The Incidence of Osteoporosis in Hepatocellular Carcinoma Patients Under 65 – A Retrospective Cohort Study

The Incidence of Osteoporosis in Hepatocellular Carcinoma Patients Under 65 – A Retrospective Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Incidence of Osteoporosis in Hepatocellular Carcinoma Patients Under 65 – A Retrospective Cohort Study Katherine Quesada Tibbetts, Rahul Mhaskar, Neelesh Prakash This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4974227/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Hepatocellular carcinoma (HCC) patients have a heightened prevalence of low bone mineral density (BMD) and the development of osteoporosis. Osteoporosis screening guidelines only recommend DEXA scans for females 65 and older and males 70 and older. We set out to analyze the incidence of low bone mineral density in HCC patients under 65 years old and encourage implementation of DEXA screenings for this patient population. Method: In this retrospective cohort study, 170 patients under 65 years old with an HCC diagnosis were analyzed. The use of Hounsfield units (HU) from L1 non-contrast CT scans is a reliable predictor of T-scores from DEXA scans and was used to predict BMD in patients, with scores of less than 165 HU indicative of osteopenia and less than 98 indicative of osteoporosis. Results: The median HU score of patients was 137.2, and the mean score was 142.6 (Min: 55.4; Max: 303.1). Approximately 75% of patients had an HU score of less than 165, indicating a high likelihood of suffering from low BMD. Approximately 20% of low BMD patients were identified as within a range of osteoporosis. Conclusions: HCC patients under 65 have an increased incidence of bone demineralization . We suggest that BMD in HCC patients is an important prognostic tool and parameter to document, as studies have shown that HCC patients with high BMD have longer overall survival than patients with low BMD. Future prospective studies using DEXA scans to assess BMD should be completed to verify the risk of osteoporosis. Osteoporosis Bone Demineralization Hepatocellular Carcinoma Cancer CT Liver Disease Endocrinology Imaging Guidelines Preventative Medicine DEXA Figures Figure 1 Figure 2 Figure 3 INTRODUCTION Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-related deaths in the United States. Often a result of chronic liver injury, HCC in patients has been linked to several nutritional deficiencies which have adverse health effects on patients and prognosis [ 1 – 3 ]. Among these risks in HCC patients is a heightened risk for low bone mineral density (BMD) and the development of osteoporosis, which can lead to increased fracture risk and joint inflammation [ 2 , 3 ]. The risk of osteoporosis or fracture is higher in patients with liver disease than in the general population [ 4 ]. It has been shown that patients with chronic liver disease suffer from vitamin deficiencies, which lead to decreased bone synthesis and a higher risk of low BMD. Additionally, studies have shown that chronic liver disease patients with low BMD have an increased risk of developing HCC [ 1 , 5 ]. For example, patients with liver cirrhosis often develop vitamin D deficiency, which further predisposes them to the development of HCC [ 1 ]. This data suggests that many HCC patients are at an increased risk for these same nutritional deficiencies and low BMD [ 5 ]. We suggest that BMD in HCC patients is an important prognostic tool and parameter to document in patients who have been diagnosed and are undergoing treatment for HCC. Studies have shown that HCC patients with high BMD have more prolonged overall survival than patients with low BMD [ 6 ]. Additionally, HCC patients with low BMD had worse survival rates post liver transplant than patients with normal BMD [ 1 , 6 , 7 ]. Additionally, osteoporosis is already a known complication of liver transplantation, and the younger patient population of HCC patients may be at increased risk of premature bone demineralization [ 8 ]. Thus, these measurements are important for HCC treatment plans. Dual-energy X-ray absorptiometry (DEXA) scans are the most reliable method of assessing BMD in patients and are regarded as the gold standard [ 9 – 13 ]. However, current screening guidelines recommend DEXA scans for osteoporosis in females 65 and older and males 70 and older [ 14 , 15 ]. Given the adverse effects and implications of low BMD in HCC patients, we believe young HCC patients under 65 must receive DEXA osteoporosis screenings if this population shows low BMD. In this study, we will use existing L1 CT scans as an alternative indicator of osteopenia or osteoporosis in HCC patients under 65 to analyze the prevalence of low BMD in this population. The use of Hounsfield units (HU) from CT scans is a reliable predictor of T-scores from DEXA scans and can be used to predict osteoporosis risk in patients [ 16 – 20 ]. Researchers have shown that the CT attenuation threshold of an L1 vertebra of less than 160 HU has a 90% sensitivity to osteoporosis as evaluated with DEXA [ 9 ]. Yang et al . has described research values for bone demineralization using HU at the L1 vertebra. In their study, researchers found a level of 165 HU to be the threshold of normal BMD, with less than indicative of osteopenia, and less than 98 to be indicative of osteoporosis [ 18 ]. Given the prevalence of nutritional deficiencies and the probability of osteoporosis in HCC patients under 65, this population may benefit from regular DEXA screenings to detect low BMD early and provide effective treatment before further damage ensues. In this study, we analyzed the prevalence of low BMD in HCC patients under 65 to assess the incidence of low BMD in this population by analyzing CT scans at the L1 vertebra on the HU scale. Considering the bone loss, high tumor burden, and prevalence of liver transplantation in HCC patients, we believe the results of this study can further improve prognostic knowledge, imaging guidelines and treatment plans for HCC patients under 65. METHODS Study Design Patients This retrospective cohort study qualified for a waiver of the requirement for signed authorization from the IRB as outlined in the HIPAA Privacy Rule regulations at 45 CFR 164.512(i). We conducted a retrospective chart and radiographic review that evaluated abdominal computed tomography (CT) scans without contrast for all patients under 65 years of age diagnosed with hepatocellular carcinoma at Tampa General Hospital between January 1, 2019, and January 1, 2021. Inclusion criteria included any patient under 65 years of age who was diagnosed in our study time frame and had an abdominal non-contrast CT scan on file. There were no exclusion criteria. Demographic information and medical history were collected. Image Acquisition The non-contrast abdominal CT scans were acquired from patient charts during our study time frame. To minimize bias, the first non-contrast CT scan from diagnosis of HCC was utilized for measurements. Image Interpretation The CT scans were analyzed at the L1 vertebra with Hounsfield units to predict bone mineral density. The HU measurement tool on the Picture Archiving and Communication System (PACS) was utilized to take the measurements at the level of the L1 vertebra. Reference Standard Given the study design as a retrospective cohort study, there was no control group. The HU results were analyzed against criteria outlined by Yang et al. According to their research, HU analysis at the L1 vertebra of less than 165 is indicative of osteopenia and less than 98 is indicative of osteoporosis [ 18 ]. Statistical Analyses We conducted the descriptive analysis to report frequencies for categorical data and mean and standard deviation (SD) or median, minimum, and maximum for continuous data. We reviewed the difference in the distribution of continuous variables across categorical variables using the Mann-Whitney U and Kruskal Wallis test. We investigated the correlation by Spearman's rho ( r ) and reported the correlation coefficient ( r ) and the 2-tailed 95% confidence intervals (95%CIs). For additional analyses, we created two groups of patients based on the 165 cut off for HU data. All analyses were conducted by SPSS version 26 software. P values less than 0.05 denoted statistical significance. RESULTS There were 170 patients who met the inclusion criteria of being under 65 years of age with a diagnosis of hepatocellular carcinoma and having a non-contrast abdominal CT scan over a 2-year period. The patient cohort was mostly Caucasian ( n = 142), non-Hispanic ( n = 134), and male ( n = 127), with an average age of 58.3 years (Figure 1A and B). BMI was recorded for the patient cohort, with a median of 27.0 kg/m 2 (Min: 10.1, Max: 72.45)and a mean of 28.4 kg/m 2 (Sd: 7.41). The median age was 60 years (Min: 26.0, Max: 64.0) and had a mean of 58.4. The median Hounsfield unit (HU) score for the patient cohort was 137.2 HU, with a minimum of 55.3 HU and a maximum of 303.1 HU (Figure 1C). The sex ratio was approximately 25% female and 75% male. For females, the median HU was 152.0 (Min: 55.4, Max: 274.9). For males, the median HU was 136.5 (Min: 65.9, Max: 303.1). The patient cohort was approximately 83.5% Caucasian, 10% black, 2% Asian, 0.5% Arab, and 3.5% native (Table 1). The cohort was 21.2% Hispanic (Median: 143.4 HU; Min: 81.0, Max: 258.1). Seventy five percent (n = 128) of patients were below the threshold of 165 HU and, therefore, had a potential for an increased probability of low bone mineral density. Of these low BMD patients, approximately 20% (n=25) were identified within the range of osteoporosis. In the full cohort, 15% of patients (n=25) were identified as potentially having osteoporosis if evaluated by DEXA. The Charlson Co-Morbidity Index was calculated for each patient and was distributed evenly across patients based on their Hounsfield unit score grouping based on the 165 cut off ( p = 0.192). In our cohort, Caucasians were most at risk for low BMD (Median HU Score: 134.4, Min: 55.4, Max: 258.1) (Figure 2). HU score had a significant negative correlation to glucose ( r = -0.159, 95% CI [-0.306, -0.004], p = 0.038), age ( r = -2.00, 95% CI [-0.344, -0.046], p = 0.009), and potassium ( r = -0.275, 95% CI [-0.413, -0.126], p < 0.001). The median albumin score for the patient cohort was 3.3 g/dL (min: 1.1, max: 4.9). HU did not have a significant relationship to albumin ( r = -0.128, 95% CI [-0.278, 0.027], p = 0.095) or BMI ( r = -0.030, 95% CI [-0.184, 0.125], p = 0.695). Only 33 patients had a vitamin D level measurement in their medical chart, and the median vitamin D level was 16.0 ng/mL (min: 3.5, max: 69.0). Analysis of the patients under vs over 165 HU was also completed (Table 2). Overall, the data for those at risk of low bone mineral density (<165 HU), has statistically significant results for potassium ( p = 0.004) and age (p = 0.022). Non-statistically significant relationships included BMI ( p = 0.233), Charlson Co-Morbidity Index ( p = 0.192), glucose ( p = 0.446), vitamin D level ( p = 0.505), and albumin ( p = 0.156). DISCUSSION Hepatocellular carcinoma patients are at risk of low bone mineral density (BMD) due to their liver disease and nutritional deficiencies, as shown by the results of this study. The technique of using HU on non-contrast CT scans to identify high risk HCC patients for prematurely developing osteopenia or osteoporosis is a useful application of this modality (Fig. 3 ) [ 21 – 24 ]. With 75% of patients from the study below the 165 HU threshold for normal bone mineral density, we recommend that hepatocellular carcinoma (HCC) patients undergo regular DEXA screening to assess individual risks for osteopenia or osteoporosis and the associated complications. Measurements for the nutritional deficiencies of the patient cohort were evaluated by the measurement of albumin, vitamin D, glucose, and BMI. Most of the cohort had an overweight BMI, indicating a serious co-morbidity. Although albumin did not have a statistically significant relationship with HU score, the median and mean albumin levels were below the normal range, indicating that the patient cohort experienced nutritional deficiencies, as expected, given the liver disease. Vitamin D levels were also consistently below normal values, strengthening the argument for better nutritional management of hepatocellular carcinoma patients [ 3 ]. Surprisingly, there was a significant inverse relationship between HU score and glucose level, indicating that hyperglycemia is associated with lower bone mineral density and, thus, worse prognostic factors. The under 165 HU subgroup analysis was not significant for a relationship between HU and glucose, indicating once low BMD is acquired, glucose levels do not indicate severity of osteopenia. However, among whole data from the HCC cohort patients, hyperglycemia was a significant predictor of having an increased risk of low BMD. This analysis shows that hyperglycemia may be a predictor of the heightened risk of developing low BMD in HCC patients. However, further investigation into the relationship between glucose and bone mineral density is needed to fully understand the implications of hyperglycemia in this patient population. Inherent limitations are present given the study design as a retrospective chart review. Limitations of this study include the varied time between cohort members from point of diagnosis to point of first non-contrast CT scan and variability in the CT machine used. These were uncontrollable variables given the nature of the retrospective study. Researchers attempted to limit time variability between individual patient CT scans and disease progression by recording HU scores from the first CT scan without contrast on patient record after diagnosis. With the nutritional markers and imaging results considered, it is evident that HCC patients suffer from declining nutritional values and increasing co-morbidities, which may have negative implications on their disease prognosis and risk of developing low bone mineral density and the associated complications [ 3 ]. Future research into cirrhotic patients is also recommended considering the clinical importance of BMD in liver disease patients as a predictor of HCC [ 1 , 25 , 26 ]. As described in Liang et al., BMD is an effective predictor of the development of HCC in cirrhotic patients [ 1 ]. With current DEXA screening guidelines recommending imaging for women 65 and older and men 70 and older, a sizeable subset of cancer patients are left with increased risk of unmonitored early-onset bone demineralization and are left to its consequences [ 14 ]. Through this study, it is evident HCC patients under 65 years old have a high incidence of low BMD and an increased fracture risk, and physicians should consider regular BMD screenings in this patient cohort. The Endocrine Society clinical guidelines recommend DEXA screenings of younger patients if they are shown to be at heightened risk of bone demineralization [ 15 ]. The results of this study identify HCC patients under 65 as high-risk patients, and future studies utilizing DEXA scans should be completed to determine appropriate screening guidelines for this patient population. Conclusion In conclusion, HCC patients under 65 were found to have low BMD, as assessed by Hounsfield unit scores at the L1 level in non-contrast CTs. Of the 170 HCC patients assessed, 75% were recorded to have low BMD. Our data supports the need for this patient population to undergo regular DEXA scans to carefully screen for the development of osteopenia and osteoporosis to avoid further complications in their care and management. Given this patient cohort was found to have poor nutritional markers, nutritional supplementation and aid must be provided to improve prognosis and mitigate unnecessary risk factors. Hyperglycemia and low BMD share a statistically significant inverse relationship, and future research is encouraged to investigate further the influence hyperglycemia can have on BMD. Given the findings of our study, we recommend that future research, such as a prospective DEXA scan study, be performed to evaluate the clinical effectiveness of BMD screening in hepatocellular carcinoma patients and determine appropriate screening recommendations. Statements and Declarations The authors declare no relevant or material financial interests that relate to the research described in this paper. Funding : The project was funded through the USF Summer Scholarly Award Experience. This award is given by the USF RISE Office to support medical student research during the summer break between first and second year of medical school. The award of $3,500 funded 8 weeks of research. ACKNOWLEDGEMENTS The project was funded through the USF Summer Scholarly Award Experience. This award is given by the USF RISE Office to support medical student research during the summer break between first and second year of medical school. The award of $3,500 funded 8 weeks of research. CONFLICT OF INTEREST The authors declare no relevant or material financial interests that relate to the research described in this paper. This retrospective cohort study was reviewed by the USF IRB and was found to qualify for a waiver of the requirement for signed authorization from the IRB as outlined in the HIPAA Privacy Rule regulations at 45 CFR 164.512(i). References Liang, K.H., et al., Morphomic Signatures Derived from Computed Tomography Predict Hepatocellular Carcinoma Occurrence in Cirrhotic Patients. Digestive Diseases and Sciences, 2020. 65 (7): p. 2130-2139. Ke, K., M. Arra, and Y. Abu-Amer, Mechanisms Underlying Bone Loss Associated with Gut Inflammation. International Journal of Molecular Sciences, 2019. 20 (24). Nakchbandi, I.A., Osteoporosis and fractures in liver disease: Relevance, pathogenesis and therapeutic implications. World Journal of Gastroenterology, 2014. 20 (28): p. 9427-9438. Cho, Y.S., et al., Computed Tomography-Determined Body Composition Abnormalities Usefully Predict Long-term Mortality in Patients With Liver Cirrhosis. 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Cauley, J.A., et al., Bone mineral density and the risk of incident nonspinal fractures in black and white women. Jama, 2005. 293 (17): p. 2102-8. Damilakis, J., T.G. Maris, and A.H. Karantanas, An update on the assessment of osteoporosis using radiologic techniques. Eur Radiol, 2007. 17 (6): p. 1591-602. Marshall, A., R.T. Kavanagh, and A.J. Crisp, The effect of pamidronate on lumbar spine bone density and pain in osteoporosis secondary to systemic mastocytosis. Br J Rheumatol, 1997. 36 (3): p. 393-6. Bone, H.G., et al., Ten years' experience with alendronate for osteoporosis in postmenopausal women. N Engl J Med, 2004. 350 (12): p. 1189-99. Cosman, F., et al., Clinician's Guide to Prevention and Treatment of Osteoporosis. Osteoporos Int, 2014. 25 (10): p. 2359-81. Watts, N.B., et al., Osteoporosis in men: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab, 2012. 97 (6): p. 1802-22. Lee, S.J. and P.J. Pickhardt, Opportunistic Screening for Osteoporosis Using Body CT Scans Obtained for Other Indications: the UW Experience. Clinical Reviews in Bone and Mineral Metabolism, 2017. 15 (3): p. 128-137. Choi, M.K., S.M. Kim, and J.K. Lim, Diagnostic efficacy of Hounsfield units in spine CT for the assessment of real bone mineral density of degenerative spine: correlation study between T-scores determined by DEXA scan and Hounsfield units from CT. Acta Neurochirurgica, 2016. 158 (7): p. 1421-1427. Yang, G., et al., Prediction of osteoporosis and osteopenia by routine computed tomography of the lumbar spine in different regions of interest. J Orthop Surg Res, 2022. 17 (1): p. 454. Kim, K.J., et al., Hounsfield Units on Lumbar Computed Tomography for Predicting Regional Bone Mineral Density. Open Medicine, 2019. 14 (1): p. 545-551. Yaprak, G., et al., CT Derived Hounsfield Unit: An Easy Way to Determine Osteoporosis and Radiation Related Fracture Risk in Irradiated Patients. Frontiers in Oncology, 2020. 10 . Pickhardt, P.J., et al., Opportunistic screening for osteoporosis using abdominal computed tomography scans obtained for other indications. Ann Intern Med, 2013. 158 (8): p. 588-95. Schreiber, J.J., P.A. Anderson, and W.K. Hsu, Use of computed tomography for assessing bone mineral density. Neurosurg Focus, 2014. 37 (1): p. E4. Alacreu, E., D. Moratal, and E. Arana, Opportunistic screening for osteoporosis by routine CT in Southern Europe. Osteoporos Int, 2017. 28 (3): p. 983-990. Wei, R.L., et al., Bone mineral density loss in thoracic and lumbar vertebrae following radiation for abdominal cancers. Radiother Oncol, 2016. 118 (3): p. 430-6. Toshima, T., et al., Impact of Osteopenia in Liver Cirrhosis: Special Reference to Standard Bone Mineral Density with Age. Anticancer Research, 2018. 38 (11): p. 6465-6471. Uchida, S., et al., Risk factors for osteoporosis in patients with end-stage liver disease. Biomedical Reports, 2016. 5 (5): p. 629-633. Table Table 1. Comparison of Hounsfield unit Scores Across Race RACE N MEDIAN MINIMUM MAXIMUM Arab 1 124.7 124.7 124.7 Asian 3 146.6 145.1 151.7 Black 17 188.9 128.5 303.1 Caucasian 142 134.4 55.4 258.1 Native 6 149.6 90.7 191.4 Total 169 137.2 55.4 303.1 Table 2. Comparison of variables between 165 HU patients HU Category Age (year) BMI (kg/m 2 ) Vitamin D (ng/mL) Glucose (mg/dL) Potassium (mmol/L) Albumin (g/dL) Less than 165 N 128 128 23 128 128 128 Median 60.0 27.2200 16.2000 106.50 4.300 3.300 Minimum 29.0 10.07 3.50 72 3.1 1.1 Maximum 64.0 72.45 29.11 320 10.6 4.9 165 or higher N 42 42 10 42 42 42 Median 58.0 26.2400 13.9000 103.50 4.000 3.200 Minimum 26.0 17.90 3.40 70 2.9 1.2 Maximum 64.0 49.25 69.00 399 4.9 4.6 Total N 170 170 33 170 170 170 Median 60.0 26.9850 16.0000 105.50 4.200 3.300 Minimum 26.0 10.07 3.40 70 2.9 1.1 Maximum 64.0 72.45 69.00 399 10.6 4.9 Additional Declarations The authors declare no competing interests. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4974227","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":344892820,"identity":"da29f3c1-9044-4a13-8e7f-907f8986ab9e","order_by":0,"name":"Katherine Quesada Tibbetts","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzUlEQVRIiWNgGAWjYBACCSjN2MDewMBQAWIQr4XnAAPDGdK0SCQQqUWyf/E2iQ9/7GT7Z74x/nCAwUZ2wwECWqQlnpVJzmxLNp5xO8dM4gBDmjFBLXISZ8ykeRuYExuAWpg/MBxOJE7Lnz/1ifNvngE57D9hLdL8PWbSDGxAw2/wGAAddoCwFskZbMWWvW3HjTeeSSuTOGCQbDyTkBaJ84c33vjxp1p23vHDmz8cqLCT7SOkhUEiwQCJZ4BTHRLgP0CUslEwCkbBKBjJAAAUPUrnj0GYuAAAAABJRU5ErkJggg==","orcid":"","institution":"USF Health Morsani College of Medicine","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Katherine","middleName":"Quesada","lastName":"Tibbetts","suffix":""},{"id":344892821,"identity":"c1e38abc-c303-41a9-b649-f367290527cc","order_by":1,"name":"Rahul Mhaskar","email":"","orcid":"","institution":"USF Health Morsani College of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Rahul","middleName":"","lastName":"Mhaskar","suffix":""},{"id":344892822,"identity":"0b06eec9-1504-40bd-9adb-f0c87bf1ff7f","order_by":2,"name":"Neelesh Prakash","email":"","orcid":"","institution":"USF Department of Radiology","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Neelesh","middleName":"","lastName":"Prakash","suffix":""}],"badges":[],"createdAt":"2024-08-25 21:46:47","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":true,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":true,"coiExplicitlySet":false},"doi":"10.21203/rs.3.rs-4974227/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4974227/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":63799035,"identity":"fa88af96-ce95-49f5-9778-1f16a97a20a1","added_by":"auto","created_at":"2024-09-02 13:00:09","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":93976,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e(A)\u003c/strong\u003e Distribution Hounsfield Unit Scores based on sex(M: Male, F: Female). \u0026nbsp;\u003cstrong\u003e(B) \u003c/strong\u003eHounsfield Unit Scores based on Ethnicity (H: Hispanic, NH: Non-hispanic). \u003cstrong\u003e(C)\u003c/strong\u003e Frequency bar graph for all HU data combined.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4974227/v1/583f979a56bfeb531cbeae66.png"},{"id":63800134,"identity":"7686b310-33a3-4f76-9419-7c64d6a19d84","added_by":"auto","created_at":"2024-09-02 13:08:09","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":36614,"visible":true,"origin":"","legend":"\u003cp\u003eRelationship between race and HU score. This graph illustrates that Caucasians had lower HU scores on average.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4974227/v1/06357e7fc32d696546ac4d4b.png"},{"id":63799037,"identity":"2e8a0b78-f55e-4960-b8d4-08f0b9d28dfc","added_by":"auto","created_at":"2024-09-02 13:00:09","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":214957,"visible":true,"origin":"","legend":"\u003cp\u003eImage in a 58-year-old man with hepatocellular carcinoma (HCC). Unenhanced axial abdominal CT scan of the L1 vertebra of this patient shows a measurement of 68.85 HU.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4974227/v1/db813af90d676edb40f49cec.png"},{"id":63800148,"identity":"09e31f7a-8cbc-4864-b96e-05c6ba3ca7b2","added_by":"auto","created_at":"2024-09-02 13:08:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":859020,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4974227/v1/7061bcb5-3cb5-4855-8645-524e80111f13.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eThe Incidence of Osteoporosis in Hepatocellular Carcinoma Patients Under 65 – A Retrospective Cohort Study\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eHepatocellular carcinoma (HCC) is one of the leading causes of cancer-related deaths in the United States. Often a result of chronic liver injury, HCC in patients has been linked to several nutritional deficiencies which have adverse health effects on patients and prognosis [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Among these risks in HCC patients is a heightened risk for low bone mineral density (BMD) and the development of osteoporosis, which can lead to increased fracture risk and joint inflammation [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The risk of osteoporosis or fracture is higher in patients with liver disease than in the general population [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. It has been shown that patients with chronic liver disease suffer from vitamin deficiencies, which lead to decreased bone synthesis and a higher risk of low BMD. Additionally, studies have shown that chronic liver disease patients with low BMD have an increased risk of developing HCC [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. For example, patients with liver cirrhosis often develop vitamin D deficiency, which further predisposes them to the development of HCC [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This data suggests that many HCC patients are at an increased risk for these same nutritional deficiencies and low BMD [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. We suggest that BMD in HCC patients is an important prognostic tool and parameter to document in patients who have been diagnosed and are undergoing treatment for HCC. Studies have shown that HCC patients with high BMD have more prolonged overall survival than patients with low BMD [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Additionally, HCC patients with low BMD had worse survival rates post liver transplant than patients with normal BMD [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Additionally, osteoporosis is already a known complication of liver transplantation, and the younger patient population of HCC patients may be at increased risk of premature bone demineralization [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Thus, these measurements are important for HCC treatment plans.\u003c/p\u003e \u003cp\u003eDual-energy X-ray absorptiometry (DEXA) scans are the most reliable method of assessing BMD in patients and are regarded as the gold standard [\u003cspan additionalcitationids=\"CR10 CR11 CR12\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. However, current screening guidelines recommend DEXA scans for osteoporosis in females 65 and older and males 70 and older [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Given the adverse effects and implications of low BMD in HCC patients, we believe young HCC patients under 65 must receive DEXA osteoporosis screenings if this population shows low BMD. In this study, we will use existing L1 CT scans as an alternative indicator of osteopenia or osteoporosis in HCC patients under 65 to analyze the prevalence of low BMD in this population. The use of Hounsfield units (HU) from CT scans is a reliable predictor of T-scores from DEXA scans and can be used to predict osteoporosis risk in patients [\u003cspan additionalcitationids=\"CR17 CR18 CR19\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Researchers have shown that the CT attenuation threshold of an L1 vertebra of less than 160 HU has a 90% sensitivity to osteoporosis as evaluated with DEXA [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Yang \u003cem\u003eet al\u003c/em\u003e. has described research values for bone demineralization using HU at the L1 vertebra. In their study, researchers found a level of 165 HU to be the threshold of normal BMD, with less than indicative of osteopenia, and less than 98 to be indicative of osteoporosis [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGiven the prevalence of nutritional deficiencies and the probability of osteoporosis in HCC patients under 65, this population may benefit from regular DEXA screenings to detect low BMD early and provide effective treatment before further damage ensues. In this study, we analyzed the prevalence of low BMD in HCC patients under 65 to assess the incidence of low BMD in this population by analyzing CT scans at the L1 vertebra on the HU scale. Considering the bone loss, high tumor burden, and prevalence of liver transplantation in HCC patients, we believe the results of this study can further improve prognostic knowledge, imaging guidelines and treatment plans for HCC patients under 65.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003e This retrospective cohort study qualified for a waiver of the requirement for signed authorization from the IRB as outlined in the HIPAA Privacy Rule regulations at 45 CFR 164.512(i). We conducted a retrospective chart and radiographic review that evaluated abdominal computed tomography (CT) scans without contrast for all patients under 65 years of age diagnosed with hepatocellular carcinoma at Tampa General Hospital between January 1, 2019, and January 1, 2021. Inclusion criteria included any patient under 65 years of age who was diagnosed in our study time frame and had an abdominal non-contrast CT scan on file. There were no exclusion criteria. Demographic information and medical history were collected.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003eImage Acquisition\u003c/h2\u003e \u003cp\u003eThe non-contrast abdominal CT scans were acquired from patient charts during our study time frame. To minimize bias, the first non-contrast CT scan from diagnosis of HCC was utilized for measurements.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003eImage Interpretation\u003c/h2\u003e \u003cp\u003eThe CT scans were analyzed at the L1 vertebra with Hounsfield units to predict bone mineral density. The HU measurement tool on the Picture Archiving and Communication System (PACS) was utilized to take the measurements at the level of the L1 vertebra.\u003c/p\u003e \u003cp\u003e \u003cem\u003eReference Standard\u003c/em\u003e \u003c/p\u003e \u003cp\u003eGiven the study design as a retrospective cohort study, there was no control group. The HU results were analyzed against criteria outlined by Yang \u003cem\u003eet al.\u003c/em\u003e According to their research, HU analysis at the L1 vertebra of less than 165 is indicative of osteopenia and less than 98 is indicative of osteoporosis [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analyses\u003c/h2\u003e \u003cp\u003eWe conducted the descriptive analysis to report frequencies for categorical data and mean and standard deviation (SD) or median, minimum, and maximum for continuous data. We reviewed the difference in the distribution of continuous variables across categorical variables using the Mann-Whitney U and Kruskal Wallis test. We investigated the correlation by Spearman's rho (\u003cem\u003er\u003c/em\u003e) and reported the correlation coefficient (\u003cem\u003er\u003c/em\u003e) and the 2-tailed 95% confidence intervals (95%CIs). For additional analyses, we created two groups of patients based on the 165 cut off for HU data. All analyses were conducted by SPSS version 26 software. P values less than 0.05 denoted statistical significance.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThere were 170 patients who met the inclusion criteria of being under 65 years of age with a diagnosis of hepatocellular carcinoma and having a non-contrast abdominal CT scan over a 2-year period. The patient cohort was mostly Caucasian (\u003cem\u003en\u003c/em\u003e = 142), non-Hispanic (\u003cem\u003en\u0026nbsp;\u003c/em\u003e= 134), and male (\u003cem\u003en\u0026nbsp;\u003c/em\u003e= 127), with an average age of 58.3 years (Figure 1A and B). BMI was recorded for the patient cohort, with a median of 27.0 kg/m\u003csup\u003e2\u0026nbsp;\u003c/sup\u003e(Min: 10.1, Max: 72.45)and a mean of 28.4 kg/m\u003csup\u003e2\u003c/sup\u003e(Sd: 7.41). \u0026nbsp;The median age was 60 years (Min: 26.0, Max: 64.0) and had a mean of 58.4. The median Hounsfield unit (HU) score for the patient cohort was 137.2 HU, with a minimum of 55.3 HU and a maximum of 303.1 HU (Figure 1C). \u0026nbsp;The sex ratio was approximately 25% female and 75% male. For females, the median HU was 152.0 (Min: 55.4, Max: 274.9). For males, the median HU was 136.5 (Min: 65.9, Max: 303.1). The patient cohort was approximately 83.5% Caucasian, 10% black, 2% Asian, 0.5% Arab, and 3.5% native (Table 1). The cohort was 21.2% Hispanic (Median: 143.4 HU; Min: 81.0, Max: 258.1). \u0026nbsp; Seventy five percent (n = 128) of patients were below the threshold of 165 HU and, therefore, had a potential for an increased probability of low bone mineral density. Of these low BMD patients, approximately 20% (n=25) were identified within the range of osteoporosis. In the full cohort, 15% of patients (n=25) were identified as potentially having osteoporosis if evaluated by DEXA.\u003c/p\u003e\n\u003cp\u003eThe Charlson Co-Morbidity Index was calculated for each patient and was distributed evenly across patients based on their Hounsfield unit score grouping based on the 165 cut off (\u003cem\u003ep =\u0026nbsp;\u003c/em\u003e0.192). In our cohort, Caucasians were most at risk for low BMD (Median HU Score: 134.4, Min: 55.4, Max: 258.1) (Figure 2). HU score had a significant negative correlation to glucose (\u003cem\u003er\u003c/em\u003e = -0.159, 95% CI [-0.306, -0.004], \u003cem\u003ep\u003c/em\u003e = 0.038), age (\u003cem\u003er\u003c/em\u003e = -2.00, 95% CI [-0.344, -0.046],\u003cem\u003e\u0026nbsp;p =\u0026nbsp;\u003c/em\u003e0.009), and potassium (\u003cem\u003er\u003c/em\u003e = -0.275, 95% CI [-0.413, -0.126], \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001). The median albumin score for the patient cohort was 3.3 g/dL (min: 1.1, max: 4.9). HU did not have a significant relationship to albumin (\u003cem\u003er\u003c/em\u003e = -0.128, 95% CI [-0.278, 0.027], \u003cem\u003ep\u003c/em\u003e = 0.095) or BMI (\u003cem\u003er\u003c/em\u003e = -0.030, 95% CI [-0.184, 0.125], \u003cem\u003ep\u003c/em\u003e = 0.695). Only 33 patients had a vitamin D level measurement in their medical chart, and the median vitamin D level was 16.0 ng/mL (min: 3.5, max: 69.0).\u003c/p\u003e\n\u003cp\u003eAnalysis of the patients under vs over 165 HU was also completed (Table 2). Overall, the data for those at risk of low bone mineral density (\u0026lt;165 HU), has statistically significant results for potassium (\u003cem\u003ep\u003c/em\u003e = 0.004) and age (p = 0.022). \u0026nbsp;Non-statistically significant relationships included BMI (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e= 0.233), Charlson Co-Morbidity Index (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e= 0.192), glucose (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e= 0.446), vitamin D level (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e= 0.505), and albumin (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e= 0.156).\u0026nbsp;\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eHepatocellular carcinoma patients are at risk of low bone mineral density (BMD) due to their liver disease and nutritional deficiencies, as shown by the results of this study. The technique of using HU on non-contrast CT scans to identify high risk HCC patients for prematurely developing osteopenia or osteoporosis is a useful application of this modality (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) [\u003cspan additionalcitationids=\"CR22 CR23\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. With 75% of patients from the study below the 165 HU threshold for normal bone mineral density, we recommend that hepatocellular carcinoma (HCC) patients undergo regular DEXA screening to assess individual risks for osteopenia or osteoporosis and the associated complications. Measurements for the nutritional deficiencies of the patient cohort were evaluated by the measurement of albumin, vitamin D, glucose, and BMI.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eMost of the cohort had an overweight BMI, indicating a serious co-morbidity. Although albumin did not have a statistically significant relationship with HU score, the median and mean albumin levels were below the normal range, indicating that the patient cohort experienced nutritional deficiencies, as expected, given the liver disease. Vitamin D levels were also consistently below normal values, strengthening the argument for better nutritional management of hepatocellular carcinoma patients [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Surprisingly, there was a significant inverse relationship between HU score and glucose level, indicating that hyperglycemia is associated with lower bone mineral density and, thus, worse prognostic factors.\u003c/p\u003e \u003cp\u003eThe under 165 HU subgroup analysis was not significant for a relationship between HU and glucose, indicating once low BMD is acquired, glucose levels do not indicate severity of osteopenia. However, among whole data from the HCC cohort patients, hyperglycemia was a significant predictor of having an increased risk of low BMD. This analysis shows that hyperglycemia may be a predictor of the heightened risk of developing low BMD in HCC patients. However, further investigation into the relationship between glucose and bone mineral density is needed to fully understand the implications of hyperglycemia in this patient population.\u003c/p\u003e \u003cp\u003eInherent limitations are present given the study design as a retrospective chart review. Limitations of this study include the varied time between cohort members from point of diagnosis to point of first non-contrast CT scan and variability in the CT machine used. These were uncontrollable variables given the nature of the retrospective study. Researchers attempted to limit time variability between individual patient CT scans and disease progression by recording HU scores from the first CT scan without contrast on patient record after diagnosis.\u003c/p\u003e \u003cp\u003eWith the nutritional markers and imaging results considered, it is evident that HCC patients suffer from declining nutritional values and increasing co-morbidities, which may have negative implications on their disease prognosis and risk of developing low bone mineral density and the associated complications [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Future research into cirrhotic patients is also recommended considering the clinical importance of BMD in liver disease patients as a predictor of HCC [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. As described in Liang et al., BMD is an effective predictor of the development of HCC in cirrhotic patients [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWith current DEXA screening guidelines recommending imaging for women 65 and older and men 70 and older, a sizeable subset of cancer patients are left with increased risk of unmonitored early-onset bone demineralization and are left to its consequences [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Through this study, it is evident HCC patients under 65 years old have a high incidence of low BMD and an increased fracture risk, and physicians should consider regular BMD screenings in this patient cohort. The Endocrine Society clinical guidelines recommend DEXA screenings of younger patients if they are shown to be at heightened risk of bone demineralization [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The results of this study identify HCC patients under 65 as high-risk patients, and future studies utilizing DEXA scans should be completed to determine appropriate screening guidelines for this patient population.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, HCC patients under 65 were found to have low BMD, as assessed by Hounsfield unit scores at the L1 level in non-contrast CTs. Of the 170 HCC patients assessed, 75% were recorded to have low BMD. Our data supports the need for this patient population to undergo regular DEXA scans to carefully screen for the development of osteopenia and osteoporosis to avoid further complications in their care and management. Given this patient cohort was found to have poor nutritional markers, nutritional supplementation and aid must be provided to improve prognosis and mitigate unnecessary risk factors. Hyperglycemia and low BMD share a statistically significant inverse relationship, and future research is encouraged to investigate further the influence hyperglycemia can have on BMD. Given the findings of our study, we recommend that future research, such as a prospective DEXA scan study, be performed to evaluate the clinical effectiveness of BMD screening in hepatocellular carcinoma patients and determine appropriate screening recommendations.\u003c/p\u003e"},{"header":"Statements and Declarations","content":"\u003cp\u003eThe authors declare no relevant or material financial interests that relate to the research described in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: The project was funded through the USF Summer Scholarly Award Experience. This award is given by the USF RISE Office to support medical student research during the summer break between first and second year of medical school. The award of $3,500 funded 8 weeks of research.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eACKNOWLEDGEMENTS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe project was funded through the USF Summer Scholarly Award Experience. This award is given by the USF RISE Office to support medical student research during the summer break between first and second year of medical school. The award of $3,500 funded 8 weeks of research.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONFLICT OF INTEREST\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no relevant or material financial interests that relate to the research described in this paper.\u003c/p\u003e\n\u003cp\u003eThis retrospective cohort study was reviewed by the USF IRB and was found to qualify for a waiver of the requirement for signed authorization from the IRB as outlined in the HIPAA Privacy Rule regulations at 45 CFR 164.512(i).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eLiang, K.H., et al., \u003cem\u003eMorphomic Signatures Derived from Computed Tomography Predict Hepatocellular Carcinoma Occurrence in Cirrhotic Patients.\u003c/em\u003e Digestive Diseases and Sciences, 2020. \u003cstrong\u003e65\u003c/strong\u003e(7): p. 2130-2139.\u003c/li\u003e\n \u003cli\u003eKe, K., M. Arra, and Y. Abu-Amer, \u003cem\u003eMechanisms Underlying Bone Loss Associated with Gut Inflammation.\u003c/em\u003e International Journal of Molecular Sciences, 2019. \u003cstrong\u003e20\u003c/strong\u003e(24).\u003c/li\u003e\n \u003cli\u003eNakchbandi, I.A., \u003cem\u003eOsteoporosis and fractures in liver disease: Relevance, pathogenesis and therapeutic implications.\u003c/em\u003e World Journal of Gastroenterology, 2014. \u003cstrong\u003e20\u003c/strong\u003e(28): p. 9427-9438.\u003c/li\u003e\n \u003cli\u003eCho, Y.S., et al., \u003cem\u003eComputed Tomography-Determined Body Composition Abnormalities Usefully Predict Long-term Mortality in Patients With Liver Cirrhosis.\u003c/em\u003e Journal of Computer Assisted Tomography, 2021. \u003cstrong\u003e45\u003c/strong\u003e(5): p. 684-690.\u003c/li\u003e\n \u003cli\u003eHayashi, F., et al., \u003cem\u003eLoss of skeletal muscle mass in patients with chronic liver disease is related to decrease in bone mineral density and exercise tolerance.\u003c/em\u003e Hepatology Research, 2018. \u003cstrong\u003e48\u003c/strong\u003e(5): p. 345-354.\u003c/li\u003e\n \u003cli\u003eMuller, L., et al., \u003cem\u003eLow bone mineral density is a prognostic factor for elderly patients with HCC undergoing TACE: results from a multicenter study.\u003c/em\u003e European Radiology.\u003c/li\u003e\n \u003cli\u003eSharma, P., et al., \u003cem\u003eBone mineral density predicts posttransplant survival among hepatocellular carcinoma liver transplant recipients.\u003c/em\u003e Liver Transplantation, 2016. \u003cstrong\u003e22\u003c/strong\u003e(8): p. 1092-1098.\u003c/li\u003e\n \u003cli\u003eChang, J.W., et al., \u003cem\u003eRisk factors for fractures following liver transplantation: a population-based cohort study.\u003c/em\u003e Ann Med, 2023. \u003cstrong\u003e55\u003c/strong\u003e(1): p. 2230871.\u003c/li\u003e\n \u003cli\u003eMiyachi, Y., et al., \u003cem\u003eBone Mineral Density as a Risk Factor for Patients Undergoing Surgery for Hepatocellular Carcinoma.\u003c/em\u003e World Journal of Surgery, 2019. \u003cstrong\u003e43\u003c/strong\u003e(3): p. 920-928.\u003c/li\u003e\n \u003cli\u003eCauley, J.A., et al., \u003cem\u003eBone mineral density and the risk of incident nonspinal fractures in black and white women.\u003c/em\u003e Jama, 2005. \u003cstrong\u003e293\u003c/strong\u003e(17): p. 2102-8.\u003c/li\u003e\n \u003cli\u003eDamilakis, J., T.G. 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Pickhardt, \u003cem\u003eOpportunistic Screening for Osteoporosis Using Body CT Scans Obtained for Other Indications: the UW Experience.\u003c/em\u003e Clinical Reviews in Bone and Mineral Metabolism, 2017. \u003cstrong\u003e15\u003c/strong\u003e(3): p. 128-137.\u003c/li\u003e\n \u003cli\u003eChoi, M.K., S.M. Kim, and J.K. Lim, \u003cem\u003eDiagnostic efficacy of Hounsfield units in spine CT for the assessment of real bone mineral density of degenerative spine: correlation study between T-scores determined by DEXA scan and Hounsfield units from CT.\u003c/em\u003e Acta Neurochirurgica, 2016. \u003cstrong\u003e158\u003c/strong\u003e(7): p. 1421-1427.\u003c/li\u003e\n \u003cli\u003eYang, G., et al., \u003cem\u003ePrediction of osteoporosis and osteopenia by routine computed tomography of the lumbar spine in different regions of interest.\u003c/em\u003e J Orthop Surg Res, 2022. \u003cstrong\u003e17\u003c/strong\u003e(1): p. 454.\u003c/li\u003e\n \u003cli\u003eKim, K.J., et al., \u003cem\u003eHounsfield Units on Lumbar Computed Tomography for Predicting Regional Bone Mineral Density.\u003c/em\u003e Open Medicine, 2019. \u003cstrong\u003e14\u003c/strong\u003e(1): p. 545-551.\u003c/li\u003e\n \u003cli\u003eYaprak, G., et al., \u003cem\u003eCT Derived Hounsfield Unit: An Easy Way to Determine Osteoporosis and Radiation Related Fracture Risk in Irradiated Patients.\u003c/em\u003e Frontiers in Oncology, 2020. \u003cstrong\u003e10\u003c/strong\u003e.\u003c/li\u003e\n \u003cli\u003ePickhardt, P.J., et al., \u003cem\u003eOpportunistic screening for osteoporosis using abdominal computed tomography scans obtained for other indications.\u003c/em\u003e Ann Intern Med, 2013. \u003cstrong\u003e158\u003c/strong\u003e(8): p. 588-95.\u003c/li\u003e\n \u003cli\u003eSchreiber, J.J., P.A. Anderson, and W.K. Hsu, \u003cem\u003eUse of computed tomography for assessing bone mineral density.\u003c/em\u003e Neurosurg Focus, 2014. \u003cstrong\u003e37\u003c/strong\u003e(1): p. E4.\u003c/li\u003e\n \u003cli\u003eAlacreu, E., D. Moratal, and E. Arana, \u003cem\u003eOpportunistic screening for osteoporosis by routine CT in Southern Europe.\u003c/em\u003e Osteoporos Int, 2017. \u003cstrong\u003e28\u003c/strong\u003e(3): p. 983-990.\u003c/li\u003e\n \u003cli\u003eWei, R.L., et al., \u003cem\u003eBone mineral density loss in thoracic and lumbar vertebrae following radiation for abdominal cancers.\u003c/em\u003e Radiother Oncol, 2016. \u003cstrong\u003e118\u003c/strong\u003e(3): p. 430-6.\u003c/li\u003e\n \u003cli\u003eToshima, T., et al., \u003cem\u003eImpact of Osteopenia in Liver Cirrhosis: Special Reference to Standard Bone Mineral Density with Age.\u003c/em\u003e Anticancer Research, 2018. \u003cstrong\u003e38\u003c/strong\u003e(11): p. 6465-6471.\u003c/li\u003e\n \u003cli\u003eUchida, S., et al., \u003cem\u003eRisk factors for osteoporosis in patients with end-stage liver disease.\u003c/em\u003e Biomedical Reports, 2016. \u003cstrong\u003e5\u003c/strong\u003e(5): p. 629-633.\u003cstrong\u003e\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table","content":"\u003cp\u003eTable 1. Comparison of Hounsfield unit Scores Across Race\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"559\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.881720430107528%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRACE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.13978494623656%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.17562724014337%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMEDIAN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.863799283154123%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMINIMUM\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.939068100358423%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMAXIMUM\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.881720430107528%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eArab\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.13978494623656%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.17562724014337%\" valign=\"top\"\u003e\n \u003cp\u003e124.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.863799283154123%\" valign=\"top\"\u003e\n \u003cp\u003e124.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.939068100358423%\" valign=\"top\"\u003e\n \u003cp\u003e124.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.881720430107528%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAsian\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.13978494623656%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.17562724014337%\" valign=\"top\"\u003e\n \u003cp\u003e146.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.863799283154123%\" valign=\"top\"\u003e\n \u003cp\u003e145.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.939068100358423%\" valign=\"top\"\u003e\n \u003cp\u003e151.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.881720430107528%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBlack\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.13978494623656%\" valign=\"top\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.17562724014337%\" valign=\"top\"\u003e\n \u003cp\u003e188.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.863799283154123%\" valign=\"top\"\u003e\n \u003cp\u003e128.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.939068100358423%\" valign=\"top\"\u003e\n \u003cp\u003e303.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.881720430107528%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCaucasian\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.13978494623656%\" valign=\"top\"\u003e\n \u003cp\u003e142\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.17562724014337%\" valign=\"top\"\u003e\n \u003cp\u003e134.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.863799283154123%\" valign=\"top\"\u003e\n \u003cp\u003e55.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.939068100358423%\" valign=\"top\"\u003e\n \u003cp\u003e258.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.881720430107528%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNative\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.13978494623656%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.17562724014337%\" valign=\"top\"\u003e\n \u003cp\u003e149.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.863799283154123%\" valign=\"top\"\u003e\n \u003cp\u003e90.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.939068100358423%\" valign=\"top\"\u003e\n \u003cp\u003e191.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.881720430107528%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.13978494623656%\" valign=\"top\"\u003e\n \u003cp\u003e169\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.17562724014337%\" valign=\"top\"\u003e\n \u003cp\u003e137.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.863799283154123%\" valign=\"top\"\u003e\n \u003cp\u003e55.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.939068100358423%\" valign=\"top\"\u003e\n \u003cp\u003e303.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 2. Comparison of variables between \u0026lt;165 HU and \u0026gt; 165 HU patients\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"599\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.05351170568562%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHU Category\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.210702341137123%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.02675585284281%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(year)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.20401337792642%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54180602006689%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVitamin D\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(ng/mL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.200668896321071%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGlucose (mg/dL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.545150501672241%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePotassium (mmol/L)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.217391304347826%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAlbumin (g/dL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.05351170568562%\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLess than 165\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.210702341137123%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.02675585284281%\" valign=\"top\"\u003e\n \u003cp\u003e128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.20401337792642%\" valign=\"top\"\u003e\n \u003cp\u003e128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54180602006689%\" valign=\"top\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.200668896321071%\" valign=\"top\"\u003e\n \u003cp\u003e128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.545150501672241%\" valign=\"top\"\u003e\n \u003cp\u003e128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.217391304347826%\" valign=\"top\"\u003e\n \u003cp\u003e128\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.737051792828685%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.56175298804781%\" valign=\"top\"\u003e\n \u003cp\u003e60.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.346613545816734%\" valign=\"top\"\u003e\n \u003cp\u003e27.2200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.9402390438247%\" valign=\"top\"\u003e\n \u003cp\u003e16.2000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.151394422310757%\" valign=\"top\"\u003e\n \u003cp\u003e106.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.13545816733068%\" valign=\"top\"\u003e\n \u003cp\u003e4.300\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.127490039840637%\" valign=\"top\"\u003e\n \u003cp\u003e3.300\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.737051792828685%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMinimum\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.56175298804781%\" valign=\"top\"\u003e\n \u003cp\u003e29.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.346613545816734%\" valign=\"top\"\u003e\n \u003cp\u003e10.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.9402390438247%\" valign=\"top\"\u003e\n \u003cp\u003e3.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.151394422310757%\" valign=\"top\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.13545816733068%\" valign=\"top\"\u003e\n \u003cp\u003e3.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.127490039840637%\" valign=\"top\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.737051792828685%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaximum\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.56175298804781%\" valign=\"top\"\u003e\n \u003cp\u003e64.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.346613545816734%\" valign=\"top\"\u003e\n \u003cp\u003e72.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.9402390438247%\" valign=\"top\"\u003e\n \u003cp\u003e29.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.151394422310757%\" valign=\"top\"\u003e\n \u003cp\u003e320\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.13545816733068%\" valign=\"top\"\u003e\n \u003cp\u003e10.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.127490039840637%\" valign=\"top\"\u003e\n \u003cp\u003e4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.05351170568562%\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e165 or higher\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.210702341137123%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.02675585284281%\" valign=\"top\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.20401337792642%\" valign=\"top\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54180602006689%\" valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.200668896321071%\" valign=\"top\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.545150501672241%\" valign=\"top\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.217391304347826%\" valign=\"top\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.737051792828685%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.56175298804781%\" valign=\"top\"\u003e\n \u003cp\u003e58.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.346613545816734%\" valign=\"top\"\u003e\n \u003cp\u003e26.2400\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.9402390438247%\" valign=\"top\"\u003e\n \u003cp\u003e13.9000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.151394422310757%\" valign=\"top\"\u003e\n \u003cp\u003e103.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.13545816733068%\" valign=\"top\"\u003e\n \u003cp\u003e4.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.127490039840637%\" valign=\"top\"\u003e\n \u003cp\u003e3.200\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.737051792828685%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMinimum\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.56175298804781%\" valign=\"top\"\u003e\n \u003cp\u003e26.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.346613545816734%\" valign=\"top\"\u003e\n \u003cp\u003e17.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.9402390438247%\" valign=\"top\"\u003e\n \u003cp\u003e3.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.151394422310757%\" valign=\"top\"\u003e\n 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valign=\"top\"\u003e\n \u003cp\u003e3.300\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.737051792828685%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMinimum\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.56175298804781%\" valign=\"top\"\u003e\n \u003cp\u003e26.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.346613545816734%\" valign=\"top\"\u003e\n \u003cp\u003e10.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.9402390438247%\" valign=\"top\"\u003e\n \u003cp\u003e3.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.151394422310757%\" valign=\"top\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.13545816733068%\" valign=\"top\"\u003e\n \u003cp\u003e2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.127490039840637%\" valign=\"top\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.737051792828685%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaximum\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.56175298804781%\" valign=\"top\"\u003e\n \u003cp\u003e64.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.346613545816734%\" valign=\"top\"\u003e\n \u003cp\u003e72.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.9402390438247%\" valign=\"top\"\u003e\n \u003cp\u003e69.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.151394422310757%\" valign=\"top\"\u003e\n \u003cp\u003e399\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.13545816733068%\" valign=\"top\"\u003e\n \u003cp\u003e10.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.127490039840637%\" valign=\"top\"\u003e\n \u003cp\u003e4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"USF Health Morsani College of Medicine","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Osteoporosis, Bone Demineralization, Hepatocellular Carcinoma, Cancer, CT, Liver Disease, Endocrinology, Imaging Guidelines, Preventative Medicine, DEXA","lastPublishedDoi":"10.21203/rs.3.rs-4974227/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4974227/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction: \u003c/strong\u003eHepatocellular carcinoma (HCC) patients have a heightened prevalence of low bone mineral density (BMD) and the development of osteoporosis. Osteoporosis screening guidelines only recommend DEXA scans for females 65 and older and males 70 and older. We set out to analyze the incidence of low bone mineral density in HCC patients under 65 years old and encourage implementation of DEXA screenings for this patient population.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod:\u003c/strong\u003e In this retrospective cohort study, 170 patients under 65 years old with an HCC diagnosis were analyzed. The use of Hounsfield units (HU) from L1 non-contrast CT scans is a reliable predictor of T-scores from DEXA scans and was used to predict BMD in patients, with scores of less than 165 HU indicative of osteopenia and less than 98 indicative of osteoporosis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe median HU score of patients was 137.2, and the mean score was 142.6 (Min: 55.4; Max: 303.1). Approximately 75% of patients had an HU score of less than 165, indicating a high likelihood of suffering from low BMD. Approximately 20% of low BMD patients were identified as within a range of osteoporosis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eHCC patients under 65 have an increased incidence of bone demineralization\u003cstrong\u003e. \u003c/strong\u003eWe suggest that BMD in HCC patients is an important prognostic tool and parameter to document, as studies have shown that HCC patients with high BMD have longer overall survival than patients with low BMD. Future prospective studies using DEXA scans to assess BMD should be completed to verify the risk of osteoporosis.\u003c/p\u003e","manuscriptTitle":"The Incidence of Osteoporosis in Hepatocellular Carcinoma Patients Under 65 – A Retrospective Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-02 13:00:05","doi":"10.21203/rs.3.rs-4974227/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2b65d9fb-9a00-41c9-ad7a-945e6f495af2","owner":[],"postedDate":"September 2nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-09-02T13:00:05+00:00","versionOfRecord":[],"versionCreatedAt":"2024-09-02 13:00:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4974227","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4974227","identity":"rs-4974227","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}