Risk of fractures and subsequent mortality in alcohol-related cirrhosis: A nationwide population-based cohort study

Background and aims
Alcohol-related cirrhosis is linked to increased risk of fractures, but this has seldom been quantified nationally or compared against non-cirrhotic controls. Here, we determined the rate and risk of fractures and post-fracture mortality in patients with alcohol-related cirrhosis compared to individuals from the general population.
In this nationwide population-based cohort study, data were retrieved from the Swedish National Patient Registry on 25,090 patients with alcohol-related cirrhosis from 1969-2016. Patients were matched for sex, age, and municipality with 239,458 controls from the Swedish Total Population Registry. Cox regression models were fitted to investigate the rates of fractures and post-fracture mortality. The cumulative incidence of fractures was calculated while accounting for competing risks (death or liver transplantation).
A total of 48,635 fractures occurred during 3,468,860 person-years of follow-up. Patients with alcohol-related cirrhosis had a higher fracture rate per 1000 person-years (38.7) than controls (13.3; adjusted hazard ratio [aHR] 3.8, 95% confidence interval [CI] 3.6-3.9). The cumulative incidence of fractures was elevated for patients the first 19 years of follow-up, with a 5-year risk of 9.6% compared to 4.5% for controls. Patients with alcohol-related cirrhosis had a higher post-fracture mortality rate compared to controls who also experienced a fracture, at both 30 days (aHR 1.6, 95% CI 1.4-1.8) and 1 year (aHR 1.8, 95% CI 1.7-2.0).

Alcohol-related cirrhosis is associated with an almost fourfold increased fracture rate, a higher risk of fractures the first two decades after initial diagnosis, and higher post-fracture mortality. Preventive interventions to reduce modifiable fracture risk factors in this population are justified.