Changing Protocol: One Liver at a Time

Changing Protocol: One Liver at a Time

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By: Madeline Dwyer
Supervisor: Dr. Angela M. Cheung

Over the summer I have had the pleasure of working in Dr. Cheung’s Osteoporosis Clinic at Toronto General Hospital. My project investigated the link between the highly prevalent condition of osteoporosis in those with liver disease, described in 12-55% of liver disease patients1. Liver disease affects more than 3 million Canadians and has a plethora of causes including alcohol, Hepatitis B/C, and high fat diets, to name a few2. All pathologies share the stages of liver decompensation, with cirrhosis being a consequence of end stages. As liver cells die, fibrous tissue takes their place preventing blood flow, causing a whole slew of complications: from jaundice to ascites – fluid buildup in the abdomen3.

The diagnosis and treatment of osteoporosis is essential to prevent fractures, which are associated with high mortality rates, making this a necessary element of liver disease treatment. The current standard of care for those with cirrhosis undergoing paracentesis, a procedure to drain ascites, is to receive a dual-energy X-ray absorptiometry (DXA) scan annually. A DXA scan is used to measure bone density and microarchitecture, known as bone mineral density and trabecular bone score, respectively. However, there is no definitive protocol for the timing of the scan, whether it be before or after paracentesis. Here lies the issue, the ascitic fluid may be distorting the DXA scan image resulting in an overdiagnosis of osteoporosis. Ultimately, my project involved recruiting patients who were undergoing paracentesis. Participants received DXA scans before and after paracentesis to determine if a significant difference exists.

I was mentored by my supervisor and her team, all of whom taught me invaluable lessons on the ins and outs of clinical research. I learned the hard way that participant recruitment is difficult, whether because of a small patient population or scheduling conflicts. It is therefore important to understand the benefit of your research so you can express this to potential participants. I also came to realize the importance of using my free time to read, which helped me thoroughly understand my project and how it fits into the current literature. Lastly, I used the opportunity to learn without the pressure of marks and exams.

During the recruitment process, while speaking with nurses and patients alike, they were shocked that we do not know this basic knowledge about the effect of ascites on bone measures given that liver disease and osteoporosis commonly co-occur. How can we know so much about protein receptors and intracellular pathways, yet not know the answer to this simple question? I was driven by the fact that what I discovered could change the protocol for accurate diagnosis of bone health and fracture risk in liver disease patients. If my findings can help clinicians better assess bone health in this population then I will have made a contribution to scientific research; every researcher’s dream.



  1. Rouillard S, Lane NE. Hepatic osteodystrophy. Hepatology. 2001;33(1):301-307.
  2. Canadian Liver Foundation. Liver disease in Canada: a crisis in the making. Markham (CA): Canadian Liver Foundation; 2013. 3 p.
  3. Tsochatzis EA, Bosch J, Burroughs AK. Liver Cirrhosis. Lancet. 2014;383(9930):1749-1761.