Original Article Effect of Ascites on Bone Density Measurement in Cirrhosis Eternity D. Labio, 1 Dante B. Del Rosario, 1 Simone I. Strasser, 1,2 Geoffrey W. McCaughan, 1 and Bronwyn A. Crawford * ,2 1 NHMRC Center of Clinical Research Excellence to Improve Outcome in Chronic Liver Disease, AW Morrow Gastroenterology and Liver Center, University of Sydney, Camperdown, New South Wales, Australia; and 2 Department of Endocrinology, Royal Prince Alfred Hospital, University of Sydney, Camperdown, New South Wales, Australia Abstract Cirrhosis is an independent risk factor for the development of osteoporosis. The presence of ascites in patients with cirrhosis may affect the accuracy of bone density measurement in the spine. Twenty cirrhotic patients had bone mineral density (BMD) measurements of the lumbar spine, femoral neck, hip, and total body using dual-energy X-ray absorptiometry (DXA; Lunar Prodigy) before and after large-volume paracentesis. To establish short-term precision of DXA measurement, 28 healthy adults also had duplicate BMD measurements on the same day. After paracentesis (6.4 Æ 2.0 L), there was a significant increase in the spine BMD of 4.2% ( p 5 0.003) and in the total hip BMD of 1.3% ( p 5 0.002), but there was no change in the femoral neck or total body. No significant differences ( p O 0.1) were seen in duplicate BMD measurements at any site among the healthy cohort. Within-patient changes in spine ( p 5 0.001) and total hip ( p 5 0.001) BMD measurements were significantly greater in patients with ascites than in the healthy cohort. These changes in BMD measurements were not associated with age, gender, amount of fluid removed, or time interval between measurements. These results suggest that ascites cause a fluid artifact in the soft tissue and bone interface that can falsely lower BMD measurements, particularly in the spine. Key Words: Ascites; bone densitometry; cirrhosis; osteoporosis; reproducibility. Introduction Osteoporosis is common in chronic liver disease, occurring in 30% to 50% of patients with cirrhosis of the liver (1,2). Ev- idence of cirrhosis as an independent risk factor for the devel- opment of osteoporosis (1,3,4) has made screening for bone disease mandatory in this high-risk population (2). Early and accurate detection is crucial to prevent the morbidity associated with fractures. One of the best predictors for osteoporosis and fracture risk is the determination of bone mineral density (BMD) by means of dual-energy X-ray absorptiometry (DXA). Factors known to influence the accuracy of BMD measurements are changes in the mass, thickness, and composition of soft tissue overlying bone (5e7). However, conflicting evidence exists regarding the extent to which these changes influence accu- racy of test results especially in the trunk region (8e11). Ascites due to portal hypertension is a common compli- cation of advanced liver disease and may cause changes in the soft tissue composition of the trunk region. Therapeutic abdominal paracentesis is now regarded as part of manage- ment protocols for the treatment of diuretic resistant ascites. This study aims to investigate the effect of ascites and its therapeutic drainage on BMD measurements of the lumbar spine, femoral neck, hip, and total body in cirrhotic pa- tients. Materials and Methods Study Population Twenty patients with cirrhosis and ascites had BMD mea- surements before and after therapeutic paracentesis (drainage Received 03/12/07; Revised 06/14/07; Accepted 07/02/07. *Address correspondence to: Dr. Bronwyn Crawford, Royal Prince Alfred Hospital Medical Center, 100 Carillon Avenue, Suite 301, Newtown, New South Wales 2042, Australia. E-mail: brcrawfo@mail.usyd.edu.au 391 Journal of Clinical Densitometry, vol. 10, no. 4, 391e394, 2007 Ó Copyright 2007 by The International Society for Clinical Densitometry 1094-6950/06/10:391e394/$32.00 DOI: 10.1016/j.jocd.2007.07.001