Osteopenia in the form of osteoporosis is a common clinical problem associated with chronic cholestatic liver disease, and clinical morbidity from atraumatic fractures is increasing as more patients with PBC and PSC undergo successful liver transplantation. In the absence of symptomatic fractures, the clinical diagnosis may not be evident and must be sought by specific means to assess bone mineral density. The clinical problem has now been defined, but much remains unknown, from etiologic mechanisms to effective therapies. At present, it seems reasonable to provide aggressive supportive therapy in an attempt to maximize skeletal well-being until more effective therapies for osteopenia become available.