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Endocrine and Bone Metabolic Complications in Chronic Liver Disease and After Liver Transplantation in Children

Högler, Wolfgang*; Baumann, Ulrich; Kelly, Deirdre

Journal of Pediatric Gastroenterology and Nutrition: March 2012 - Volume 54 - Issue 3 - p 313–321
doi: 10.1097/MPG.0b013e31823e9412
Invited Reviews

ABSTRACT With improved survival of orthotopic liver transplantation (OLT) in children, prevention and treatment of pre- and posttransplant complications have become a major focus of care. End-stage liver failure can cause endocrine complications such as growth failure and hepatic osteodystrophy, and, like other chronic illnesses, also pubertal delay, relative adrenal insufficiency, and the sick euthyroid syndrome. Drug-induced diabetes mellitus post-OLT affects approximately 10% of children. Growth failure is found in 60% of children assessed for OLT. Despite optimisation of nutrition, rarely can further stunting of growth before OLT be prevented. Catch-up growth is usually observed after steroid weaning from 18 months post-OLT. Whether growth hormone treatment would benefit the 20% of children who fail to catch up in height requires testing in randomised controlled trials. Hepatic osteodystrophy in children comprises vitamin D deficiency rickets, low bone mass, and fractures caused by malnutrition and malabsorption. Vitamin D deficiency requires aggressive treatment with ergocalciferol (D2) or cholecalciferol (D3). The active vitamin D metabolites alphacalcidol or calcitriol increase gut calcium absorption but do not replace vitamin D stores. Prevalence of fractures is increased both before OLT (10%–28% of children) and after OLT (12%–38%). Most fractures are vertebral, are associated with low spine bone mineral density, and frequently occur asymptomatically, but they may also cause chronic pain. Fracture prediction in these children is limited. OLT in children is also associated with a greater risk of developing avascular bone necrosis (4%) and scoliosis (13%–38%). This article reviews the literature on endocrine and skeletal complications of liver disease and presents preventive screening recommendations and therapeutic strategies.

*Department of Endocrinology and Diabetes

Liver Unit, Birmingham Children's Hospital, Birmingham, UK

Division of Paediatric Gastroenterology and Hepatology, Children's Hospital Hannover, Hannover, Germany.

Address correspondence and reprint requests to Dr Wolfgang Högler, Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Steelhouse Lane, B4 6NH, Birmingham, UK (e-mail:

Received 16 December, 2010

Accepted 24 August, 2011

The authors report no conflicts of interest.

Copyright 2012 by ESPGHAN and NASPGHAN