We read with great interest the article by Chang et al. published in the Journal Annals Of medicine. The authors performed a retrospective cohort study to assess the risk factors leading to fractures following a liver transplant. The risk of fractures was significantly increased in female patients, patients who were older than 65 years of age at the time of transplant, who had fractures within 1 year prior to transplant, hepatitis C carrier, alcoholics and those receiving daily prednisolone dose (1.61–3.78 mg/d). However, the risk of fractures was lower in patients who received tacrolimus and sirolimus/everolimus [Citation1].
While these findings are an important addition to the existing body of evidence, there is a lack of certain significant confounders that could potentially influence the risk of fractures in these patients. Fractures are usually caused by either an inciting trauma such as falls and road traffic accidents or could be pathological without a preceding traumatic event [Citation2]. Similarly, studies have demonstrated that visit-to-visit blood pressure variability (BPV), regardless of the mean blood pressure levels, is correlated with an increased risk of fractures. After accounting for age, sex, income, lifestyle factors, and comorbidities, Yoo et al. revealed a notable increase in fracture risk associated with higher quartiles of BPV compared to the lowest quartile group. The adjusted hazard ratios (95% confidence intervals) for incident any fracture was 1.07 (1.06–1.08) for the higher quartile of systolic BPV, 1.06 (1.05–1.07) for diastolic BPV, and 1.07 (1.06–1.08) for both systolic and diastolic BPV. This is particularly important as early BPV has also been identified as a potential prognostic factor for predicting overall mortality in liver transplant recipients [Citation3,Citation4].
In summary, the mode of fractures along with emerging prognostic factors such as BPV can potentially facilitate and improve risk stratification for fractures in patients who underwent liver transplantation. These factors are readily available and can be an inexpensive addition to the risk stratification model outlined by the authors.
Abbasi Shaheed Hospital, Karachi, Pakistan
[email protected]
Anusha Fatima
Jinnah Sindh Medical Hospital, Karachi, Pakistan
Nabeel Aamir
Abbasi Shaheed Hospital, Karachi, Pakistan
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References
- Chang JW, Yang HH, Lin NC, et al. Risk factors for fractures following liver transplantation: a population-based cohort study. Ann Med. 2023;55(1):1. doi:10.1080/07853890.2023.2230871.
- Järvinen TL, Sievänen H, Khan KM, et al. Shifting the focus in fracture prevention from osteoporosis to falls. BMJ. 2008;336(7636):124–126. doi:10.1136/bmj.39428.470752.AD.
- Yoo JE, Yoon JW, Park HE, et al. Blood pressure variability and the risk of fracture: a nationwide cohort study. J Clin Endocrinol Metab. 2022;107(4):e1488–e1500. doi:10.1210/clinem/dgab856.
- Truitt K, Chen K, Yano Y, et al. Blood pressure variability early after liver transplantation predicts long-term mortality. Liver Transpl. 2022;28(4):615–622. doi:10.1002/lt.26370.