Pa ge 1 Pa ge 11 3 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 Pa ge 11 4 https://journals.e-palli.com/home/index.php/ajmsi Am. J. Med. Sci. Innov. 4(1) 113-125, 2025 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 Pa ge 11 5 https://journals.e-palli.com/home/index.php/ajmsi Am. J. Med. Sci. Innov. 4(1) 113-125, 2025 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) Pa ge 11 6 https://journals.e-palli.com/home/index.php/ajmsi Am. J. Med. Sci. Innov. 4(1) 113-125, 2025 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) Pa ge 11 7 https://journals.e-palli.com/home/index.php/ajmsi Am. J. Med. Sci. Innov. 4(1) 113-125, 2025 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. Pa ge 11 8 https://journals.e-palli.com/home/index.php/ajmsi Am. J. Med. Sci. Innov. 4(1) 113-125, 2025 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 Pa ge 11 9 https://journals.e-palli.com/home/index.php/ajmsi Am. J. Med. Sci. Innov. 4(1) 113-125, 2025 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. Pa ge 12 0 https://journals.e-palli.com/home/index.php/ajmsi Am. J. Med. Sci. Innov. 4(1) 113-125, 2025 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% Pa ge 12 1 https://journals.e-palli.com/home/index.php/ajmsi Am. J. Med. Sci. Innov. 4(1) 113-125, 2025 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 Pa ge 12 2 https://journals.e-palli.com/home/index.php/ajmsi Am. J. Med. Sci. Innov. 4(1) 113-125, 2025 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 Pa ge 12 3 https://journals.e-palli.com/home/index.php/ajmsi Am. J. Med. Sci. Innov. 4(1) 113-125, 2025 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. REFERENCES Ahmadi, N., Mao, S., Hajsadeghi, F., Arnold, B., Kiramijyan, S., Gao, Y., Flores, F., Azen, S., & Budoff, M. (2018). 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