Association between osteoporosis and waitlist mortality in liver transplant candidates

Osteoporosis is a common comorbidity in end-stage liver disease (ESLD), yet its impact on waitlist survival remains underexplored, particularly in non-Western populations. This prospective cross-sectional study evaluated bone mineral density (BMD) and its association with mortality in 702 adult candidates, including 424 (60.4%) males and 278 (39.6%) females with an overall mean age of 45.13 ± 13.67 years, awaiting their first deceased-donor liver transplantation at a major referral center in Iran. BMD was assessed via dual-energy X-ray absorptiometry (DXA) at the lumbar spine, femoral neck, and total hip. Osteoporosis was present in 43.4% of patients, osteopenia in 36.9%, and only 19.7% had normal BMD. The mean Model for End-Stage Liver Disease (MELD) score was 18.1 ± 6.53. Patients with autoimmune hepatitis (AIH) exhibited the highest prevalence of osteoporosis (53.61%) among all etiologies. Multivariate Cox regression analysis revealed that osteoporosis was independently associated with increased waitlist mortality (HR = 1.90, 95% CI: 1.17–3.07). Conversely, primary sclerosing cholangitis (PSC) was associated with reduced mortality risk (HR = 0.42, 95% CI: 0.19–0.93). These findings underscore the high prevalence of bone disease in ESLD patients, identify AIH as a high-risk etiology for osteoporosis, and establish osteoporosis as a significant predictor of waitlist survival, highlighting the potential value of BMD assessment in pre-transplant risk stratification.