medications influencing bone metabolism such 
as corticosteroids, hormone replacement therapy, 
calcitonin, bisphosphonates, cytotoxics, anti-metabolites, 
anticoagulants, anti-convulsants, thyroxin and interferon 
were excluded from the study. 

Sample Size Calculation
The sample size was calculated using the following 
formula:
N = ((z)2 P (1-P))/(d)2 
N = ((1.96)2 x 0.05 (1-0.05))/(0.05)2 
N = 80 Cirrhotic patients
Where;
N = Sample Size
Z = Confidence interval 
P = Previous prevalence (5%)
d = marginal error (0.05)

Data Collection 
The data was collected through structured questionnaires 
consisting of  6 components: a) demographic data, b) 
etiology and complications of  liver cirrhosis, c) symptoms 
of  osteoporosis, d) cirrhosis severity by using (CTP 
and MELD scores), e) lab investigations, and f) DEXA 
findings. 

Clinical Procedure
Bone mineral density was assessed in the patient’s heel using 
the Furuno CM-200 light ultrasound bone densitometer, 
a compact and portable device manufactured by Furuno 
Electric Co. LTD in Japan. During the procedure, the 
patient placed their bare feet, right and left, in designated 
spaces within the machine while a lubrication gel was 
applied. Subsequently, the system adapts to accurately 



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interpret the score. The results were interpreted according 
to the criteria of  WHO: 

• T-score of  -1.0 or above = normal bone density
• T-score between -1.0 and -2.5 = low bone density or 

osteopenia
• T-score of  -2.5 or lower = osteoporosis

Data Analysis
The data was analyzed using Statistical Package for Social 
Sciences (SPSS Inc., Chicago, IL, USA) version 21.0. 
Descriptive statistics were calculated, which included 
frequencies and percentages, whereas the Chi-square 
(χ2) test was employed to analyze categorical data. The 

P-value of  < 0.05 was considered statistically significant.

RESULTS AND DISCUSSIONS
The results section displays data analysis and statistical 
interpretations based on data collection. A total of  80 
patients were included in the study, with a majority of  
male (63.8%) patients and female patients accounting for 
(36.2%). With a mean age of  49.6±13.9 years (31.3%), 
patients between the ages of  51 and 60. However, the 
majority of  patients with cirrhosis were from the Sudan 
Central region (35%), followed by Khartoum (26.3%) and 
West (21.3%), as shown in Table 1.

Table 1: Demographic characteristics (N= 80)
Characteristics Frequency Percentage
Gender
Male 51 63.8%
Female 29 36.2%
Age (Years); mean ± SD
49.6±13.9
< 20 2 2.5%
20-30 7 8.8%
31-40 16 20%
41-50 15 18.8%
51-60 25 31.3%
> 60 15 18.8%
Origin
Khartoum 21 26.3%
Central 28 35%
West 17 21.3%
North 11 13.8%
East 3 3.8%

Figure 1 revealed that Hepatitis B (HBV) accounts 
for (61.3%) of  liver cirrhosis cases, while alcohol 
addiction accounts for (22.5%). The prevalence rates 
of  autoimmune diseases, unknown etiology cases, and 

Hepatitis C virus were (8.8%), (3.8%), and (3.8%), 
respectively. This analysis suggested a need for further 
investigation into potential risk factors.

Figure 1: Etiologies of  liver cirrhosis (N= 80)



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Table 2 presents the distribution symptoms of  
osteoporosis, patients’ performance, ascites, and 
encephalopathy among cirrhotic patients.
Encephalopathy and ascites indicate severe liver disease, 
classifying cirrhosis based on their quantity and intensity, 
which can significantly impact medical treatment for 

cirrhosis patients. The analysis revealed that a significant 
proportion experienced diminished energy (52.5%), 
while (35%) and (12.8%) experienced back or body aches. 
Furthermore, cirrhosis was characterized by ascites in 
(37.5%) of  cases, with (92%) of  patients reporting no 
encephalopathy.

Table 2: Distribution of  Clinical Characteristics
Characteristics Frequency Percentage
Symptoms of  osteoporosis
Fatigability 42 52.5%
Back pain 28 35%
Bone pain 10 12.5%
Patient performance
Freely mobile 64 80%
Mobile at home 10 12.5%
Bedridden 6 7.5%
Assessment Indicators
Ascites
Absent 30 37.5%
Slight 34 42.5%
Moderate 16 20%
Encephalopathy
Absent 74 92.5%
Grade1-2 6 7.5%
Grade3-4 0 0%

Table 3 shows blood chemical composition, coagulation 
status, and liver functionality in study patients. A severe 
deficiency of  albumin in the blood was observed, 
with (31.3%) of  serum albumin values below 2.8g/Dl. 
Bilirubin levels were also low, with (70%) of  patients 

below 2 mg/dL. The International Normalized Ratio 
(INR) was used to assess coagulation status, with (85%) 
of  patients showing an INR value < 1.7. Most patients 
had sodium levels over 130 mmol/L (85%), and (30%) 
had elevated creatinine levels.

Table 3: Laboratory investigations of  cirrhotic patients (N= 80)
Investigations Frequency Percentage
Albumin (g/dl)
< 2.8 25 31.3%
2.8-3.5 30 37.5%
> 3.5 25 31.3%
Bilirubin (mg/dl)
< 2 56 70%
2-3 18 22.5%
> 3 6 7.5%
INR
< 1.7 68 85%
1.7-2.2 9 11.3%
> 2.2 3 3.8%
Sodium (mmol/L)
< 130 12 15%
≥ 130 68 85%
Creatinine (mg/dl)



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Figure 2 illustrates the 3 categories of  cirrhosis patients 
based on their Child-Turcotte-Pugh (CTP) scores. The 
results revealed that (49%) of  patients had moderate 
cirrhosis (CTP-B), indicating moderate liver dysfunction. 

Whereas, (35%) showed mild cirrhosis (CTP-A), 
suggesting some liver function was intact and a favorable 
prognosis. Only (16%) had severe cirrhosis (CTP-C), 
indicating severe liver disease.

< 1 56 70%
> 1 24 30%

Figure 2: Child-Pugh classification (N= 80)

Figure 3: MELD score of  cirrhotic patients (N= 80)

Figure 4: Bone mineral density by DEXA (N= 80)

Figure 3 shows the Model for End-Stage Liver Disease 
(MELD) scores. These scores were based on laboratory 
findings like serum bilirubin, creatinine, and INR. MELD 

score among study patients was 15±6, and (77.5%) of  
patients fell within the MELD score range of  10-19, 
indicating a (6%) mortality rate (in 3 months).

The DEXA scan results indicated that (36.2%) of  
patients had normal bone mineral density, with a mean 
DEXA score of  0.14. Additionally, (55%) of  patients 
had osteopenia, with a mean DEXA score of  -1.5, while 

(8.8%) of  patients had osteoporosis, with a mean DEXA 
score of  -2.8, as shown in Figure 4. This analysis showed 
that a significant proportion of  patients had moderate or 
severe cirrhosis.



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Table 4 presents the correlation between the demographic 
characteristics of  patients with cirrhosis and the results 
of  Dual-Energy X-ray Absorptiometry (DEXA). The 
analysis showed that males had a higher prevalence of  
osteopenia (49%) than females (65.5%), while both 
genders had a comparable proportion of  osteoporosis 
(9.8%) and (6.9%), respectively. Osteoporosis had a 

higher prevalence (16%) among patients aged 51-60, 
while osteopenia was more prevalent (73.3%) among 
those aged 41-50. Moreover, the East region exhibited 
a higher prevalence of  osteoporosis (33.3%), while the 
West region had a higher frequency (70.6%). The p-values 
showed a significant association between DEXA findings 
and demographic characteristics of  cirrhotic patients.

Table 4: Association between DEXA findings and demographics (N= 80)
Characteristics Normal Osteopenia Osteoporosis P. value
Gender
Male 21 25 5

0.36141.2% 49.0% 9.8%
Female 8 19 2

27.6% 65.5% 6.9%
Age (Years)
< 20 1 1 0

0.606

50.0% 50.0% 0.0%
20-30 4 3 0

57.1% 42.9% 0.0%
31-40 8 7 1

50.0% 43.8% 6.3%
41-50 4 11 0

26.7% 73.3% 0.0%
51-60 7 14 4

28.0% 56.0% 16.0%
> 60 5 8 2

33.3% 53.3% 13.3%
Origin
Khartoum 12 9 0

0.072

57.1% 42.9% 0.0%
Central 7 17 4

25.0% 60.7% 14.3%
West 5 12 0

29.4% 70.6% 0.0%
East 2 0 1

66.7% 0.0% 33.3%
North 3 6 2

27.3% 54.5% 18.2%

Table 5 analyzes the relationship between liver cirrhosis 
causes and DEXA findings. It showed that patients with 
cirrhosis associated with HCV had a higher incidence of  

osteopenia (66.7%) and autoimmune causes (42.9%). The 
p-value (0.854) showed no significant correlation between 
DEXA findings and cirrhosis causes among patients.

Table 5: Association between DEXA findings and cirrhosis causes (N= 80)
Liver cirrhosis causes Normal Osteopenia Osteoporosis P. value
HBV 19 25 5

38.8% 51.0% 10.2%
HCV 1 2 0

33.3% 66.7% 0.0%
Alcohol 0 3 0



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0.0% 100.0% 0.0% 0.854
Autoimmune 3 3 1

42.9% 42.9% 14.3%
Unidentified diagnosis 6 11 1

33.3% 61.1% 5.6%

Table 6 shows a correlation between DEXA findings 
and osteoporosis symptoms.  Patients with osteoporosis 
often report symptoms, indicating a higher prevalence 
rate. A significant association was observed between 
osteoporosis and bone pain symptoms (p = 0.000), 
highlighting the correlation between bone pain and 

reduced bone density. Although there was no significant 
association between fatigability and back pain and 
DEXA findings, these patterns suggest increased 
sensitivity to osteoporosis. The p-value <0.05 indicated 
a significant association between osteoporosis and back 
pain.

Table 6: Association between DEXA findings and symptoms of  osteoporosis (N= 80)
Symptoms of  osteoporosis Normal Osteopenia Osteoporosis P. value
Fatigability
Yes 18 24 6

0.28337.5% 50.0% 12.5%
No 11 20 1

34.4% 62.5% 3.1%
Back pain
Yes 9 15 4

0.42232.1% 53.6% 14.3%
No 20 29 3

38.5% 55.8% 5.8%
Bone pain
Yes 2 8 0

0.000*20.0% 80.0% 0.0%
No 27 36 7

38.6% 51.4% 10.0%

Table 7: Association between DEXA findings and patient physical performance (N= 80)
Patient performance Normal Osteopenia Osteoporosis P. value
Bedridden 2 4 0

0.662

33.3% 66.7% 0.0%
Mobile at home 3 5 2

30.0% 50.0% 20.0%
24 35 5

Freely mobile 37.5% 54.7% 7.8%

Table 8: Association of   DEXA findings with ascites and encephalopathy (N=80)
Indicators Normal Osteopenia Osteoporosis P. value
Ascites
Absent 13 16 1

Table 7 examines the relationship between DEXA 
findings and patients with cirrhosis, focusing on their 
mobility. The results showed no significant correlation 
(p = 0.662). However, there were notable trends, such 
as a s higher prevalence of  osteoporosis among home-
mobile patients and a greater proportion of  the disease 
among bedridden patients.

Table 8 shows a significant correlation between ascites, 
encephalopathy and bone density. The p-value of  ascites 
(p=0.496) showed no statistical significance, whereas 
encephalopathy had a significant association (p=0.002*) 
with osteoporosis, particularly in patients with Grade 1-2 
encephalopathy.



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43.3% 53.3% 3.3%

0.496
Slight 10 19 5

29.4% 55.9% 14.7%
Moderate 6 9 1

37.5% 56.3% 6.3%
Encephalopathy
Absent 29 40 5

0.002*39.2% 54% 6.8%
Grade1-2 0 4 2

0.0% 66.7% 33.3%

Table 9 indicates a correlation between laboratory tests 
and DEXA findings. Patients with osteoporosis had 
elevated bilirubin levels (p=0.000*), with a significant 
proportion (77.2%) falling within 2-3 mg/dL. Similarly, 
low sodium levels (<130 mmol/L) were significantly 

associated with osteoporosis (p=0.000*), suggesting an 
electrolyte imbalance and reduced bone density. Albumin 
levels were approaching statistical significance (p=0.386), 
indicating a positive trend in bone health.

Table 9: Association between DEXA findings and laboratory investigations (N=80)
Lab Analysis Normal Osteopenia Osteoporosis P. value
Albumin (g/dL)
< 2.8 7 14 4

0.386

28.0% 56.0% 16.0%
2.8-3.5 10 18 2

33.3% 60.0% 6.7%
> 3.5 12 12 1

48.0% 48.0% 4.0%
Bilirubin (mg/dL)
< 2 27 28 1

0.000*

48.2% 50% 1.8%
2-3 2 14 2

11.1% 77.2% 11.1%
> 3 0 2 4

0.0% 33.3% 66.7%
INR
< 1.7 26 38 4

0.093

38.2% 55.9% 5.9%
1.7-2.2 2 4 3

22.2% 44.4% 33.3%
> 2.2 1 2 0

33.3% 66.7% 0.0%
Sodium (mmol/L)
< 130 0 8 4

0.000*0.0% 66.7% 33.3%
≥ 130 29 36 3

42.7% 52.9% 4.4%
Creatinine (mg/dL)
< 1 23 27 6 0.167

41.1% 48.2% 10.7%
> 1 6 17 1

25.0% 70.8% 4.2%



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Table 10 presents a significant correlation between the 
Child-Pugh classification and DEXA findings. Patients 
with severe cirrhosis, specifically (CTP-C) had a higher 

prevalence of  osteoporosis (23.1%) while (CTP-A) 
showed a reduced occurrence of  osteoporosis (3.6%). 
The p-value < 0.05 indicated a statistical significance.

Table 10: Association between DEXA findings and Child-Pugh classification (N=80)
Child-Pugh class Normal Osteopenia Osteoporosis P. value
CTP-A 15 12 1

0.041*

53.6% 42.9% 3.6%
CTP-B 10 26 3

25.6% 66.7% 7.7%
CTP-C 4 6 3

30.8% 46.2% 23.1%

Table 11 reveals a correlation between MELD scores 
and DEXA findings among cirrhosis patients. Greater 
MELD scores indicated severe liver disease and an 
increased mortality risk. Osteoporosis prevalence was 

high (71.4%0 in patients with MELD scores 20-29, with 
a 19.6% mortality risk. Patients with MELD scores 30-
39 had a 52.6% mortality rate, and lower MELD scores 
showed regular bone density and a reduced death rate.

Table 11: Association between DEXA findings and MELD score (N=80)
MELD Score Normal Osteopenia Osteoporosis P. value
≤9 (1.9% mortality) 1 0 0

0.000*

100.0% 0.0% 0.0%
10-19 (6.0% mortality) 27 34 1

43.5% 54.8% 1.6%
20-29 (19.6% mortality) 1 10 3

7.1% 71.4% 21.4%
30-39 (52.6% mortality) 0 0 3

0.0% 0.0% 100.0%

Discussion
Chronic liver disease impacts almost 1.5 billion individuals 
globally, with Alcoholic Liver Disease (ALD) accounting 
for (2%), Hepatitis B Virus (HBV) accounting for (29%), 
Hepatitis C Virus (HCV) accounting for 9%, and Non-
Alcoholic Fatty Liver Disease (NAFLD) accounting for 
(60%) (Moon et al., 2020; Traub et al., 2021; Ye et al., 
2020). The median prevalence of  cirrhosis in European 
countries was 833 cases per 100,000. The Global Burden 
of  Disease study revealed a (13%) growth in the age-
standardized incidence rate of  CLD and cirrhosis in 
2015 (Asrani et al., 2019). In Europe, the prevalence of  
cirrhosis is 26.0 cases per 100,000 individuals (Moon et 
al., 2020). Cirrhosis is the 11th most common cause of  
death globally and the 15th leading cause of  morbidity 
(Cheemerla & Balakrishnan, 2021). West Europe and 
South Sub Suharan Africa had the fourth to sixth lowest 
age-standardized death rates of  cirrhosis in 2017, with 
alcohol-related liver disease and hepatitis C being the 
primary cause (Ye et al., 2022; Younossi et al., 2023). 
North Africa and the Middle East had modest rates 
of  age-standardized death and prevalence rates due to 
cirrhosis driven by hepatitis B and C (Huang et al., 2023; 
Mokdad et al., 2014). In contrast, Sudan is among the 
countries with high hepatitis B virus seroprevalence, with 
exposure ranging from (47%) to (78%) (Elsheikh et al., 

2016; Mudawi, 2008). It is the common cause of  CLD 
and hepatocellular carcinoma, and the second common 
cause of  acute liver failure in Sudan (Konyn et al., 2021; 
Lan et al., 2023; Mohammed et al., 2015; Moses, 2021).
Liver Cirrhosis can be diagnosed by various techniques 
and a definitive method for diagnosing cirrhosis is liver 
biopsy (Jain et al., 2021). However, if  clinical, laboratory, 
and radiologic findings indicate cirrhosis, a biopsy 
is unnecessary. Cirrhosis increases the susceptibility 
to complications from liver biopsy (Chowdhury & 
Mehta, 2023). The most reliable indicators of  cirrhosis 
include ascites, a platelet count below 160,000/mm3, 
spider angiomata, and a Bonacini cirrhosis discriminant 
score (Sharma, 2022). Ultrasound is also used for 
assessing liver cirrhosis, but other methods include 
transient elastography, acoustic radiation force impulse 
imaging, supersonic shear imaging, magnetic resonance 
elastography, and endoscopy (Ahmed, 2022; Cui et 
al., 2022). Elastography offers painless sampling and 
examination of  a broader area as compared to biopsy. 
While abdominal Computed Tomography (CT) scan 
and Magnetic Resonance Imaging (MRI) are also used 
under specific conditions for diagnosis (Nadarevic et 
al., 2021). Decompensated cirrhosis anagement should 
focus on preventing progression rather than treating 
complications. Treatment targets liver pathological 



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alterations, suppressing inflammation, fibrosis regression, 
and normalizing cell function. 
The present study analyzed bone mineral density in liver 
cirrhotic patients and examined the rate of  osteoporosis, 
osteopenia, and risks of  fractures. The results revealed 
that most patients were males, with an average age of  
49.6±13.9 years. The male (63.8%) to female (36.2%) 
ratio was 1.8:1 with a higher proportion from Sudan 
Central region (35%). Based on the etiological findings, 
alcohol consumption was found to be the second most 
prevalent factor contributing to liver cirrhosis (22.5%), 
followed by HBV which accounts for (61.3%) of  cases. 
The prevalence rates of  HCV, autoimmune diseases, 
and unknown etiology were (3.8%, 3.8%, and 8.8%), 
respectively. Notably, a significant proportion of  patients 
(52.5%) experienced reduced energy levels, while (37.5%) 
exhibited ascites, a typical indicator of  severe livere disease. 
Encephalopathy, a sign of  nuerological problems, was 
observed in (7.5%) of  the patients. Moreover, laboratory 
investigations demonstrated significant abnormalities in 
liver functions. A total of  (13%) of  the patients exhibited a 
significant deficiency of  albumin, with levels below 2.8g/
dL, indicating poor synthetic liver function. The patients’ 
bilirubin levels (70%) were below 2mg/Dl. INR showed 
that (85%) of  the patients had normal coagulation levels. 
the child-pugh score system was employed to categorize 
liver dysfunction into various stages. Among 80 patients, 
(49%) exhibited moderate cirrhosis (CTP-B), (35%) 
showed mild cirrhosis (CTP-A), and (16%) showed severe 
cirrhosis (CTP-C). Furthermore, (75%) of  patients with 
cirrhosis had a mean score of  15±6, indicating a high 
risk of  mortality. The DEXA scan revealed that (35.2%) 
had normal bone density, (55.5%) had osteopenia, and 
(8.8%) had osteoporosis. The DEXA findings showed 
a significant correlation with child-pugh scores, MELD 
scores, and bone diseases. A notable association was also 
observed between the intensity of  encephalopathy and 
DEXA findings. 
A study by Zheng et al. 2018 evaluated (20.3%) cases 
of  osteoporosis in liver cirrhotic patients and observed 
that it resulted from alcohol consumption and hepatitis 
virus. Notably, individuals with a lower BMI and higher 
fibroscan scores exhibited a greater occurrence of  
osteoporosis (Zheng et al., 2018). The occurrence of  
osteoporosis in individuals with CLD varied from (13%) 
to (55%) in Western countries (Chinnaratha et al., 2015; 
Collier, 2007). Another study conducted by Meena et al. 
2018 analyzed patients aged 20-65, with varying degrees 
of  liver cirrhosis severity. Elderly patients had a poorer 
prognosis and reduced quality of  life compared to 
younger patients, with a significant difference observed 
(p=0.0003) (Meena et al., 2018). A study by Younossi et 
al. revealed comparable results indicating that the age of  
cirrhosis patients had a detrimental effect on their quality 
of  life (Younossi et al., 2001). In contrast, the finding of  
the study by Marchesini et al. demonstrated that younger 
patients with cirrhosis experienced a more severe decline 
in Health Related Quality of  Life (HRQL) compared to 
older patients (Marchesini et al., 2001). 

Furthermore, a study by Shukla et al. 2023 found that 
(34.3%) of  the patients had liver cirrhosis attributable 
to alcohol consumption. Among 70 patients, (25.7%) 
had HBV, while (20%) had cryptogenic cirrhosis and 
HCV. The combined prevalence of  osteoporosis and 
and osteopenia was found to be 22.9%, respectively 
(Shukla et al., 2023). Similarly, Soylu et al. examined the 
prevalence of  osteoporosis was (1.9%) and osteopenia 
was (20%) (Soylu et al., 2012). Ninkovic et al. found a 
higher prevalence of  (48.8%) for osteopenia and (36.6%) 
for osteoporosis among cirrhotic patients (Ninkovic et 
al., 2001). Sokhi et al. demonstrated that (11.5%) of  the 
patients had osteoporosis, while (34.6%) had osteopenia 
(Sokhi et al., 2004). Other (Danford et al., 2020; Mantovani 
et al., 2019; Shukla et al., 2023). Moschen et al. reported 
(37.8%) osteopenia and (12.8%) osteoporosis (Moschen 
et al., 2005).
However, numerous studies showed a statistical significance 
and a positive correlation was between bone mineral 
density and liver cirrhosis. The prevalence of  osteoporosis, 
osteopenia, and fractures were found to be 45% to 47% on 
average among chronic liver disease patients (Goral et al., 
2010; Luxon, 2011; Turkeli et al., 2008; Vargas et al., 2012). 
In order to increase bone density, correct vitamin D levels, 
calcium supplements, regular physical activity, a balanced 
diet, and an individualized approach to health care are 
recommended (Rondanelli et al., 2021). 

CONCLUSION 
In conclusion, the study findings revealed that bone 
diseases were a prevalent consequence in Sudanese 
patients with liver cirrhosis. The majority of  cases were 
related to osteoporosis and osteopenia. Bone diseases 
such as osteopenia and osteoporosis were significantly 
associated with encephalopathy, higher bilirubin levels, 
hypernatremia, high MELD scores and severe liver disease 
(CTP-B and CTP-C). However, HBV was found to be 
the primary cause of  liver cirrhosis, followed by alcohol 
consumption. Patients with severe cirrhosis had a higher 
prevalence of  osteoporosis, which was linked to low 
sodium levels and elevated bilirubin levels. In contrast, 
osteopenia was more prevalent than osteoporosis 
among patients. Furthermore, the study emphasized the 
importance of  early detection and treatment of  bone 
health problems in patients with liver cirrhosis.

LIMITATIONS AND STRENGTHS
• The limitations of  the study may include the 

generalizability due to a single-center trial with 80 patients 
and a cross-sectional design. 

• However, the study is crucial for determining 
healthcare accessibility for patients with cirrhosis.

•  This study offers insights into the complex relationship 
between liver cirrhosis and bone health, providing the way 
for further examination and clinical therapy. 

RECOMMENDATIONS
• Cirrhotic patients often experience bone pain and 

fractures due to bone disease, and orthopedic care is often 



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neglected. Regular bone mineral density assessments are 
recommended for all patients with liver cirrhosis.

• Patients with severe stages of  cirrhosis should be 
advised to receive anti-osteoporotic treatment due to the 
increased risk of  bone disease.

• Larger prospective studies or longitudinal studies 
with frequent clinical evaluations and more accurate 
biochemical or laboratory assessments are needed to 
determine the effect of  liver disease stage on bone 
mineral density.

Acknowledgment
The authors are thankful to Ibn Sina Hospital for their 
continuous support throughout the study.

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