Patients with PBC have been reported to be at increased risk of osteoporosis in some studies [67] , but reports in the literature remain contradictory. Patients with advanced PBC may be at particular risk for osteoporosis and may present with osteoporosis and yet be otherwise asymptomatic from their liver disease. The development of osteoporosis in PBC patients has been attributed to both, decreased osteoblast activity and increased osteoclast activity [68] . Metabolism of vitamin D is normal in PBC, but malabsorption of both calcium and vitamin D may occur predominantly in latestage disease. Pancreatic insufficiency and celiac disease, which are associated with PBC [69] [70] [71] , may further aggravate malabsorption.