Altered BANKL/OPG system in hepatic osteodystrophy

The coexistence of liver disease and metabolic bone disease has been recognized for many years and is now the subject of increasing attention. Hepatic Osteodystrophy was established in patients with cholestatic liver disease, but new research suggests that it is prevalent in patients with other chronic liver diseases. Its etiology is complex and multifactorial. Receptor activator of nuclear factor Kb ligand [RANKL] plays a role in the differentiation and activation of bone resorbing osteoclasts by binding to its high affinity receptor [RANK] located on the surface of osteoclasts. This effect is counterbalanced by osteoprotegren [OPG], which acts as a decoy receptor competing with RANKL for RANK. To evaluate bone mineral density [BMD] and OPG/RANKL system in cirrhotic patients with backache. This study included 50 subjects suffering from backache, divided into 4 groups as follows: Group I: 10 subjects with normal BMD, Group II: 10 patients with pathological BMD but otherwise healthy considered as control, Group III: 15 patients with cirrhosis and normal BMD, Group IV: 15 patients with cirrhosis and pathological BMD. All patients underwent clinical examination, routine liver function tests, alkaline phosphatase, total calcium, serum OPG, serum RANKL, added to BMD. The lowest BMD values are estimated at the lumber spine, femoral neck, and lastly lower end of radius. There was a significant decrease in OPG in osteopenic/ osteoporotic non cirrhotic patients compared to control group, while it is significantly higher than control in both osteopenic/osteoporotic and patients with normal BMD of cirrhotic groups. RANKL, was significantly higher in non cirrhotic patients with pathological BMD compared to control group, but lower than control in cirrhotic groups both with normal and pathological BMD, with significant difference in cirrhotic with pathological BMD and non significant in those with normal BMD compared to controls. Serum OPG was negatively correlated to serum calcium, albumin, and International Normalized Ratio [INR], but positively correlated to bone alkaline phosphatase, and AST in cirrhotic patients of both groups. In cirrhotic patients, low BMD has tendency to affect axial bone early, which is similar to postmenopausal osteoporosis. On the contrary, higher OPG and lower RANKL levels are opposite to postmenopausal osteoporosis. This difference indicates that: OPG/RANKL system is activated in a different way in cirrhosis, suggesting a role for OPG/RANKL system in pathogenesis of hepatic osteodystrophy

Some therapeutic options in treating chronic sciatic pain

Chronic back pain has become one of the most expensive causes of disability among people under the age of 45 years. A wide variety of non operative treatment options are advocated in the management of chronic sciatic pain [CSP] due to lumbar disc prolapse [LDP]. The most prevalent therapy for this pain is physical therapy. Recently electro-acupuncture [EA] is an established adjuvant analgesic modality in the management of chronic pain. In our study we tried to evaluate the efficacy of exercise therapy, low power laser therapy [LPL] and electro-acupuncture [EA] in the treatment of chronic sciatic pain due to lumbar disc prolapse. 45 patients with chronic sciatic pain due to [LDP] were included in this study. Their age ranged from 20 to 45 years. They were divided into 3 groups: Group I [Exercise only], Group II [LPL+ Exercise] and Group III [EA + Exercise]. The treatment program continued 3 months. All patients were evaluated by taking full history, full clinical examination and investigated by plain X-ray and MRI. They were assessed by VAS, Roland Disability Questionnaire [RDQ], Schober's test, Finger Floor Test, Straight Leg Raising [SLR] test and Japanese Orthopedic Association [JOA] score. Our results demonstrated significant improvement in all parameters in the 3 studied groups with best improvement was in group III. Electro-acupuncture is an effective modality in controlling chronic sciatic pain and complications and may thus be used as a good alternative in indicated cases