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Bartlett S, Yiu TH, Valaydon Z. Nutritional assessment of patients with liver cirrhosis in the outpatient setting: A narrative review. Nutrition 2025; 132:112675. [PMID: 39798260 DOI: 10.1016/j.nut.2024.112675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 08/13/2024] [Accepted: 12/25/2024] [Indexed: 01/15/2025]
Abstract
Malnutrition is common in liver cirrhosis and is associated with increased rates of complications, hospitalization, and mortality. There are no consensus guidelines for malnutrition assessment in liver cirrhosis and a large number of clinicians do not routinely assess for malnutrition in patients with liver cirrhosis. This review explores the tools available for assessment of malnutrition in patients with liver cirrhosis, including nutritional screening protocols, anthropometric tools, biochemical tools, techniques analyzing body composition and functional assessments. We evaluate these tools and offer recommendations regarding their suitability for outpatient settings. In this review, we recommend the Royal Free Hospital-Nutritional Prioritising Tool for identifying patients at risk of malnutrition. Additionally, we recommend the use of the anthropometric tools Triceps Skinfold Thickness for females and Mid-Arm Muscle Circumference for males, due to differing patterns of muscle and fat malnutrition. Complementing this Bioelectrical Impedance Analysis can be utilized to assess body composition for the diagnosis of malnutrition. Biochemical markers have thus far failed to show a correlation with malnutrition. While hand grip strength is useful for detecting sarcopenia, a common complication of malnutrition, further evidence is required to validate its correlation with malnutrition.
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Affiliation(s)
- Stuart Bartlett
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.
| | - Tsz Hong Yiu
- Department of Gastroenterology, Western Health, Melbourne, Victoria, Australia
| | - Zina Valaydon
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia; Department of Gastroenterology, Western Health, Melbourne, Victoria, Australia
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Carteri RB, Marroni CA, Ferreira LF, Pinto LP, Czermainski J, Tovo CV, Fernandes SA. Do Child-Turcotte-Pugh and nutritional assessments predict survival in cirrhosis: A longitudinal study. World J Hepatol 2025; 17:99183. [PMID: 39871909 PMCID: PMC11736485 DOI: 10.4254/wjh.v17.i1.99183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2024] [Revised: 10/23/2024] [Accepted: 12/06/2024] [Indexed: 01/06/2025] Open
Abstract
BACKGROUND Cirrhotic patients face heightened energy demands, leading to rapid glycogen depletion, protein degradation, oxidative stress, and inflammation, which drive disease progression and complications. These disruptions cause cellular damage and parenchymal changes, resulting in vascular alterations, portal hypertension, and liver dysfunction, significantly affecting patient prognosis. AIM To analyze the association between Child-Turcotte-Pugh (CTP) scores and different nutritional indicators with survival in a 15-year follow-up cohort. METHODS This was a retrospective cohort study with 129 cirrhotic patients of both sexes aged > 18 years. Diagnosis of cirrhosis was made by liver biopsy. The first year of data collection was 2007, and data regarding outcomes were collected in 2023. Data were gathered from medical records, and grouped by different methods, including CTP, handgrip strength, and triceps skinfold cutoffs. The prognostic values for mortality were assessed using Kaplan-Meier curves and multivariate binary logistic regression models. RESULTS The coefficient for CTP was the only statistically significant variable (Wald = 5.193, P = 0.023). This suggests that with a negative change in CTP classification score, the odds of survival decrease 52.6%. The other evaluated variables did not significantly predict survival outcomes in the model. Kaplan-Meier survival curves also indicated that CTP classification was the only significant predictor. CONCLUSION Although different classifications showed specific differences in stratification, only CTP showed significant predictive potential. CTP score remains a simple and effective predictive tool for cirrhotic patients even after longer follow-up.
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Affiliation(s)
- Randhall B Carteri
- Department of Nutrition, Centro Universitário CESUCA, Cachoeirinha 94935-630, Brazil
- Postgraduate in Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre 90050-170, Brazil
| | - Claudio A Marroni
- Postgraduate in Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre 90050-170, Brazil
| | - Luis F Ferreira
- Postgraduate in Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre 90050-170, Brazil
- School of Electronics, Electrical Engineering and Computer Science, Queen's University Belfast, Belfast BT9 5BN, Northern Ireland, United Kingdom
| | - Letícia P Pinto
- Postgraduate in Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre 90050-170, Brazil
| | - Juliana Czermainski
- Postgraduate in Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre 90050-170, Brazil
| | - Cristiane V Tovo
- Postgraduate in Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre 90050-170, Brazil
| | - Sabrina A Fernandes
- Postgraduate in Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre 90050-170, Brazil.
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Mulugeta B, Fisseha H, Argaw AM, Kassu R, Desalegn H. Prevalence of under-nutrition and associated factors among patients with liver cirrhosis at a tertiary hospital in Ethiopia. Medicine (Baltimore) 2025; 104:e41226. [PMID: 40184078 PMCID: PMC11709151 DOI: 10.1097/md.0000000000041226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2024] [Revised: 12/01/2024] [Accepted: 12/18/2024] [Indexed: 04/05/2025] Open
Abstract
Liver cirrhosis is a major health burden, resulting in over 1 million deaths per year worldwide. Nutritional imbalance often complicates the course of liver diseases, particularly of cirrhosis and has been linked to increased mortality. Despite the high disease burden, there is paucity of literature regarding the magnitude of under-nutrition in patients with cirrhosis and its associated factors in Ethiopia and sub-Saharan Africa. The study aimed to assess the prevalence of under-nutrition and its associated factors among adult out-patients with liver cirrhosis. A hospital-based cross-sectional study was conducted among 136 adult out-patients with cirrhosis who visited the hepatology clinic of St. Paul's Hospital Millennium Medical College. Data were obtained through patient interviews, medical record reviews, anthropometric and handgrip strength measurements and collected using a structured checklist and analyzed using Statistical Package for the Social Sciences (SPSS) version 26.0. Body mass index with cutoff points adjusted for the degree of ascites were used to diagnose under-nutrition. Descriptive statistical tools and binary and multivariable logistic regression analyses were employed, and statistical significance was set at <0.05. The mean age of study participants was 39.5 years (standard deviation: ±11.2) and 62.5% were males. Chronic hepatitis B virus infection (57.4%) was the most common cause of liver cirrhosis, followed by alcohol-associated liver cirrhosis (12.5%). The majority (70.6%) of the study participants were undernourished. The factors found to have statistically significant association with under-nutrition were, rural area of residence (adjusted odds ratios [AOR]: 5.65, 95% confidence interval [CI]: 1.98-16.1), presence of ascites (AOR: 2.43, 95% CI: 1.03-5.7) and the disease severity, as measured by the child-pugh class (AOR, 1.11; 95% CI: 0.45-2.7). Under-nutrition was found to be a common problem among out-patients with liver cirrhosis and patients from rural areas and those with advanced disease were disproportionately affected. It is imperative to implement routine nutritional screening and plan on appropriate interventions for patients with liver cirrhosis.
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Affiliation(s)
- Biruk Mulugeta
- Department of Internal Medicine, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Henok Fisseha
- Department of Internal Medicine, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Abel Mureja Argaw
- Department of Internal Medicine, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Rodas Kassu
- Division of Neurosurgery, University of Wisconsin, IL
| | - Hailemichael Desalegn
- Department of Internal Medicine, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
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Jiang M, Hua X, Wu M, Wu J, Xu X, Li J, Meng Q. Longitudinal changes in sarcopenia was associated with survival among cirrhotic patients. Front Nutr 2024; 11:1375994. [PMID: 38873566 PMCID: PMC11169581 DOI: 10.3389/fnut.2024.1375994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 05/15/2024] [Indexed: 06/15/2024] Open
Abstract
Background Sarcopenia is common in patients with liver cirrhosis and is an independent predictor of multiple clinical outcomes. Most studies to date have used a static assessment of sarcopenia. However, there is very limited data evaluating the temporal course of muscle area in cirrhosis. To bridge this gap in clinical studies, we performed a longitudinal analysis to evaluate the impact of changes in sarcopenia for cirrhotic patients. Methods Adult patients with clinically diagnosed liver cirrhosis who underwent at least 2 abdominal computed tomography (CT) scans in the hospital were enrolled. The interval between the two abdominal scans was 6 ± 1 months. Patients were categorized into persistent non-sarcopenia, new-onset sarcopenia, sarcopenia to non-sarcopenia, and persistent sarcopenia based on changes in sarcopenia. Kaplan-Meier method and Log-rank tests were used to separately compare unadjusted survival curves by different statuses of sarcopenia. Cox regression analysis was performed to assess the associations between different states of sarcopenia and overall mortality. The association between persistent non-sarcopenia and new-onset sarcopenia was analyzed by multivariate logistic regression analysis. Results A total of 307 patients were included for analysis. At the second assessment, 10.10% (31/307) patients were new-onset sarcopenia, 27.69% (85/307) with persistent sarcopenia status, while 13.03% (40/307) patients with sarcopenia developed non-sarcopenia and 49.19% (151/307) with persistent non-sarcopenia status. The overall survival rate was significantly lower in the persistent sarcopenia and new-onset sarcopenia than in the non-sarcopenia group and sarcopenia to non-sarcopenia group (p < 0.001). Persistent sarcopenia (HR 5.799, 95%CI 1.563-21.521, p = 0.009) and new onset sarcopenia (HR 5.205, 95%CI 1.482-18.282, p = 0.010) were identified as poor prognostic factors for cirrhotic patients. The etiology of cirrhosis and the initial skeletal muscle mass were independent risk factors for new-onset sarcopenia. Conclusion Sarcopenia is a dynamically changing process in patients with cirrhosis. Persistent and new-onset sarcopenia were independently and robustly associated with overall survival.
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Affiliation(s)
- Minjie Jiang
- Department of Medical Oncology, Beijing Youan Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Hepatology, Beijing, China
| | - Xin Hua
- Department of Clinical Nutrition, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Muchen Wu
- Department of Medical Oncology, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Jing Wu
- Department of Hepatology, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Xiaotong Xu
- Department of Medical Oncology, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Juan Li
- Department of Medical Oncology, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Qinghua Meng
- Department of Medical Oncology, Beijing Youan Hospital, Capital Medical University, Beijing, China
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Jiang MJ, Wu MC, Duan ZH, Wu J, Xu XT, Li J, Meng QH. Prevalence and clinical impact of sarcopenia in liver transplant recipients: A meta-analysis. World J Gastroenterol 2024; 30:956-968. [PMID: 38516245 PMCID: PMC10950632 DOI: 10.3748/wjg.v30.i8.956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/03/2024] [Accepted: 02/01/2024] [Indexed: 02/26/2024] Open
Abstract
BACKGROUND The prevalence of sarcopenia in patients undergoing liver transplantation (LT) remains to be determined partly because of different diagnostic criteria. Sarcopenia has recently been recognized as a new prognostic factor for predicting outcomes in LT candidates. AIM To estimate the prevalence of sarcopenia and evaluate its clinical effect on LT candidates. METHODS This systematic search was conducted in PubMed, Web of Science, Embase, and Cochrane Library for original English-language articles that investigated the prevalence and influence of sarcopenia in patients undergoing LT from database inception to November 30, 2022. Cohort studies of the definition of sarcopenia that estimate sarcopenia prevalence and evaluate its effect on clinical outcomes and the risk of mortality were included. RESULTS Twenty-five studies involving 7760 patients undergoing LT were included. The pooled prevalence of sarcopenia in patients undergoing LT was 40.7% [95% confidence intervals (95%CI): 32.1-49.6]. The 1-, 3-, and 5-year cumulative probabilities of post-LT survival in patients with preoperative sarcopenia were all lower than those without sarcopenia (P < 0.05). Sarcopenia was associated with an increased risk of post-LT mortality in patients undergoing LT (adjusted hazard ratio: 1.58; 95%CI: 1.21-2.07). Patients with preoperative sarcopenia had a longer intensive care unit stay, a high risk ratio of sepsis, and serious post-LT complications than those without sarcopenia. CONCLUSION Sarcopenia is prevalent in a substantial proportion of patients undergoing LT and is strongly and independently associated with higher a risk of mortality risk.
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Affiliation(s)
- Min-Jie Jiang
- Department of Hepatology, Beijing You-An Hospital, Capital Medical University, Beijing 100069, China
| | - Mu-Chen Wu
- Department of Hepatology, Beijing You-An Hospital, Capital Medical University, Beijing 100069, China
| | - Zhong-Hui Duan
- Department of Emergency, Beijing You-An Hospital, Capital Medical University, Beijing 100069, China
| | - Jing Wu
- Department of Hepatology, Beijing You-An Hospital, Capital Medical University, Beijing 100069, China
| | - Xiao-Tong Xu
- Department of Hepatology, Beijing You-An Hospital, Capital Medical University, Beijing 100069, China
| | - Juan Li
- Department of Hepatology, Beijing You-An Hospital, Capital Medical University, Beijing 100069, China
| | - Qing-Hua Meng
- Department of Hepatology, Beijing You-An Hospital, Capital Medical University, Beijing 100069, China
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Rodge GA, Goenka U, Jajodia S, Agarwal R, Afzalpurkar S, Roy A, Goenka MK. Psoas Muscle Index: A Simple and Reliable Method of Sarcopenia Assessment on Computed Tomography Scan in Chronic Liver Disease and its Impact on Mortality. J Clin Exp Hepatol 2023; 13:196-202. [PMID: 36950487 PMCID: PMC10025677 DOI: 10.1016/j.jceh.2022.12.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 12/02/2022] [Indexed: 03/24/2023] Open
Abstract
OBJECTIVES Psoas muscle parameters have been proposed as a simple and quick method for sarcopenia assessment. The aim of this study was to assess sarcopenia in cirrhotics by psoas muscle on computed tomography and its impact on mortality. METHODS One hundred and fifty patients (75 cirrhotics, 75 subjects) were assessed for psoas muscle on CT scan. Psoas muscle index (PMI) was calculated as 'total psoas muscle area/(height of subject)2'. Cut off values for sarcopenia diagnosis were derived from local subjects (n = 75) who did not have cirrhosis/other causes of sarcopenia. RESULTS Sarcopenia assessed by PMI was seen in 36% (n = 27) of the cirrhotics. Sarcopenia was significantly higher in patients having Child-Pugh C. Ascites, hepatic encephalopathy (HE) and gastro-intestinal bleed were seen in 48%, 18.7% and 24%, respectively. Sarcopenia was significantly associated with ascites and HE (P < 0.05). Out of the 75 cases, 53 cases completed the follow-up period of 1 year. Among the 20 cases who had sarcopenia, 35% (n = 7) succumbed to liver-related illness during 1 year follow-up, and out of the 33 cases without sarcopenia, only 6% (n = 2) died. The association of sarcopenia and 1 year mortality was statistically significant (P = 0.01). CONCLUSIONS The PMI, a simple method for sarcopenia assessment detected sarcopenia in 36% of cirrhotics. Patients with sarcopenia had a significantly higher 1 year mortality rate and appropriate prognostication of such patients is needed.
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Key Words
- CLD, Chronic Liver Disease
- CT scan
- CT, Computed Tomography
- GI, Gastro-Intestinal
- HBV, Hepatitis B Virus
- HCV, Hepatitis C Virus
- HE, Hepatic Encephalopathy
- HG, Hand Grip
- L3SMI
- MAC, Mid-Arm Circumference
- MAMC, Mid-Arm Muscle Circumference
- MELD, Model for End Stage Liver Disease
- NASH, Non-Alcoholic Steato-Hepatitis
- PBC, Primary Biliary Cholangitis
- PMI, Psoas Muscle Index
- PMTH, Psoas Muscle Thickness by Height of subject
- SMI, Skeletal Muscle Index
- TST, Tricep Skin fold Thickness
- chronic liver disease
- psoas muscle index
- sarcopenia
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Affiliation(s)
- Gajanan A. Rodge
- Institute of Gastrosciences & Liver, Apollo Multispeciality Hospital, Kolkata, India
| | - Usha Goenka
- Department of Interventional Radiology & Clinical Imaging, Apollo Multispeciality Hospital, Kolkata, India
| | - Surabhi Jajodia
- Department of Interventional Radiology & Clinical Imaging, Apollo Multispeciality Hospital, Kolkata, India
| | - Rachit Agarwal
- Department of Gastroenterology, Orange City Hospital & Research Hospital, Nagpur, India
| | - Shivaraj Afzalpurkar
- Institute of Gastrosciences & Liver, Apollo Multispeciality Hospital, Kolkata, India
| | - Akash Roy
- Institute of Gastrosciences & Liver, Apollo Multispeciality Hospital, Kolkata, India
| | - Mahesh K. Goenka
- Institute of Gastrosciences & Liver, Apollo Multispeciality Hospital, Kolkata, India
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Sehgal P, Sharma S, Sood A, Dharni K, Kakkar C, Batta S, Sahotra M. Assessment and prediction of malnutrition and sarcopenia in liver cirrhosis patients. NUTRIRE 2023; 48:6. [DOI: 10.1186/s41110-023-00189-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 01/03/2023] [Indexed: 06/27/2023]
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Reshetnyak VI, Maev IV. Mechanism for development of malnutrition in primary biliary cholangitis. World J Meta-Anal 2022; 10:81-98. [DOI: 10.13105/wjma.v10.i3.81] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 04/14/2022] [Accepted: 05/23/2022] [Indexed: 02/06/2023] Open
Abstract
Primary biliary cholangitis (PBC) is a chronic cholestatic liver disease that is associated with impaired biliary excretion processes. Along with the development of cholestasis, there is a deficient flow of bile acids into the intestinal lumen causing malnutrition (MN) that is manifested in deficiencies of both macro- and micronutrients. The mechanism for development of trophological insufficiency is multifactorial. However, the trigger of MN in PBC is impaired enterohepatic circulation of bile acids. The ingress of bile acids with a detergent effect into the general bloodstream, followed by elimination via the kidneys and skin, triggers a cascade of metabolic disturbances, which leads to the gradual development and progression of calorie MN. The latter gradually transforms into protein-calorie MN (PСM) (as marasmus) due to the insufficient entry of bile acids into the duodenum, which is accompanied by a decrease in the emulsification, hydrolysis, and absorption of fats and fat-soluble vitamins, as well as disturbance of intestinal motility and bacterial overgrowth. Fat-soluble vitamin deficiencies complement PСM with vitamin and mineral MN. The development of hepatocellular failure enhances the progression of PСM due to the impaired protein synthetic function of hepatocytes in the advanced stage of PBC, which results in deficiency of not only the somatic but also the visceral pool of proteins. A mixed PСM form of marasmus and kwashiorkor develops. Early recognition of energy, protein, micronutrient, and macronutrient deficiencies is of great importance because timely nutritional support can improve liver function and quality of life in patients with PBC. In this case, it is important to know what type (energy, protein-calorie, vitamin, and vitamin-mineral) and form (marasmus, marasmus-kwashiorkor) of MN is present in the patient and how it is associated with the stage of the disease. Therefore, it is recommended to screen all patients with PBC for MN, from the early asymptomatic stage of the disease in order to identify and avoid preventable complications, such as fatigue, malaise, performance decrement, sarcopenia, osteoporosis, and hepatic encephalopathy, which will be able to provide appropriate nutritional support for correction of the trophological status.
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Affiliation(s)
- Vasiliy Ivanovich Reshetnyak
- Department of Propaedeutic of Internal Diseases and Gastroenterology, A.I. Yevdokimov Moscow State University of Medicine and Dentistry, Moscow 127473, Russia
| | - Igor Veniaminovich Maev
- Department of Propaedeutic of Internal Diseases and Gastroenterology, A.I. Yevdokimov Moscow State University of Medicine and Dentistry, Moscow 127473, Russia
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Sandoval C, Farías J, Zamorano M, Herrera C. Vitamin Supplements as a Nutritional Strategy against Chronic Alcohol Consumption? An Updated Review. Antioxidants (Basel) 2022; 11:564. [PMID: 35326214 PMCID: PMC8945215 DOI: 10.3390/antiox11030564] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 03/12/2022] [Accepted: 03/12/2022] [Indexed: 02/07/2023] Open
Abstract
Several studies have shown that blood vitamin levels are low in alcoholic patients. In effect, alcohol use abuse is considered a chronic disease that promotes the pathogenesis of many fatal diseases, such as cancer and liver cirrhosis. The alcohol effects in the liver can be prevented by antioxidant mechanisms, which induces enzymatic as well as other nonenzymatic pathways. The effectiveness of several antioxidants has been evaluated. However, these studies have been accompanied by uncertainty as mixed results were reported. Thus, the aim of the present review article was to examine the current knowledge on vitamin deficiency and its role in chronic liver disease. Our review found that deficiencies in nutritional vitamins could develop rapidly during chronic liver disease due to diminished hepatic storage and that inadequate vitamins intake and alcohol consumption may interact to deplete vitamin levels. Numerous studies have described that vitamin supplementation could reduce hepatotoxicity. However, further studies with reference to the changes in vitamin status and the nutritional management of chronic liver disease are in demand.
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Affiliation(s)
- Cristian Sandoval
- Escuela de Tecnología Médica, Facultad de Salud, Universidad Santo Tomás, Los Carreras 753, Osorno 5310431, Chile
- Departamento de Ingeniería Química, Facultad de Ingeniería y Ciencias, Universidad de La Frontera, Temuco 4811230, Chile; (J.F.); (M.Z.)
- Departamento de Ciencias Preclínicas, Facultad de Medicina, Universidad de La Frontera, Temuco 4811230, Chile;
| | - Jorge Farías
- Departamento de Ingeniería Química, Facultad de Ingeniería y Ciencias, Universidad de La Frontera, Temuco 4811230, Chile; (J.F.); (M.Z.)
- Núcleo Científico y Tecnológico en Biorecursos (BIOREN), Universidad de La Frontera, Temuco 4811230, Chile
| | - Mauricio Zamorano
- Departamento de Ingeniería Química, Facultad de Ingeniería y Ciencias, Universidad de La Frontera, Temuco 4811230, Chile; (J.F.); (M.Z.)
- Núcleo Científico y Tecnológico en Biorecursos (BIOREN), Universidad de La Frontera, Temuco 4811230, Chile
| | - Christian Herrera
- Departamento de Ciencias Preclínicas, Facultad de Medicina, Universidad de La Frontera, Temuco 4811230, Chile;
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Bakshi N, Singh K, Soin A. Impact of pretransplant malnutrition on short-term clinical outcomes of liver transplantation - An exploratory study. INDIAN JOURNAL OF TRANSPLANTATION 2022. [DOI: 10.4103/ijot.ijot_153_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Zeng X, Shi ZW, Yu JJ, Wang LF, Luo YY, Jin SM, Zhang LY, Tan W, Shi PM, Yu H, Zhang CQ, Xie WF. Sarcopenia as a prognostic predictor of liver cirrhosis: a multicentre study in China. J Cachexia Sarcopenia Muscle 2021; 12:1948-1958. [PMID: 34520115 PMCID: PMC8718091 DOI: 10.1002/jcsm.12797] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 07/25/2021] [Accepted: 08/23/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Diagnostic criteria for sarcopenia have not been established in Chinese. This study established criteria based on the L3-skeletal muscle index (L3-SMI) and assessed its value for outcomes predicting in cirrhotic Chinese patients. METHODS Totally 911 subjects who underwent a CT scan at two centres were enrolled in Cohort 1 (394 male and 417 female subjects, aged 20-80 years). The data of those subjects younger than 60 years (365 male and 296 female subjects) were used to determine the reference intervals of the L3-SMI and its influencing factors. Cohort 2 consisted of 480 patients (286 male and 184 female patients) from three centres, and their data were used to investigate the prevalence of sarcopenia and evaluate the value of L3-SMI for predicting the prognosis and complications of cirrhosis. RESULTS Age and sex had the greatest effects on the L3-SMI (P < 0.001). The L3-SMI scores were clearly higher in male patients than in female patients (52.94 ± 8.41 vs. 38.91 ± 5.65 cm2 /m2 , P < 0.001) and sharply declined in subjects aged ≥ 60 years. Based on the mean -1.28 × SD among adults aged < 60 years, the L3-SMI cut-off value for sarcopenia was 44.77 cm2 /m2 in male patients and 32.50 cm2 /m2 in female patients. Using these values, 22.5% of the cirrhotic patients (28.7% of male patients and 11.9% of female patients) were diagnosed with sarcopenia. Compared with non-sarcopenia individuals, sarcopenia patients had lower body mass index (21.28 ± 3.01 vs. 24.09 ± 3.39 kg/m2 , P < 0.001) and serum albumin levels (31.54 ± 5.93 vs. 32.93 ± 5.95 g/L, P = 0.032), longer prothrombin times (16.39 ± 3.05 vs. 15.71 ± 3.20 s, P = 0.049), higher total bilirubin concentrations (41.33 ± 57.38 vs. 32.52 ± 31.48 μmol/L, P = 0.039), worse liver function (Child-Pugh score, 8.05 ± 2.11 vs. 7.32 ± 2.05, P = 0.001), higher prevalence of cirrhosis-related complications (81.82% vs. 62.24%, P < 0.001) and mortality (30.68% vs. 11.22%, P < 0.001). Overall survival was significantly lower in the sarcopenia group [risk ratio (RR) = 2.643, 95% confidence interval (CI) 1.646-4.244, P < 0.001], accompanied with an increased cumulative incidence of ascites (RR = 1.827, 95% CI 1.259-2.651, P = 0.002), spontaneous bacterial peritonitis (RR = 3.331, 95% CI 1.404-7.903, P = 0.006), hepatic encephalopathy (RR = 1.962, 95% CI 1.070-3.600, P = 0.029), and upper gastrointestinal varices (RR = 2.138, 95% CI 1.319-3.466, P = 0.002). Subgroup analysis showed sarcopenia shortened the survival of the patients with Model For End-Stage Liver Disease score > 14 (RR = 4.310, 95% CI 2.091-8.882, P < 0.001) or Child-Pugh C (RR = 3.081, 95% CI 1.516-6.260, P = 0.002). CONCLUSIONS Sarcopenia is a common comorbidity of cirrhosis and can be used to predict cirrhosis-related complications and the prognosis.
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Affiliation(s)
- Xin Zeng
- Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Zhi-Wen Shi
- Department of Gastroenterology, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Jia-Jun Yu
- Department of Gastroenterology, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Li-Fen Wang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Yuan-Yuan Luo
- Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Si-Min Jin
- Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China.,Department of Nuclear Radiation Injury Protection and Treatment, Naval Medical Center, Shanghai, China
| | - Li-Yuan Zhang
- Department of Gastroenterology, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Wei Tan
- Department of Gastroenterology, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Pei-Mei Shi
- Department of Gastroenterology, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Hong Yu
- Department of Radiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Chun-Qing Zhang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Wei-Fen Xie
- Department of Gastroenterology, Changzheng Hospital, Second Military Medical University, Shanghai, China
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12
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Shin S, Jun DW, Saeed WK, Koh DH. A narrative review of malnutrition in chronic liver disease. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:172. [PMID: 33569474 PMCID: PMC7867872 DOI: 10.21037/atm-20-4868] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Interest in research on malnutrition is decreasing due to thoughts that the problem of malnutrition has been solved in an age of over-nourishment or obesity and defining malnutrition is not uniform. This study aimed to critically appraise the prevalence of malnutrition according to various diagnostic tools and proportion of severity used in previous studies. A literature review was performed using a total of 16 studies published between 1980 and 2020 regarding malnutrition in patients with chronic liver disease. Most of the analyzed studies were conducted before 2010, and only a few studies were conducted after 2010. Nutrition assessment tool (NAT) and nutrition screening tool (NST) to explain malnutrition were distinguished; however, there was no clear distinction between them. NST often used questionnaires while NST used various malnutrition measuring tools. Our results show that, in the age of over-nourishment, reduction in malnutrition in chronic liver disease still hasn’t been significant. Malnutrition prevalence in studies published prior to 2,000 ranged between 13.3% and 85% (mean, 37.6%), whereas that in studies published after 2,000 ranged between 13.3% and 78.5% (mean, 35.2%). Malnutrition prevalence largely depends on the diagnostic tool and proportion of disease severity in the target population. The prevalence of malnutrition in patients with chronic liver diseases varies widely. This big difference is related to various diagnostic tools, mixed etiologies, and different disease severity in different studies. The prevalence of malnutrition was 36.4% (10–80.3%) in all patients with liver disease, 39.9% (13.3–80.3%) in compensated liver disease, and 44.1% (26.7–93.6%) in decompensated cirrhosis. Malnutrition prevalence was 38.2% and 23.7% in alcoholism-related and hepatitis C virus (HCV)-related diseases, respectively. Malnutrition also largely depended on the judgement tool. Malnutrition prevalence according to the diagnostic tool was approximately 28–85% for subjective global assessment (SGA), 30.8–78.5% for anthropometric approach, and 21–80.3% for clinical judgment. It became similar over time.
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Affiliation(s)
- Soan Shin
- School of Medicine, Hanyang University, Seoul, South Korea
| | - Dae Won Jun
- School of Medicine, Hanyang University, Seoul, South Korea.,Department of Internal Medicine, School of Medicine, Hanyang University, Seoul, South Korea
| | - Waqar Khalid Saeed
- Department of Biomedical Sciences, Pak-Austria Fachhochschule: Institute of Applied Sciences and Technology, Mang, Haripur, Pakistan
| | - Dong Hee Koh
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong-si, South Korea
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13
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Puri P, Dhiman RK, Taneja S, Tandon P, Merli M, Anand AC, Arora A, Acharya SK, Benjamin J, Chawla YK, Dadhich S, Duseja A, Eapan C, Goel A, Kalra N, Kapoor D, Kumar A, Madan K, Nagral A, Pandey G, Rao PN, Saigal S, Saraf N, Saraswat VA, Saraya A, Sarin SK, Sharma P, Shalimar, Shukla A, Sidhu SS, Singh N, Singh SP, Srivastava A, Wadhawan M. Nutrition in Chronic Liver Disease: Consensus Statement of the Indian National Association for Study of the Liver. J Clin Exp Hepatol 2021; 11:97-143. [PMID: 33679050 PMCID: PMC7897902 DOI: 10.1016/j.jceh.2020.09.003] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 09/22/2020] [Indexed: 02/06/2023] Open
Abstract
Malnutrition and sarcopenia are common in patients with chronic liver disease and are associated with increased risk of decompensation, infections, wait-list mortality and poorer outcomes after liver transplantation. Assessment of nutritional status and management of malnutrition are therefore essential to improve outcomes in patients with chronic liver disease. This consensus statement of the Indian National Association for Study of the Liver provides a comprehensive review of nutrition in chronic liver disease and gives recommendations for nutritional screening and treatment in specific clinical scenarios of malnutrition in cirrhosis in adults as well as children with chronic liver disease and metabolic disorders.
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Key Words
- ACLF, acute on chronic liver failure
- ASM, appendicular skeletal muscle mass
- BCAA, branched chain amino acids
- BIA, bioimpedance analysis
- BMD, bone mineral densitometry
- BMI, body mass index
- CLD, chronic liver disease
- CS, corn-starch
- CT, computed tomography
- CTP, Child–Turcotte–Pugh
- DEXA, dual-energy X-ray absorptiometry
- EASL, European Association for the Study of the Liver
- ESPEN, European society for Clinical Nutrition and Metabolism
- GSD, glycogen storage disease
- HGS, hand-grip strength
- IBW, ideal body weight
- IEM, inborn error of metabolism
- INASL, Indian National Association for Study of the Liver
- L3, third lumbar
- LFI, Liver Frailty Index
- MCT, medium-chain triglyceride
- MELD, model for end-stage liver disease
- MLD, metabolic liver disease
- MRI, magnetic resonance imaging
- RDA, recommended daily allowance
- REE, NASH
- RFH-NPT, Royal Free Hospital-Nutritional Prioritizing Tool
- SMI, skeletal muscle index
- Sarcopenia
- TEE, total energy expenditure
- chronic liver disease
- cirrhosis
- malnutrition
- non-alcoholic liver disease, resting energy expenditure
- nutrition
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Affiliation(s)
- Pankaj Puri
- Fortis Escorts Liver & Digestive Diseases Institute, New Delhi, 110025, India
| | - Radha K. Dhiman
- Department of Hepatobiliary Sciences, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Puneeta Tandon
- Department of Medicine, University of Alberta, Edmonton, AB T6G 2R3, Canada
| | - Manuela Merli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, 00185, Italy
| | - Anil C. Anand
- Kalinga Institute of Medical Sciences, Bhubhaneswar, 751024, Odisha, India
| | - Anil Arora
- Institute of Liver, Gastroenterology and Pancreatico-Biliary Sciences of Sir Ganga Ram Hospital, New Delhi, 110060, India
| | - Subrat K. Acharya
- Fortis Escorts Liver & Digestive Diseases Institute, New Delhi, 110025, India
| | - Jaya Benjamin
- Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, 110070, India
| | - Yogesh K. Chawla
- Kalinga Institute of Medical Sciences, Bhubhaneswar, 751024, Odisha, India
| | - Sunil Dadhich
- Department of Gastroenterology SN Medical College, Jodhpur, 342003, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - C.E. Eapan
- Department of Gastroenterology, Christian Medical College, Vellore, 632004, India
| | - Amit Goel
- Department of Hepatobiliary Sciences, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Naveen Kalra
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Dharmesh Kapoor
- Department of Gastroenterology, Global Hospital, Hyderabad, 500004, India
| | - Ashish Kumar
- Institute of Liver, Gastroenterology and Pancreatico-Biliary Sciences of Sir Ganga Ram Hospital, New Delhi, 110060, India
| | - Kaushal Madan
- Max Smart Super Speciality Hospital, New Delhi, India
| | - Aabha Nagral
- Department of Gastroenterology, Jaslok Hospital, Mumbai, 400026, India
| | - Gaurav Pandey
- Department of Hepatobiliary Sciences, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Padaki N. Rao
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, 500082, India
| | - Sanjiv Saigal
- Department of Hepatology, Medanta Hospital, Gurugram, 122001, India
| | - Neeraj Saraf
- Department of Hepatology, Medanta Hospital, Gurugram, 122001, India
| | - Vivek A. Saraswat
- Department of Hepatobiliary Sciences, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Anoop Saraya
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110016, India
| | - Shiv K. Sarin
- Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, 110070, India
| | - Praveen Sharma
- Institute of Liver, Gastroenterology and Pancreatico-Biliary Sciences of Sir Ganga Ram Hospital, New Delhi, 110060, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110016, India
| | - Akash Shukla
- Department of Gastroenterology, Seth GSMC & KEM Hospital, Mumbai, 400022, India
| | - Sandeep S. Sidhu
- Department of Gastroenterology, SPS Hospital, Ludhiana, 141001, India
| | - Namrata Singh
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110016, India
| | - Shivaram P. Singh
- Department of Gastroenterology, SCB Medical College, Cuttack, 753007, India
| | - Anshu Srivastava
- Department of Hepatobiliary Sciences, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Manav Wadhawan
- Institute of Liver & Digestive Diseases, BL Kapur Memorial Hospital, New Delhi, 110005, India
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14
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Fernandes SA, Leonhardt LR, da Silva DM, Alves FD, Marroni CA. Bioelectrical impedance vector analysis evaluates cellularity and hydration in cirrhotic patients. World J Hepatol 2020; 12:1276-1288. [PMID: 33442454 PMCID: PMC7772738 DOI: 10.4254/wjh.v12.i12.1276] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/07/2020] [Accepted: 11/05/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Malnutrition in cirrhotic patients is correlated with mortality and a better response to liver transplantation. However, recovery of the nutritional status in these patients is a challenge due to the difficulty in establishing a reliable nutritional diagnosis. The bioelectrical impedance vector analysis (BIVA) method appears as a feasible tool in clinical practice to define the physiological state of cirrhotic patients by assessing hydration and body cellularity. AIM To evaluate body composition in cirrhotic patients using BIVA. METHODS This retrospective cross-sectional study was carried out by following cirrhotic outpatients at a hospital in Porto Alegre, Brazil. A tetrapolar bioelectrical impedance analysis device was used to evaluate cellularity and hydration and to perform the BIVA. The BIVA graphic was elaborated by software and for statistical analysis a significance level of 5% (P ≤ 0.05) was considered. RESULTS One hundred and ninety patients, 61.1% males, with a mean age of 56.6 ± 11.0 years, were evaluated. Of these, 56.3% had Child-Turcotte-Pugh (CTP) A score, and the prevalent etiology was hepatitis C virus (47.4%). The patients were classified according to cellularity and hydration by the quadrants and ellipses of the BIVA method, quadrant 1 (47.9%); quadrant 2 (18.9%); quadrant 3 (14.2%); and quadrant 4 (18.9%). Those classified in quadrant 1 and 2 had a higher phase angle compared to those in quadrants 3 and 4 (P < 0.001). Quadrant 2 patients had a lower average age than the other groups. The association with CTP score showed that patients in quadrant 2 had a higher proportion of CTP A, and those in quadrant 4 had a higher proportion of CTP C (P < 0.052). CONCLUSION The BIVA method allows identification of the cellularity and hydration status of cirrhotic patients, and its association with clinical factors determines the disease severity, age and prognostic index.
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Affiliation(s)
- Sabrina Alves Fernandes
- Department of Nutrition, Centro Universitário Metodista IPA, Porto Alegre 90420-060, RS, Brazil.
| | - Lara Rigon Leonhardt
- Gastroenterology and Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre 91760-470, RS, Brazil
| | - Daniella Miranda da Silva
- Postgraduate Program in Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre 90050-170, RS, Brazil
| | - Fernanda Donner Alves
- Department of Nutrition, Centro Universitário Ritter dos Reis - Uniritter, Porto Alegre 90840-440, Rio Grande do Sul, Brazil
| | - Cláudio Augusto Marroni
- Gastroenterology and Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre 91760-470, RS, Brazil
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15
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Association between Circulating Growth Differentiation Factor 15 and Cirrhotic Primary Biliary Cholangitis. BIOMED RESEARCH INTERNATIONAL 2020; 2020:5162541. [PMID: 33178828 PMCID: PMC7644315 DOI: 10.1155/2020/5162541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 10/05/2020] [Accepted: 10/14/2020] [Indexed: 01/10/2023]
Abstract
Primary biliary cholangitis (PBC) is a common condition that usually shows a progressive course towards cirrhosis without adequate treatment. Growth differentiation factor 15 (GDF15) plays multiple roles in various pathological conditions. The overall role of circulating GDF15 in cirrhotic PBC requires further investigation. Twenty patients with cirrhotic PBC, 26 with non-cirrhotic PBC, and 10 healthy subjects were enrolled between 2014 and 2018, and the serum levels of GDF15 were measured via enzyme immunoassay. The correlations between serum GDF15, weight, biochemical parameters, and the prognosis were analysed. Serum levels of GDF15 were significantly higher in cirrhotic PBC patients than in non-cirrhotic PBC patients or healthy controls (p = 0.009 and p < 0.001, respectively). The circulating GDF15 levels strongly correlated with weight changes (r = −0.541, p = 0.0138), albumin (r = −0.775, p < 0.0001), direct bilirubin (r = −0.786, p < 0.0001), total bile acids (r = 0.585, p = 0.007), and C-reactive protein (r = 0.718, p = 0.0005). Moreover, circulating GDF15 levels strongly correlated with the Mayo risk score (r = 0.685, p = 0.0009) and Model for End-stage Liver Disease score (r = 0.687, p = 0.0008). Determined by the area under the receiver operating characteristic curves, the overall diagnostic accuracies of GDF15 were as follows: cirrhosis = 0.725 (>3646.55 pg/mL, sensitivity: 70.0%, specificity: 69.2%), decompensated cirrhosis = 0.956 (>4073.30 pg/mL, sensitivity: 84.62%, specificity: 100%), and cirrhotic biochemical non-responders = 0.835 (>3479.20 pg/mL, sensitivity: 71.43%, specificity: 92.31%). GDF15 may be a useful and integrated biochemical marker to evaluate not only the disease severity and prognosis but also the nutrition and response to treatment of cirrhotic PBC patients, and its overall performance is satisfactory. Therapy targeting GDF15 is likely to benefit cirrhotic PBC patients and is worth further research.
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16
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Oliveira KS, Oliveira LR, Fernandes SA, Coral GP. MALNUTRITION IN CIRRHOSIS: ASSOCIATION WITH ETIOLOGY AND HEPATOCELLULAR DYSFUNCTION. ARQUIVOS DE GASTROENTEROLOGIA 2020; 57:375-380. [PMID: 33331472 DOI: 10.1590/s0004-2803.202000000-71] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 07/12/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND The protein-energy malnutrition alters the prognosis of patients with cirrhosis. Its prevalence may vary according to the etiology of liver disease, it´s severity and the evaluation of the method applied. The infection by the hepatitis C virus (HCV) and alcoholism are the main etiologies of cirrhosis and result in a significant morbidity and mortality. OBJECTIVE To evaluate the nutritional status of patients with cirrhosis according the liver disease etiology and severity. METHODS It is a prospective study, in which the sample was for convenience and consisted of patients with cirrhosis, infected by HCV or alcoholic etiology. The nutritional status evaluation was carried out through anthropometry, food consumption, bioelectrical impedance (BIA) and subjective global assessment (SGA). The anthropometric data evaluated were weight, height, body mass index (BMI), triceps skinfold (TSF), circumference of the arm (CA), non-dominant handshake strength (FAM) and the adductor pollicis muscle thickness (APM). Patients were classified according to the severity of liver disease, using the Child-Pugh and Model for End-stage Liver Diseases (MELD) scores. RESULTS Ninety patients with cirrhosis were evaluated, 47 with HCV and 43 with alcoholic etiology. The prevalence of protein-calorie malnutrition ranged from 10.9% to 54.3% in the HCV group and from 4.7% to 20.9% in the alcoholic group, depending on the method used for evaluation. The group with HCV infection presented a higher malnutrition prevalence in comparison to the alcoholic in the following evaluations: TSF (P<0.001), phase angle (PA) (P=0.016) and SGA (P=0.010). PA values were lower in patients with viral cirrhosis (5.68±1.05) when compared to those with alcoholic etiology (6.61±2.31) (P=0.016). When all patients were analyzed, regardless of etiology, an inversely correlation was observed among Child-Pugh score and PA values (P=0.018). CONCLUSION HCV cirrhosis showed worse nutritional parameters in comparison to alcoholic etiology; however, the PA was associated with worse liver function in both etiologies.
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Affiliation(s)
- Kalinca S Oliveira
- Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Programa de Pós-Graduação em Hepatologia, Porto Alegre, RS, Brasil
| | | | | | - Gabriela P Coral
- Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Programa de Pós-Graduação em Hepatologia, Porto Alegre, RS, Brasil
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17
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Skeletal muscle loss phenotype in cirrhosis: A nationwide analysis of hospitalized patients. Clin Nutr 2020; 39:3711-3720. [PMID: 32303380 DOI: 10.1016/j.clnu.2020.03.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 03/09/2020] [Accepted: 03/25/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND & AIMS There are very limited data on the healthcare burden of muscle loss, the most frequent complication in hospitalized cirrhotics. We determined the healthcare impact of a muscle loss phenotype in hospitalized cirrhotics. METHODS The Nationwide Inpatient Sample (NIS) database (years 2010-2014) was analyzed. Search terms included cirrhosis and its complications, and an expanded definition of a muscle loss phenotype that included all conditions associated with muscle loss. In-hospital mortality, length of stay (LOS), post-discharge disposition, co-morbidities and cost during admission were analyzed. Univariate and multivariate analyses were performed to identify associations between a muscle loss phenotype and outcomes. Impact of muscle loss in cirrhotics was compared to that in a random sample (2%) of general medical inpatients. RESULTS A total of 162,694 hospitalizations for cirrhosis were reported, of which 18,261 (11.2%) included secondary diagnosis codes for a muscle loss phenotype. A diagnosis of muscle loss was associated with a significantly (p < 0.001 for all) higher mortality (19.3% vs 8.2%), LOS (14.2 ± 15.8 vs. 4.6 ± 6.9 days), and median hospital charge per admission ($21,400 vs. $8573) and a lower likelihood of discharge to home (30.1% vs. 60.2%). All evaluated outcomes were more severe in cirrhotics than general medical patients (n = 534,687). Multivariate regression analysis showed that a diagnosis of muscle loss independently increased mortality by 130%, LOS by 80% and direct cost of care by 119% (p < 0.001 for all). Alcohol use, female gender, malignancies and other organ dysfunction were independently associated with muscle loss. CONCLUSIONS Muscle loss contributed to higher mortality, LOS, and direct healthcare costs in hospitalized cirrhotics.
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18
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Bunchorntavakul C, Reddy KR. Review article: malnutrition/sarcopenia and frailty in patients with cirrhosis. Aliment Pharmacol Ther 2020; 51:64-77. [PMID: 31701570 DOI: 10.1111/apt.15571] [Citation(s) in RCA: 122] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 05/20/2019] [Accepted: 10/13/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Malnutrition/sarcopenia and frailty are common in patients with cirrhosis and are associated with poor outcomes. AIM To provide an overview of data on the importance, assessment and management of malnutrition/sarcopenia and frailty in cirrhosis. METHODS A literature search was conducted in PubMed and other sources, using the search terms "sarcopenia," "muscle," "malnutrition," "cirrhosis," "liver" and "frailty" from inception to April 2019, to identify the relevant studies and international guidelines. RESULTS The prevalence of malnutrition/sarcopenia in cirrhosis is 23%-60%. Frailty generally overlaps with malnutrition/sarcopenia in cirrhosis, leading to increased morbidity and mortality. Rapid nutritional screening assessment should be performed in all patients with cirrhosis, and more specific tests for sarcopenia should be performed in those at high risk. The pathogenesis of malnutrition/sarcopenia in cirrhosis is complex/multifactorial and not just reduction in protein/calorie intake. Hyperammonemia appears to be the main driver of sarcopenia in cirrhosis through several molecular signalling pathways. Nutritional management in malnourished patients with cirrhosis should be undertaken by a multidisciplinary team to achieve adequate protein/calorie intake. While the role of branched-chained amino acids remains somewhat contentious in achieving a global benefit of decreasing mortality- and liver-related events, they, and vitamin supplements, are recommended for those with advanced liver disease. Novel strategies to reverse sarcopenia such as hormone supplementation, long-term ammonia-lowering agents and myostatin antagonists, are currently under investigation. CONCLUSIONS Malnutrition/sarcopenia and frailty are unique, inter-related and multi-dimensional problems in cirrhosis which require special attention, prompt assessment and appropriate management as they significantly impact morbidity and mortality.
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Affiliation(s)
- Chalermrat Bunchorntavakul
- Division of Gastroenterology and Hepatology, Department of Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok, Thailand
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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19
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Luong R, Kim M, Lee A, Carey S. Assessing nutritional status in a cohort of liver cirrhosis outpatients: A prospective cross-sectional study. Nutr Health 2019; 26:19-25. [PMID: 31779515 DOI: 10.1177/0260106019888362] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Malnutrition impairs prognosis in patients with liver cirrhosis (LC). There is limited research exploring the prevalence of malnutrition in patients with LC in an Australian population and in outpatient settings. AIMS One aim of this study was to investigate the prevalence of malnutrition in patients with LC in an outpatient liver clinic at a tertiary metropolitan hospital in Sydney, Australia, and explore other factors that may be associated with malnutrition. The second aim was to compare different versions of Subjective Global Assessment (SGA). METHODS This cross-sectional study evaluated the nutritional status of 42 prospectively recruited participants by SGA, SGA modified for liver disease (SGA-LD) and patient-generated SGA (PG-SGA). Anthropometric measures and handgrip strength (HGS) were also measured for comparison. Clinical and demographic data were compared with nutritional status. RESULTS SGA, SGA-LD and PG-SGA yielded the same prevalence of malnutrition of 40% with very good agreement (kappa value = 1.00). Malnourished patients had a lower median HGS% of normal than those who were well-nourished. Malnourished patients also had anthropometric measurements trending towards the lower percentiles of a healthy population. Nutritional status was significantly associated with ethnicity (p = 0.02) and PG-SGA score (p < 0.0001). CONCLUSION The present study showed that nearly half of our study population were malnourished (40%). Thus, nutrition intervention in terms of nutrition support could improve patient outcomes. It appears that the standard SGA is suitable to assess nutritional status in patients in the early stages of LC compared to more time-consuming SGA versions.
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Affiliation(s)
- Rebecca Luong
- Molecular Bioscience, University of Sydney, Australia
| | - Marcellinus Kim
- Nutrition and Dietetics Department, Concord Repatriation General Hospital, Australia
| | - Alice Lee
- Gastroenterology and Hepatology Department, Concord Repatriation General Hospital, Australia
| | - Sharon Carey
- Nutrition and Dietetics Department, Royal Prince Alfred Hospital, Australia
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20
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Nutritional assessment of Oraons of West Bengal: a comparison between biochemical and anthropometric methods. ANTHROPOLOGICAL REVIEW 2019. [DOI: 10.2478/anre-2019-0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Comprehensive nutritional assessment is the basis of nutritional diagnosis and necessary to identify the individual or the population at a risk of dietary deficiencies. However, there is no specific and confirmatory method to measure nutritional status. Present study tried to find out the efficacy of two nutritional assessment method (1) biochemical test like Total serum protein (TSP) and (2) anthropological measurements like body mass index (BMI) and mid-upper-arm-circumference (MUAC). Later, three methods were tested and compared for the strength of assessing the nutritional status. Study was conducted among 198 adult Oraon, 84 male, 114 female individuals of Madarihat and Falakata police station area, Alipurduar district, West Bengal. Selected blood parameters such as total serum protein (TSP), serum albumin and haemoglobin and anthropometric measurements (height, weight, mid-upper arm circumference, waist circumference, hip circumference, calf circumference, biceps skinfold, triceps skinfold, and calf skinfold) were obtained following standard instruments and protocols. Nutritional status of all individuals was assessed by TSP, BMI and MUAC classification methods. Comparison between/among three classification methods (TSP, BMI and MUAC) was done and discriminant function analysis was adopted to find out the percentage of correct classification by each methods. It was found that prevalence of undernutrition using TSP classification was 38.1% male and 43.0% female; using BMI was 34.5% male and 53.5% female; using MUAC was 45.2% male and 64.9% female. Discriminant function analysis showed that BMI (97.0%) had the highest capability of correct classification followed by MUAC (84.80%) and TSP (63.60%). Results indicate that however, TSP is an objective way of nutritional assessment, but BMI had the highest capability of correct classification of nutritional status. It may be pointed out that the evaluation with TSP was expensive and invasive whereas BMI is non-expensive and completely a non-invasive way of evaluation. Therefore, BMI may widely be used for nutritional assessment.
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21
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Yao J, Zhou X, Yuan L, Niu LY, Zhang A, Shi H, Duan Z, Xu J. Prognostic value of the third lumbar skeletal muscle mass index in patients with liver cirrhosis and ascites. Clin Nutr 2019; 39:1908-1913. [PMID: 31472986 DOI: 10.1016/j.clnu.2019.08.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 05/12/2019] [Accepted: 08/09/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND & AIMS The objective nutritional assessment indicators, body mass index (BMI), upper arm muscle circumference (MAMC), and triceps skinfold thickness (TSF), are often limited due to ascites. This study investigated the prognostic value of the third lumbar vertebrae skeletal muscle mass index (L3 SMI) in addition to the objective nutritional evaluation indicators (BMI, MAMC and TSF) in patients with liver cirrhosis and ascites. METHODS In this retrospective analysis, a total of 147 patients with liver cirrhosis and ascites were included. The L3 SMI, BMI, MAMC and TSF were detected in all patients. The severity of liver disease was assessed by the Model End-Stage Liver Disease (MELD) score and Child-Turcotte-Pugh (CTP) classification. These variables were compared between non-surviving and surviving patients who were classified according to 5-year mortality. RESULTS Of the 147 patients, 62 (42.2%) died and 85 (57.8%) survived within 5 years. The L3 SMI of patients was significantly lower than that of the normal control group (39.58 ± 7.18 cm2/m2 vs. 53.73 ± 7.92 cm2/m,2p < 0.001). The L3 SMI (OR 4.02; 95% CI 2.17-9.63; p < 0.001), MELD score (OR 2.11; 95% CI 1.12-4.13; p < 0.001) and CTP class (OR 2.69; 95% CI 1.09-5.06; p < 0.001) were independent predictive indicators of 5-year mortality. Furthermore, the performance of the two variables (L3 SMI and MELD) together (AUROC: 0.812) was significantly better than that of MELD alone (AUROC: 0.787) for prediction of 5-year mortality (p < 0.001). CONCLUSION Compared with MAMC, TSF and BMI, L3 SMI is an independent risk factor for 5-year mortality in patients with liver cirrhosis and ascites. Further nutritional intervention studies are needed to confirm the impact of the L3 SMI index on clinical outcomes.
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Affiliation(s)
- Jia Yao
- Department of Gastroenterology and General Surgery, Shanxi Dayi Hospital, Shanxi Medical University, Taiyuan, China
| | - Xiaoshuang Zhou
- Shanxi Provincial People's Hospital, Shanxi Medical University, Taiyuan, China
| | - Lili Yuan
- Department of Gastroenterology and General Surgery, Shanxi Dayi Hospital, Shanxi Medical University, Taiyuan, China
| | - Ling Yun Niu
- Department of Gastroenterology and General Surgery, Shanxi Dayi Hospital, Shanxi Medical University, Taiyuan, China
| | - Aiqing Zhang
- Department of Gastroenterology and General Surgery, Shanxi Dayi Hospital, Shanxi Medical University, Taiyuan, China
| | - Hongbo Shi
- Difficult & Complicated Liver Diseases and Artificial Liver Center, Beijing Youan Hospital, Capital Medical University, Beijing Municipal Key Laboratory of Liver Failure and Artificial Liver Treatment Research, Beijing, China.
| | - Zhongping Duan
- Difficult & Complicated Liver Diseases and Artificial Liver Center, Beijing Youan Hospital, Capital Medical University, Beijing Municipal Key Laboratory of Liver Failure and Artificial Liver Treatment Research, Beijing, China.
| | - Jun Xu
- Department of Gastroenterology and General Surgery, Shanxi Dayi Hospital, Shanxi Medical University, Taiyuan, China.
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22
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Abstract
PURPOSE OF REVIEW This review discusses the prevalence of malnutrition in cirrhosis, metabolic functions of the liver and alterations in cirrhosis, malnutrition screening tools, and common macronutrient and micronutrient deficiencies encountered in individuals with chronic liver disease and their impact on morbidity and mortality. RECENT FINDINGS Several meta-analyses and international society guidelines recommend malnutrition screening and nutrition interventions to improve outcomes in all patients with chronic liver disease given their high risk of malnutrition which is often under recognized. Malnutrition is common in individuals with chronic liver disease and has a significant impact on patient outcomes. Thus, it is critical that validated malnutrition screening tools are used routinely in this patient population in order to identify high-risk patients and implement nutrition and exercise interventions early.
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Affiliation(s)
- Lena B Palmer
- Division of Gastroenterology, Southeast Louisiana Veterans Affairs Healthcare System, 2400 Canal St, New Orleans, LA, 70119, USA.
| | - Gabriela Kuftinec
- Department of Internal Medicine, Division of Gastroenterology & Hepatology, University of Miami Health Systems, Miller School of Medicine, Miami, FL, USA
| | - Michelle Pearlman
- Department of Internal Medicine, Division of Gastroenterology & Hepatology, University of Miami Health Systems, Miller School of Medicine, Miami, FL, USA
| | - Caitlin Homberger Green
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, SC, USA
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23
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Desalegn H, Aberra H, Berhe N, Medhin G, Mekasha B, Gundersen SG, Johannessen A. Predictors of mortality in patients under treatment for chronic hepatitis B in Ethiopia: a prospective cohort study. BMC Gastroenterol 2019; 19:74. [PMID: 31092203 PMCID: PMC6521482 DOI: 10.1186/s12876-019-0993-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 05/09/2019] [Indexed: 12/22/2022] Open
Abstract
Background Antiviral treatment for chronic hepatitis B (CHB) is largely unavailable in sub-Saharan Africa; hence, little is known about the prognosis after initiating treatment in African CHB patients. In this study we aimed to assess predictors of mortality in one of the largest CHB cohorts in sub-Saharan Africa. Methods Two-hundred-and-seventy-six CHB patients who started treatment with tenofovir disoproxil fumarate at a public hospital in Ethiopia between March 18, 2015, and August 1, 2017, were included in this analysis. Patients were followed up until October 1, 2017, and deaths were ascertained through hospital records and telephone interview with relatives. Decompensated cirrhosis was defined as current or past evidence of ascites, either by clinical examination or by ultrasonography. Cox proportional hazard models were used to identify independent predictors of mortality. Results Thirty-five patients (12.7%) died during follow-up, 33 of whom had decompensated cirrhosis at recruitment. The median duration from start of treatment to death was 110 days (interquartile range 26–276). The estimated survival was 90.3, 88.2 and 86.3% at 6, 12 and 24 months of follow-up, respectively. Independent predictors of mortality were decompensated cirrhosis (adjusted hazard ratio [AHR] 23.68; 95% CI 3.23–173.48; p = 0.002), body mass index < 18.5 kg/m2 (AHR 3.65; 95% CI 1.73–7.72; p = 0.001) and older age (per 1-year increment; AHR 1.06; 95% CI 1.02–1.10; p = 0.007). Conclusions Decompensated cirrhosis, low body mass index and older age were independent predictors of mortality. Improved access to antiviral treatment and earlier initiation of therapy could improve the survival of African CHB patients. Trial registration NCT02344498 (ClinicalTrials.gov identifier). Registered 16 January 2015.
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Affiliation(s)
- Hailemichael Desalegn
- Medical Department, St. Paul's Hospital Millennium Medical College, Po. Box 1271, Addis Ababa, Ethiopia.
| | - Hanna Aberra
- Medical Department, St. Paul's Hospital Millennium Medical College, Po. Box 1271, Addis Ababa, Ethiopia
| | - Nega Berhe
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia.,Centre for Imported and Tropical Diseases, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Girmay Medhin
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Bitsatab Mekasha
- Medical Department, St. Paul's Hospital Millennium Medical College, Po. Box 1271, Addis Ababa, Ethiopia
| | - Svein Gunnar Gundersen
- Research Unit, Sørlandet Hospital HF, Kristiansand, Norway.,Department of Global Development and Planning, University of Agder, Kristiansand, Norway
| | - Asgeir Johannessen
- Centre for Imported and Tropical Diseases, Oslo University Hospital, Ullevål, Oslo, Norway.,Department of Infectious Diseases, Vestfold Hospital Trust, Tønsberg, Norway
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24
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Miao JP, Quan XQ, Zhang CT, Zhu H, Ye M, Shen LY, Guo QH, Zhu GY, Mei QJ, Wu YX, Li SG, Zhou HL. Comparison of two malnutrition risk screening tools with nutritional biochemical parameters, BMI and length of stay in Chinese geriatric inpatients: a multicenter, cross-sectional study. BMJ Open 2019; 9:e022993. [PMID: 30782871 PMCID: PMC6411257 DOI: 10.1136/bmjopen-2018-022993] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES The aims of this study were to assess malnutrition risk in Chinese geriatric inpatients using Nutritional Risk Screening 2002 (NRS2002) and Mini-Nutritional Assessment (MNA), and to identify the most appropriate nutritional screening tool for these patients. DESIGN Cross-sectional study. SETTING Eight medical centres in Hubei Province, China. PARTICIPANTS A total of 425 inpatients aged ≥70 years were consecutively recruited between December 2014 and May 2016. PRIMARY AND SECONDARY OUTCOME MEASURES Nutritional risk was assessed using NRS2002, MNA, anthropometric measurements and biochemical parameters within 24 hours of admission. Comorbidities and length of hospitalisation were recorded. Nutritional parameters, body mass index (BMI) and length of hospital stay (LOS) were employed to compare MNA and NRS2002. Kappa analysis was used to evaluate the consistency of the two tools. RESULTS The average age was 81.2±5.9 years (range, 70-98). The prevalence of undernutrition classified by NRS2002 and MNA was 40.9% and 58.6%, respectively. Patients undergoing malnutrition had lower BMI, haemoglobin, albumin and prealbumin (p<0.05), and longer LOS (p<0.05). The NRS2002 showed moderate agreement (κ=0.521, p<0.001) with MNA. Both tools presented significant correlation with age, BMI and laboratory parameters (p<0.001). In addition, a significant association between both tools and LOS was found (p<0.05). In addition, the NRS2002 was not different from MNA in predicting nutritional risk in terms of the area under the receiver operating characteristic curve (p>0.05). CONCLUSIONS The results show a relatively high prevalence of malnutrition risk in our sample cohort. We found that NRS2002 and MNA were both suitable in screening malnutrition risk among Chinese geriatric inpatients.
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Affiliation(s)
- Jian-Ping Miao
- Department of Geriatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Prevention Treatment and Health Care Medicine of Geriatric Diseases in Hubei Province, Wuhan, China
- Wuhan Clinical Research Center for Treatment and Rehabilitation of Elderly Multi-Organ Dysfunction, Wuhan, China
| | - Xiao-Qing Quan
- Department of Geriatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Prevention Treatment and Health Care Medicine of Geriatric Diseases in Hubei Province, Wuhan, China
- Wuhan Clinical Research Center for Treatment and Rehabilitation of Elderly Multi-Organ Dysfunction, Wuhan, China
| | - Cun-Tai Zhang
- Department of Geriatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Prevention Treatment and Health Care Medicine of Geriatric Diseases in Hubei Province, Wuhan, China
- Wuhan Clinical Research Center for Treatment and Rehabilitation of Elderly Multi-Organ Dysfunction, Wuhan, China
| | - Hong Zhu
- Department of Geriatrics, The Central Hospital of Wuhan University, Wuhan, China
| | - Mei Ye
- Department of Geriatrics, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Li-Ya Shen
- Department of Geriatrics, Wuhan No 6 Hospital, Wuhan, China
| | - Qiu-Hui Guo
- Department of Geriatrics, Wuhan No 6 Hospital, Wuhan, China
| | - Gang-Yan Zhu
- Department of Geriatrics, Hubei General Hospital, Wuhan, China
| | - Qi-Jian Mei
- Department of Geriatrics, General Hospital of the Yangtze River Shipping, Wuhan, China
| | - Yan-Xia Wu
- Department of Geriatrics, Wuhan No 1 Hospital, Wuhan, China
| | - Shu-Guo Li
- Department of Geriatrics, First Clinical Medical College, Three Gorges University and Yichang Central People’s Hospital, Yichang, China
| | - Hong-Lian Zhou
- Department of Geriatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Prevention Treatment and Health Care Medicine of Geriatric Diseases in Hubei Province, Wuhan, China
- Wuhan Clinical Research Center for Treatment and Rehabilitation of Elderly Multi-Organ Dysfunction, Wuhan, China
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Crossland H, Smith K, Atherton PJ, Wilkinson DJ. The metabolic and molecular mechanisms of hyperammonaemia- and hyperethanolaemia-induced protein catabolism in skeletal muscle cells. J Cell Physiol 2018; 233:9663-9673. [PMID: 30144060 PMCID: PMC6220958 DOI: 10.1002/jcp.26881] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 05/23/2018] [Indexed: 12/13/2022]
Abstract
Hyperammonaemia and hyperethanolaemia are thought to be driving factors behind skeletal muscle myopathy in liver disease, that is, cirrhosis. Despite this, the singular and combined impacts of ethanol‐ and ammonia‐induced protein catabolism are poorly defined. As such, we aimed to dissect out the effects of ammonia and ethanol on muscle catabolism. Murine C2C12 myotubes were treated with ammonium acetate (10 mM) and ethanol (100 mM) either alone or in combination for 4 hr and/or 24 hr. Myotube diameter, muscle protein synthesis and anabolic and catabolic signalling pathways were assessed. In separate experiments, cells were cotreated with selected inhibitors of protein breakdown to assess the importance of proteolytic pathways in protein loss with ammonia and ethanol. Ammonia and ethanol in combination resulted in a reduction in myotube width and total protein content, which was greater than the reduction observed with ammonia alone. Both ammonia and ethanol caused reductions in protein synthesis, as assessed by puromycin incorporation. There was also evidence of impairments in regulation of protein translation, and increased protein expression of markers of muscle protein breakdown. Myotube protein loss with ammonia plus ethanol was not affected by autophagy inhibition, but was completely prevented by proteasome inhibition. Thus, combined ammonia and ethanol incubation of C2C12 myotubes exacerbated myotube atrophy and dysregulation of anabolic and catabolic signalling pathways associated with either component individually. Ubiquitin proteasome‐mediated protein breakdown appears to play an important role in myotube protein loss with ethanol and ammonia.
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Affiliation(s)
- Hannah Crossland
- MRC-ARUK Centre for Musculoskeletal Ageing Research, NIHR Biomedical Research Centre, Clinical, Metabolic and Molecular Physiology, Division of Medical Sciences and Graduate Entry Medicine, Royal Derby Hospital, School of Medicine, University of Nottingham, Derby, UK
| | - Kenneth Smith
- MRC-ARUK Centre for Musculoskeletal Ageing Research, NIHR Biomedical Research Centre, Clinical, Metabolic and Molecular Physiology, Division of Medical Sciences and Graduate Entry Medicine, Royal Derby Hospital, School of Medicine, University of Nottingham, Derby, UK
| | - Philip J Atherton
- MRC-ARUK Centre for Musculoskeletal Ageing Research, NIHR Biomedical Research Centre, Clinical, Metabolic and Molecular Physiology, Division of Medical Sciences and Graduate Entry Medicine, Royal Derby Hospital, School of Medicine, University of Nottingham, Derby, UK
| | - Daniel J Wilkinson
- MRC-ARUK Centre for Musculoskeletal Ageing Research, NIHR Biomedical Research Centre, Clinical, Metabolic and Molecular Physiology, Division of Medical Sciences and Graduate Entry Medicine, Royal Derby Hospital, School of Medicine, University of Nottingham, Derby, UK
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Abstract
As the cirrhosis progresses, development of complication like ascites, hepatic encephalopathy, variceal bleeding, kidney dysfunction, and hepatocellular carcinoma signify increasing risk of short term mortality. Malnutrition and muscle wasting (sarcopenia) is yet other complications that negatively impact survival, quality of life, and response to stressors, such as infection and surgery in patients with cirrhosis. Conventionally, these are not routinely looked for, because nutritional assessment can be a difficult especially if there is associated fluid retention and/or obesity. Patients with cirrhosis may have a combination of loss of skeletal muscle and gain of adipose tissue, culminating in the condition of "sarcopenic obesity." Sarcopenia in cirrhotic patients has been associated with increased mortality, sepsis complications, hyperammonemia, overt hepatic encephalopathy, and increased length of stay after liver transplantation. Assessment of muscles with cross-sectional imaging studies has become an attractive index of nutritional status evaluation in cirrhosis, as sarcopenia, the major component of malnutrition, is primarily responsible for the adverse clinical consequences seen in patients with liver disease. Cirrhosis is a state of accelerated starvation, with increased gluconeogenesis that requires amino acid diversion from other metabolic functions. Protein homeostasis is disturbed in cirrhosis due to several factors such as hyperammonemia, hormonal, and cytokine abnormalities, physical inactivity and direct effects of ethanol and its metabolites. New approaches to manage sarcopenia are being evolved. Branched chain amino acid supplementation, Myostatin inhibitors, and mitochondrial protective agents are currently in various stages of evaluation in preclinical studies to prevent and reverse sarcopenia, in cirrhosis.
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Key Words
- (PG) SGA, patient-generated SGA
- AMPK, 5′ adenosine monophosphate-activated protein kinase
- ASPEN, American Society of Parenteral and Enteral Nutrition
- ATP, adenosine triphosphate
- Akt/PKB, serine/threonine-specific protein kinase B
- BIA, bio-electric impedance analysis
- BMC, bone mineral content
- BMI, body mass index
- CT, computed tomography
- DDLT, deceased donor liver transplantation
- DRM, disease-related malnutrition
- DXA, dual X-ray absorptiometry
- ESPEN, European Society of Parenteral and Enteral Nutrition
- FFI, Fried Frailty Index
- FFM, fat free mass
- FFMI, fat free mass index
- FM, fat mass
- HE, hepatic encephalopathy
- LDLT, living donor liver transplant
- LST, lean soft tissue
- MAC, mid arm circumference
- MAMC, mid arm muscle circumference
- MELD, model for end-stage liver disease
- MNA, Mini Nutritional Assessment
- MRI, magnetic resonance imaging
- NASH, non-alcoholic steatohepatitis
- PCM, protein-calorie nalnutrition
- REE, resting energy expenditure
- RQ, respiratory quotient (or RQ or respiratory coefficient)
- SGA, Subjective Global Assessment
- SMI, Skeletal Muscle Index
- SPPB, Short Physical Performance Battery
- TIPS, trans jugular intrahepatic portocaval shunts
- TNF, tumour necrosis factor
- TSF, triceps skin fild thickness
- WHO, World Health Organisation
- YPA, total psoas area
- aKG, alfa keto glutarate
- cirrhosis
- mTORC1, mammalian target of rapamycin complex 1
- nutrition
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Dasarathy J, McCullough AJ, Dasarathy S. Sarcopenia in Alcoholic Liver Disease: Clinical and Molecular Advances. Alcohol Clin Exp Res 2017; 41:1419-1431. [PMID: 28557005 DOI: 10.1111/acer.13425] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 05/16/2017] [Indexed: 12/18/2022]
Abstract
Despite advances in treatment of alcohol use disorders that focus on increasing abstinence and reducing recidivism, alcoholic liver disease (ALD) is projected to be the major cause of cirrhosis and its complications. Malnutrition is recognized as the most frequent complication in ALD, and despite the high clinical significance, there are no effective therapies to reverse malnutrition in ALD. Malnutrition is a relatively imprecise term, and sarcopenia or skeletal muscle loss, the major component of malnutrition, is primarily responsible for the adverse clinical consequences in patients with liver disease. It is, therefore, critical to define the specific abnormality (sarcopenia) rather than malnutrition in ALD, so that therapies targeting sarcopenia can be developed. Skeletal muscle mass is maintained by a balance between protein synthesis and proteolysis. Both direct effects of ethanol (EtOH) and its metabolites on the skeletal muscle and the consequences of liver disease result in disturbed proteostasis (protein homeostasis) and consequent sarcopenia. Once cirrhosis develops in patients with ALD, abstinence is unlikely to be effective in completely reversing sarcopenia, as other contributors including hyperammonemia, hormonal, and cytokine abnormalities aggravate sarcopenia and maintain a state of anabolic resistance initiated by EtOH. Cirrhosis is also a state of accelerated starvation, with increased gluconeogenesis that requires amino acid diversion from signaling and substrate functions. Novel therapeutic options are being recognized that are likely to supplant the current "deficiency replacement" approach and instead focus on specific molecular perturbations, given the increasing availability of small molecules that can target specific signaling components. Myostatin antagonists, leucine supplementation, and mitochondrial protective agents are currently in various stages of evaluation in preclinical studies to prevent and reverse sarcopenia, in cirrhosis in general, and ALD, specifically. Translation of these data to human studies and clinical application requires priority for allocation of resources.
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Affiliation(s)
| | - Arthur J McCullough
- Department of Gastreoenterology, Hepatology and Pathobiology, Cleveland Clinic, Cleveland, Ohio
| | - Srinivasan Dasarathy
- Department of Gastreoenterology, Hepatology and Pathobiology, Cleveland Clinic, Cleveland, Ohio
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Nutritional status using subjective global assessment independently predicts outcome of patients waiting for living donor liver transplant. Indian J Gastroenterol 2017; 36:275-281. [PMID: 28856568 DOI: 10.1007/s12664-017-0779-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 07/22/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Malnutrition is an important risk factor for adverse outcomes in patients awaiting liver transplant. Living donor liver transplant, being an elective procedure, allows nutritional rehabilitation and optimization of these patients before transplant. AIM This paper aimed to evaluate the outcome of end-stage liver disease (ESLD) patients with various degrees of malnutrition waiting for living donor liver transplant. METHODS Nutritional status was assessed using subjective global assessment (SGA) in patients who were evaluated for a liver transplant at our center from January 2015 to September 2015. All the data were collected prospectively. Predictive factors for mortality were analyzed using logistic regression and survival was obtained using Kaplan-Meier curves. RESULTS One hundred and seventeen patients were grouped based on their nutrition status into normal, mild-moderate, and severe malnutrition. The groups were comparable in terms of age, sex, etiology of liver disease except alcoholic liver disease. Graft recipient weight ratio was comparable among groups. There was no significant difference in hospital stay. However, severe malnourished patients had higher incidence of sepsis (p=0.005) and death due to sepsis (p=0.01). Nutritional status was the only independent predictor of mortality on multivariate analysis. CONCLUSION Nutritional status measured with SGA independently predicts short-term outcome of ESLD patients waiting and after living donor liver transplant.
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Sharma P, Rauf A, Matin A, Agarwal R, Tyagi P, Arora A. Handgrip Strength as an Important Bed Side Tool to Assess Malnutrition in Patient with Liver Disease. J Clin Exp Hepatol 2017; 7:16-22. [PMID: 28348466 PMCID: PMC5357713 DOI: 10.1016/j.jceh.2016.10.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 10/21/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Malnutrition is frequently present in patients with cirrhosis. Anthropometric measures such as body mass index (BMI), mid arm muscle circumference (MAMC), triceps skin fold thickness (TST) and subjective global assessment (SGA) have some limitations in assessment of malnutrition. This study aims to determine the prevalence of malnutrition in non-hospitalized cirrhotic and chronic hepatitis patients and to assess handgrip (HG) strength as a tool for identifying malnutrition. METHODS Consecutive patients of cirrhosis (n = 352), chronic hepatitis (n = 189) and healthy controls (n = 159) were enrolled. All patients underwent MAMC, TST, HG and SGA assessment. Malnutrition was diagnosed on basis of SGA score. Values of MAMC, TST and HG below the 5th percentile or less than 60% of healthy controls were considered as abnormal. RESULTS According to SGA (taken as standard) 24% patients with chronic hepatitis and 56% of patients with cirrhosis had malnutrition (P = 0.001). In patients with chronic hepatitis prevalence of malnutrition according to MAMC (12%), TST (31%) and HG (18%). In patients with cirrhosis prevalence of malnutrition according to MAMC (27%), TST (60%) and HG (42%). HG exercise strength had the highest area under curve 0.82 (95% confidence interval (CI) 0.78-0.86, P = 0.001) compared to MAMC 0.60 (95% CI 0.55-0.64, P = 0.001) and TST 0.65 (95% CI 0.61-0.69, P = 0.001) for assessing malnutrition. On comparison of HG, TST and MAMC, the sensitivity was 67%, 60% and 31%, respectively, Specificity was 95%, 71% and 89%, respectively, and diagnostic accuracy was 87%, 67% and 71%, respectively. CONCLUSION HG strength is an excellent tool to assess at bed side the nutrition status in patients with cirrhosis and has the highest diagnostic accuracy compared to other anthropometric tests such as MAMC and TST.
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Affiliation(s)
- Praveen Sharma
- Address for correspondence: Praveen Sharma, Department of Gastroenterology, Sir Ganga Ram Hospital, New Delhi, India.Department of Gastroenterology, Sir Ganga Ram HospitalNew DelhiIndia
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30
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Abstract
Malnutrition is associated with alcoholic liver disease (ALD) and related complications such as hepatic encephalopathy and increased rate of infections. Avoidance of prolonged fasting and overly restrictive diets is important to avoid poor nutrition. Adequate intake of calories, protein, and micronutrients via frequent small meals and evening supplements and/or enteral and parenteral nutrition when indicated has been associated with reduced mortality and morbidity in patients with ALD. Modification of protein/fat sources and composition in addition to probiotic supplementation are promising interventions for decreased progression of ALD and its complications.
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31
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Abou-Assi SG, Mihas AA, Gavis EA, Gilles HS, Haselbush A, Levy JR, Habib A, Heuman DM. Safety of an Immune-Enhancing Nutrition Supplement in Cirrhotic Patients With History of Encephalopathy. JPEN J Parenter Enteral Nutr 2017; 30:91-6. [PMID: 16517953 DOI: 10.1177/014860710603000291] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Malnutrition in advanced cirrhosis may worsen liver function and increase susceptibility to infections. Immune-enhancing nutrition supplements (IENS) may be of value, but their safety in patients with decompensated cirrhosis and history of encephalopathy is unknown. We assessed the safety of Impact Recover (Novartis, St. Louis Park, MN), an orally palatable IENS, in 12 men with hepatic cirrhosis of Child-Turcotte-Pugh (CTP) class B or C, ages 40-60. On day 0, patients were evaluated serially for 6 hours after ingestion of 2 packets of Impact Recover. Despite a transient doubling of the blood ammonia, no cognitive abnormalities were noted on clinical assessment or psychometric testing. Subsequently, patients were instructed to ingest 3 packets per day of Impact Recover for 56 days, after which supplements were stopped. Patients were evaluated in a fasting state on days 0 (baseline), 56 (end of treatment), and 112 (follow-up). One patient was transplanted on day 21, and another died after an urgent cholecystectomy on day 30. The remaining 10 patients completed the study. Mean value of CTP score was 9 (range, 7-11) and mean value of model for end-stage liver disease (MELD) score was 14 (7-21), and there was no change after 8 weeks of IENS. Only 1 experienced transient worsening of encephalopathy after omitting lactulose. Performances on psychometric tests did not change. Transferrin levels increased rapidly with IENS, then returned toward baseline after IENS was stopped. Fasting insulin and peptide YY (PYY) levels also increased, but fasting glucose and hemoglobin A1C did not change. Trends in other nutrition and immune parameters did not reach significance. We conclude that acute and chronic administration of Impact Recover was well tolerated in cirrhotic patients with controlled encephalopathy. Further studies are justified to assess potential efficacy of long-term IENS in preventing infection and slowing progression in advanced cirrhosis.
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Affiliation(s)
- Souheil G Abou-Assi
- Department of Medicine, Virginia Commonwealth University Health System & McGuire Veteran Affairs Medical Center, Richmond, VA 23236, USA.
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Bakshi N, Singh K. Nutrition assessment and its effect on various clinical variables among patients undergoing liver transplant. Hepatobiliary Surg Nutr 2016; 5:358-71. [PMID: 27500148 PMCID: PMC4960422 DOI: 10.21037/hbsn.2016.03.09] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 03/09/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Malnutrition is highly prevalent in patients undergoing liver transplantation and has been associated to various clinical variables and outcome of the surgery. METHODS We recruited 54 adult patients undergoing living donor liver transplant (LT) as study sample. Nutrition assessment was performed by body mass index (BMI), BMI for ascites, albumin, subjective global assessment (SGA) and anthropometry [mid upper arm circumference (MUAC), mid arm muscle circumference (MAMC), and triceps skin-fold (TSF)], Hand Grip strength, and phase angle of the body. Prevalence and comparison of malnutrition was performed with various clinical variables: aetiology, Child Turcotte Pugh scores and model for end stage liver disease (ESLD) grades, degree of ascites, blood product usage, blood loss during the surgery, mortality, days [intensive care unit (ICU), Ventilator and Hospital], and Bio-impedance analysis [weight, fat mass, fat free mass (FFM), muscle mass and body fat%]. RESULTS Assessment of nutrition status represents a major challenge because of complications like fluid retention, hypoalbuminemia and hypoproteinemia. Different nutrition assessment tools show great disparity in the level of malnutrition among ESLD patients. In the present study recipient nutrition status evaluation by different nutrition assessment tools used showed malnutrition ranging from 3.7% to 100%. BMI and anthropometric measurements showed lower prevalence of malnutrition than phase angle and SGA whereas hand grip strength showed 100% malnutrition. Agreement among nutrition assessment methods showed moderate agreement (κ=0.444) of SGA with phase angle of the body. Malnutrition by different assessment tools was significantly associated to various clinical variables except MELD and days (ICU, Ventilator and Hospital). SGA was significantly (P<0.05) associated to majority of the clinical variables like aetiology, child Turcotte Pugh grades, degree of ascites, blood product usage, blood loss during the surgery, BIA (fat mass, FFM, muscle mass and body fat%). CONCLUSIONS The different nutrition assessment tools showed great variability of results. SGA showed moderate agreement with phase angle of the body and was associated with various clinical and prognostic variables of liver transplantation.
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Affiliation(s)
- Neha Bakshi
- Department of Foods and Nutrition, Lady Irwin College, University of Delhi, New Delhi 110001, India
| | - Kalyani Singh
- Department of Foods and Nutrition, Lady Irwin College, University of Delhi, New Delhi 110001, India
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Gottschall CBA, Pereira TG, Rabito EI, Álvares-Da-Silva MR. NUTRITIONAL STATUS AND DIETARY INTAKE IN NON-CIRRHOTIC ADULT CHRONIC HEPATITIS C PATIENTS. ARQUIVOS DE GASTROENTEROLOGIA 2016; 52:204-9. [PMID: 26486288 DOI: 10.1590/s0004-28032015000300010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 05/15/2015] [Indexed: 03/05/2023]
Abstract
BACKGROUND The hepatitis C virus is one of the main causes of liver disease worldwide and may develop nutritional deficiencies. OBJECTIVE The objective of this study was to assess and compare different nutritional status methods of adult patients with chronic hepatitis C virus, and to describe inadequacies in dietary intake. METHODS A cross-sectional study was conducted with adult outpatients with hepatitis C virus at a Brazilian hospital. Nutritional assessment included the 24-hour dietary recall, anthropometry (body weight, height, body mass index, triceps skinfold, mid-upper arm circumference, mid-arm muscle circumference, mid-upper arm muscle area, adductor policis muscle), Subjective Global Assessment, Royal Free Hospital Global Assessment and handgrip strength. RESULTS A total of 94 outpatients (ages 30 to 76 years), was included, 46 were men. The prevalence of malnutrition as measured by the different methods was 6.4% (body mass index); 60.6% (handgrip strength), and 53.2% (Royal Free Hospital Global Assessment). There was correlation between mid-upper arm circumference and mid-arm muscle circumference (r=0.821), mid-upper arm circumference and triceps skinfold (r=0.575) and mid-upper arm circumference and mid-upper arm muscle area (r=0.781). Energy and protein intakes were below recommended levels in 49 (52.1%) and 44 (46.8%) of patients, respectively. Inadequate calcium, potassium, zinc and vitamin C intakes occurred in 92.6%, 97.9%, 63.8% and 60.6% of patients. There was an association between dietary energy and protein intake with Royal Free Hospital Global Assessment (P<0.001) and a tendency for them to be associated with handgrip strength (P=0.076 and P=0.054). CONCLUSION Malnutrition is frequently in hepatitis C virus patients. They have high prevalence of inadequate energy, protein and micronutrients intake, even in the absence of cirrhosis.
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Affiliation(s)
- Catarina B A Gottschall
- Departamento de Nutrição, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, BR
| | - Thainá G Pereira
- Departamento de Nutrição, Universidade Federal do Paraná, Curitiba, PR, BR
| | - Estela I Rabito
- Faculdade de Nutrição, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, BR
| | - Mário R Álvares-Da-Silva
- Programa de Pós-Graduação Ciências em Gastroenterologia, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, BR
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Lopez-Delgado JC, Ballus J, Esteve F, Betancur-Zambrano NL, Corral-Velez V, Mañez R, Betbese AJ, Roncal JA, Javierre C. Outcomes of abdominal surgery in patients with liver cirrhosis. World J Gastroenterol 2016; 22:2657-2667. [PMID: 26973406 PMCID: PMC4777990 DOI: 10.3748/wjg.v22.i9.2657] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 10/30/2015] [Accepted: 12/14/2015] [Indexed: 02/06/2023] Open
Abstract
Patients suffering from liver cirrhosis (LC) frequently require non-hepatic abdominal surgery, even before liver transplantation. LC is an important risk factor itself for surgery, due to the higher than average associated morbidity and mortality. This high surgical risk occurs because of the pathophysiology of liver disease itself and to the presence of contributing factors, such as coagulopathy, poor nutritional status, adaptive immune dysfunction, cirrhotic cardiomyopathy, and renal and pulmonary dysfunction, which all lead to poor outcomes. Careful evaluation of these factors and the degree of liver disease can help to reduce the development of complications both during and after abdominal surgery. In the emergency setting, with the presence of decompensated LC, alcoholic hepatitis, severe/advanced LC, and significant extrahepatic organ dysfunction conservative management is preferred. A multidisciplinary, individualized, and specialized approach can improve outcomes; preoperative optimization after risk stratification and careful management are mandatory before surgery. Laparoscopic techniques can also improve outcomes. We review the impact of LC on surgical outcome in non-hepatic abdominal surgeries required in this cirrhotic population before, during, and after surgery.
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Romeiro FG, Augusti L. Nutritional assessment in cirrhotic patients with hepatic encephalopathy. World J Hepatol 2015; 7:2940-2954. [PMID: 26730273 PMCID: PMC4691697 DOI: 10.4254/wjh.v7.i30.2940] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 09/23/2015] [Accepted: 12/14/2015] [Indexed: 02/06/2023] Open
Abstract
Hepatic encephalopathy (HE) is one of the worst complications of liver disease and can be greatly influenced by nutritional status. Ammonia metabolism, inflammation and muscle wasting are relevant processes in HE pathophysiology. Malnutrition worsens the prognosis in HE, requiring early assessment of nutritional status of these patients. Body composition changes induced by liver disease and limitations superimposed by HE hamper the proper accomplishment of exams in this population, but evidence is growing that assessment of muscle mass and muscle function is mandatory due to the role of skeletal muscles in ammonia metabolism. In this review, we present the pathophysiological aspects involved in HE to support further discussion about advantages and drawbacks of some methods for evaluating the nutritional status of cirrhotic patients with HE, focusing on body composition.
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Huang SS, Chen CL, Huang FW, Johnson FE, Huang JS. Ethanol Enhances TGF-β Activity by Recruiting TGF-β Receptors From Intracellular Vesicles/Lipid Rafts/Caveolae to Non-Lipid Raft Microdomains. J Cell Biochem 2015; 117:860-71. [PMID: 26419316 DOI: 10.1002/jcb.25389] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 09/28/2015] [Indexed: 12/16/2022]
Abstract
Regular consumption of moderate amounts of ethanol has important health benefits on atherosclerotic cardiovascular disease (ASCVD). Overindulgence can cause many diseases, particularly alcoholic liver disease (ALD). The mechanisms by which ethanol causes both beneficial and harmful effects on human health are poorly understood. Here we demonstrate that ethanol enhances TGF-β-stimulated luciferase activity with a maximum of 0.5-1% (v/v) in Mv1Lu cells stably expressing a luciferase reporter gene containing Smad2-dependent elements. In Mv1Lu cells, 0.5% ethanol increases the level of P-Smad2, a canonical TGF-β signaling sensor, by ∼ 2-3-fold. Ethanol (0.5%) increases cell-surface expression of the type II TGF-β receptor (TβR-II) by ∼ 2-3-fold from its intracellular pool, as determined by I(125) -TGF-β-cross-linking/Western blot analysis. Sucrose density gradient ultracentrifugation and indirect immunofluorescence staining analyses reveal that ethanol (0.5% and 1%) also displaces cell-surface TβR-I and TβR-II from lipid rafts/caveolae and facilitates translocation of these receptors to non-lipid raft microdomains where canonical signaling occurs. These results suggest that ethanol enhances canonical TGF-β signaling by increasing non-lipid raft microdomain localization of the TGF-β receptors. Since TGF-β plays a protective role in ASCVD but can also cause ALD, the TGF-β enhancer activity of ethanol at low and high doses appears to be responsible for both beneficial and harmful effects. Ethanol also disrupts the location of lipid raft/caveolae of other membrane proteins (e.g., neurotransmitter, growth factor/cytokine, and G protein-coupled receptors) which utilize lipid rafts/caveolae as signaling platforms. Displacement of these membrane proteins induced by ethanol may result in a variety of pathologies in nerve, heart and other tissues.
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Affiliation(s)
| | - Chun-Lin Chen
- Department of Biological Science, National Sun Yat-sen University, Kaohsiung, 804, Taiwan.,Doctoral Degree Program in Marine Biotechnology, National Sun Yat-sen University and Academia Sinica, Kaohsiung, 804, Taiwan
| | - Franklin W Huang
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, 02115.,Harvard Medical School, Boston, Massachusetts, 02115
| | - Frank E Johnson
- Department of Surgery, Saint Louis University School of Medicine, St. Louis, Missouri, 63104
| | - Jung San Huang
- Department of Biochemistry and Molecular Biology, Saint Louis University School of Medicine, Doisy Research Center, St. Louis, Missouri, 63104
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Maharshi S, Sharma BC, Srivastava S. Malnutrition in cirrhosis increases morbidity and mortality. J Gastroenterol Hepatol 2015; 30:1507-13. [PMID: 25974421 DOI: 10.1111/jgh.12999] [Citation(s) in RCA: 108] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/27/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Malnutrition is frequent in patients with cirrhosis and is associated with complications like ascites, hepatic encephalopathy, infections, and death. We determined the prevalence of malnutrition by various methods and its clinical importance in patients with cirrhosis. METHODS Consecutive patients of cirrhosis from August 2013 to February 2015 were assessed. Nutritional status was assessed by traditional model (mid-arm circumference, triceps skinfold thickness, serum albumin, creatinine height index, total lymphocyte count), handgrip, and body composition analysis measuring skeletal muscle mass and body fat mass. All patients were followed up for 12 months to assess the outcome. RESULTS 247 patients (age 42.10 ± 10.14 years, 81% male) were included in the study. Etiology of cirrhosis was alcohol in 53% patients. Prevalence of malnutrition was 59.5% according to traditional model, 66.8% by body composition analysis and 71.4% by handgrip. Nutritional status was poor in alcoholic cirrhotics versus nonalcoholics as assessed by triceps skinfold thickness (9.33 ± 2.9 vs 11.64 ± 3.5 mm; P = 0.001), serum albumin (25.1 ± 4 vs 28.1 ± 4 g/L; P = 0.001), and body fat mass (7.6 ± 3.1 vs 8.7 ± 3.3 kg; P = 0.008). Prevalence of malnutrition was 12/27 (44.5%), 96/131 (73.3%) and 84/89 (94.4%) in Child's class A, B, and C respectively. Complications requiring hospitalization (71.3% vs 38.2%; 0.002) and mortality (41.1% vs 18.2%; P = 0.001) were more in malnourished patients compared to well nourished. Nutritional assessment parameters significantly correlated with the liver disease severity (P < 0.05). CONCLUSIONS Prevalence of malnutrition is high in patients with cirrhosis. It is associated with increased complications and mortality.
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Affiliation(s)
- Sudhir Maharshi
- Department of Gastroenterology, G.B. Pant Hospital, New Delhi, India
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Liver Cirrhosis: Evaluation, Nutritional Status, and Prognosis. Mediators Inflamm 2015; 2015:872152. [PMID: 26494949 PMCID: PMC4606163 DOI: 10.1155/2015/872152] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 07/08/2015] [Accepted: 07/13/2015] [Indexed: 02/07/2023] Open
Abstract
The liver is the major organ for the metabolism of three major nutrients: protein, fat, and carbohydrate. Chronic hepatitis C virus infection is the major cause of chronic liver disease. Liver cirrhosis (LC) results from different mechanisms of liver injury that lead to necroinflammation and fibrosis. LC has been seen to be not a single disease entity but one that can be graded into distinct clinical stages related to clinical outcome. Several noninvasive methods have been developed for assessing liver fibrosis and these methods have been used for predicting prognosis in patients with LC. On the other hand, subjects with LC often have protein-energy malnutrition (PEM) and poor physical activity. These conditions often result in sarcopenia, which is the loss of skeletal muscle volume and increased muscle weakness. Recent studies have demonstrated that PEM and sarcopenia are predictive factors for poorer survival in patients with LC. Based on these backgrounds, several methods for evaluating nutritional status in patients with chronic liver disease have been developed and they have been preferably used in the clinical field practice. In this review, we will summarize the current knowledge in the field of LC from the viewpoints of diagnostic method, nutritional status, and clinical outcomes.
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Zhou J, Wang M, Wang H, Chi Q. Comparison of two nutrition assessment tools in surgical elderly inpatients in Northern China. Nutr J 2015; 14:68. [PMID: 26170020 PMCID: PMC4499876 DOI: 10.1186/s12937-015-0054-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 06/29/2015] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND & OBJECTIVE Nutrition assessment enables early identification of malnourished patients and those at risk of malnutrition. To determine the prevalence of malnutrition, to analyze the correlation between short-form Mini Nutritional Assessment (MNA-SF) and Nutritional Risk Screening 2002 (NRS2002) with classical nutritional markers among elderly hospitalized patients in surgery departments, with a view to improving nutrition advice for these patients. METHODS A total of 142 elderly patients admitted for surgery were enrolled in the study. Within 48 hours of admission, MNA-SF and NRS2002 scale, anthropometric measures and biochemical tests were carried out to assess the nutritional status of each patient. RESULTS The prevalence of malnutrition classified by MNA-SF, NRS2002, BMI, serum albumin, hemoglobin, total lymphocyte count, handgrip strength, calf circumference and mid-arm circumference were 45%, 38%, 17%, 22%, 24%, 71%, 36%, 12 % and 15 %, respectively. As the nutritional status classified by both MNA-SF and NRS2002 deteriorated, BMI, serum albumin, hemoglobin, handgrip strength, mid-arm circumference and calf circumference of patients with malnutrition were lower (P < 0.05). MNA-SF and NRS2002 had a unanimous correlation with classical nutritional markers (P < 0.05) except total lymphocyte count (P > 0.05). MNA-SF results showed a moderate agreement (P < 0.001) with NRS2002. Malnourished patients were older than well-nourished patients with NRS2002 (P < 0.05). Digestive disease patients tend to suffer from malnutrition, evaluated by MNA-SF (P < 0.05). CONCLUSIONS The results show a relatively high prevalence of malnutrition among elderly patients in our general surgery department, especially in patients with digestive disease. NRS2002 and MNA-SF on elderly patients showed great consistency but significant difference in elderly patients with digestive disease. Both MNA-SF and NRS2002 correlated with each other and with BMI, serum albumin, hemoglobin, handgrip strength, calf circumference and mid-arm circumference. MNA-SF may be a more suitable tool for the nutrition assessment of surgical elderly inpatients.
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Affiliation(s)
- JunDe Zhou
- Department of General Surgery, The Second Affiliated Hospital, Harbin Medical University, 148, Bao Jian Road, Harbin, 150081, China
| | - Miao Wang
- Center for Animal Disease Control of Heilongjiang Province, Harbin, 150069, China
| | - HaiKuan Wang
- Department of General Surgery, The Second Affiliated Hospital, Harbin Medical University, 148, Bao Jian Road, Harbin, 150081, China
| | - Qiang Chi
- Department of General Surgery, The Second Affiliated Hospital, Harbin Medical University, 148, Bao Jian Road, Harbin, 150081, China.
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Tsien C, Davuluri G, Singh D, Allawy A, Ten Have GAM, Thapaliya S, Schulze JM, Barnes D, McCullough AJ, Engelen MP, Deutz NE, Dasarathy S. Metabolic and molecular responses to leucine-enriched branched chain amino acid supplementation in the skeletal muscle of alcoholic cirrhosis. Hepatology 2015; 61:2018-29. [PMID: 25613922 PMCID: PMC4441611 DOI: 10.1002/hep.27717] [Citation(s) in RCA: 155] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 12/22/2014] [Accepted: 01/20/2015] [Indexed: 12/12/2022]
Abstract
UNLABELLED Skeletal muscle loss (sarcopenia) is a major clinical complication in alcoholic cirrhosis with no effective therapy. Skeletal muscle autophagic proteolysis and myostatin expression (inhibitor of protein synthesis) are increased in cirrhosis and believed to contribute to anabolic resistance. A prospective study was performed to determine the mechanisms of sarcopenia in alcoholic cirrhosis and potential reversal by leucine. In six well-compensated, stable, alcoholic patients with cirrhosis and eight controls, serial vastus lateralis muscle biopsies were obtained before and 7 hours after a single oral branched chain amino acid mixture enriched with leucine (BCAA/LEU). Primed-constant infusion of l-[ring-(2) H5 ]-phenylalanine was used to quantify whole-body protein breakdown and muscle protein fractional synthesis rate using liquid chromatography/mass spectrometry. Muscle expression of myostatin, mammalian target of rapamycin (mTOR) targets, autophagy markers, protein ubiquitination, and the intracellular amino acid deficiency sensor general control of nutrition 2 were quantified by immunoblots and the leucine exchanger (SLC7A5) and glutamine transporter (SLC38A2), by real-time polymerase chain reaction. Following oral administration, plasma BCAA concentrations showed a similar increase in patients with cirrhosis and controls. Skeletal muscle fractional synthesis rate was 9.63 ± 0.36%/hour in controls and 9.05 ± 0.68%/hour in patients with cirrhosis (P = 0.54). Elevated whole-body protein breakdown in patients with cirrhosis was reduced with BCAA/LEU (P = 0.01). Fasting skeletal muscle molecular markers showed increased myostatin expression, impaired mTOR signaling, and increased autophagy in patients with cirrhosis compared to controls (P < 0.01). The BCAA/LEU supplement did not alter myostatin expression, but mTOR signaling, autophagy measures, and general control of nutrition 2 activation were consistently reversed in cirrhotic muscle (P < 0.01). Expression of SLC7A5 was higher in the basal state in patients with cirrhosis than controls (P < 0.05) but increased with BCAA/LEU only in controls (P < 0.001). CONCLUSIONS Impaired mTOR1 signaling and increased autophagy in skeletal muscle of patients with alcoholic cirrhosis is acutely reversed by BCAA/LEU.
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Affiliation(s)
- Cynthia Tsien
- Departments of Gastroenterology, Toronto General Hospital, Toronto, Canada
| | | | - Dharmvir Singh
- Departments of Gastroenterology, Hepatology, Cleveland Clinic, Cleveland Ohio
| | - Allawy Allawy
- Department of Pathobiology, Cleveland Clinic, Cleveland Ohio
| | | | - Samjhana Thapaliya
- Departments of Gastroenterology, Hepatology, Cleveland Clinic, Cleveland Ohio
| | - John M Schulze
- Molecular Structure Facility, University of California, Davis, California
| | - David Barnes
- Departments of Gastroenterology, Hepatology, Cleveland Clinic, Cleveland Ohio
| | | | | | | | - Srinivasan Dasarathy
- Department of Pathobiology, Cleveland Clinic, Cleveland Ohio,Departments of Gastroenterology, Hepatology, Cleveland Clinic, Cleveland Ohio
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Salso A, De Leonardis F, Lionetti R, Lenci I, Angelico M, Telese A, Baiocchi L. Standard bowel cleansing is highly ineffective in cirrhotic patients undergoing screening colonoscopy. Dig Liver Dis 2015; 47:523-525. [PMID: 25819557 DOI: 10.1016/j.dld.2015.02.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 02/11/2015] [Accepted: 02/26/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Few data are available on tolerability and quality of standard bowel cleansing for colonoscopy in patients with chronic disease. AIM We seek to evaluate the tolerability and results of lavage solution for colonoscopy in cirrhotic patients in comparison with controls. METHODS Fifty-three cirrhotic and fifty-two normal subjects undergoing colonoscopy were prospectively enrolled in the study. Data regarding tolerability of lavage solution were harvested at the pre-procedure visit. Data on level of bowel cleansing and other endoscopic variables were recorded after the procedure. RESULTS Rate of failure to complete the prescribed bowel preparation and incidence of side effects during its administration were similar between cirrhotic and normal subjects. Despite this, cirrhotic patients exhibited an insufficient level of bowel preparation with approximately half exhibiting bad colon cleansing level (49% versus 5% control, p<0.001). CONCLUSION Alternative bowel cleansing protocols are needed for cirrhotic subjects to better match their colonoscopic screening needs.
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Affiliation(s)
- Angela Salso
- Hepatology Unit, Policlinico Tor Vergata, Rome, Italy; Interdepartmental Endoscopic Service, Policlinico Tor Vergata, Rome, Italy
| | - Francesco De Leonardis
- Hepatology Unit, Policlinico Tor Vergata, Rome, Italy; Interdepartmental Endoscopic Service, Policlinico Tor Vergata, Rome, Italy
| | | | - Ilaria Lenci
- Hepatology Unit, Policlinico Tor Vergata, Rome, Italy
| | | | - Andrea Telese
- Hepatology Unit, Policlinico Tor Vergata, Rome, Italy
| | - Leonardo Baiocchi
- Hepatology Unit, Policlinico Tor Vergata, Rome, Italy; Interdepartmental Endoscopic Service, Policlinico Tor Vergata, Rome, Italy.
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Bémeur C, Butterworth RF. Reprint of: Nutrition in the Management of Cirrhosis and its Neurological Complications. J Clin Exp Hepatol 2015; 5:S131-40. [PMID: 26041952 PMCID: PMC4442848 DOI: 10.1016/j.jceh.2015.02.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 05/19/2013] [Indexed: 12/12/2022] Open
Abstract
Malnutrition is a common feature of chronic liver diseases that is often associated with a poor prognosis including worsening of clinical outcome, neuropsychiatric complications as well as outcome following liver transplantation. Nutritional assessment in patients with cirrhosis is challenging owing to confounding factors related to liver failure. The objectives of nutritional intervention in cirrhotic patients are the support of liver regeneration, the prevention or correction of specific nutritional deficiencies and the prevention and/or treatment of the complications of liver disease per se and of liver transplantation. Nutritional recommendations target the optimal supply of adequate substrates related to requirements linked to energy, protein, carbohydrates, lipids, vitamins and minerals. Some issues relating to malnutrition in chronic liver disease remain to be addressed including the development of an appropriate well-validated nutritional assessment tool, the identification of mechanistic targets or therapy for sarcopenia, the development of nutritional recommendations for obese cirrhotic patients and liver-transplant recipients and the elucidation of the roles of vitamin A hepatotoxicity, as well as the impact of deficiencies in riboflavin and zinc on clinical outcomes. Early identification and treatment of malnutrition in chronic liver disease has the potential to lead to better disease outcome as well as prevention of the complications of chronic liver disease and improved transplant outcomes.
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Key Words
- AAAs, aromatic amino acids
- BCAAs, branched-chain amino acids
- BMI, body mass index
- CNS, central nervous system
- CONUT, controlling nutritional status
- HE, hepatic encephalopathy
- ISHEN, International Society for Hepatic Encephalopathy and Nitrogen metabolism
- NAFLD, non-alcoholic fatty liver disease
- NASH, non-alcoholic steato-hepatitis
- PNI, prognostic nutritional index
- complications
- hepatic encephalopathy
- liver disease
- liver transplantation
- nutritional status
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Affiliation(s)
- Chantal Bémeur
- Département de nutrition, Faculté de médecine, Université de Montréal, Montréal, Canada
- Unité de recherche en sciences neurologiques, Hôpital Saint-Luc (CHUM), Université de Montréal, Montréal, Canada
| | - Roger F. Butterworth
- Unité de recherche en sciences neurologiques, Hôpital Saint-Luc (CHUM), Université de Montréal, Montréal, Canada
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Gowda C, Compher C, Amorosa VK, Re VL. Association between chronic hepatitis C virus infection and low muscle mass in US adults. J Viral Hepat 2014; 21:938-43. [PMID: 24989435 PMCID: PMC4236264 DOI: 10.1111/jvh.12273] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Accepted: 05/17/2014] [Indexed: 12/15/2022]
Abstract
Given that low muscle mass can lead to worse health outcomes in patients with chronic infections, we assessed whether chronic hepatitis C virus (HCV) infection was associated with low muscle mass among US adults. We performed a cross-sectional study of the National Health Examination and Nutrition Study (1999-2010). Chronic HCV-infected patients had detectable HCV RNA. Low muscle mass was defined as <10th percentile for mid-upper arm circumference (MUAC). Multivariable logistic regression was used to determine adjusted odds ratios (aORs) with 95% confidence intervals (CIs) of low muscle mass associated with chronic HCV. Among 18 513 adults, chronic HCV-infected patients (n = 303) had a higher prevalence of low muscle mass than uninfected persons (13.8% vs 6.7%; aOR, 2.22; 95% CI, 1.39-3.56), and this association remained when analyses were repeated among persons without significant liver fibrosis (aOR, 2.12; 95% CI, 1.30-3.47). This study demonstrates that chronic HCV infection is associated with low muscle mass, as assessed by MUAC measurements, even in the absence of advanced liver disease.
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Affiliation(s)
- Charitha Gowda
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA (C.G., V.K.A., V.L.R.), Department of Biostatistics and Epidemiology and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA (C.G., V.L.R.)
| | - Charlene Compher
- Department of Nutrition, University of Pennsylvania School of Nursing, Philadelphia, PA (C.C.)
| | - Valerianna K. Amorosa
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA (C.G., V.K.A., V.L.R.), Philadelphia Veterans Affairs Medical Center, Philadelphia, PA (V.K.A.)
| | - Vincent Lo Re
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA (C.G., V.K.A., V.L.R.), Department of Biostatistics and Epidemiology and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA (C.G., V.L.R.)
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Kalaitzakis E. Gastrointestinal dysfunction in liver cirrhosis. World J Gastroenterol 2014; 20:14686-14695. [PMID: 25356031 PMCID: PMC4209534 DOI: 10.3748/wjg.v20.i40.14686] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 04/27/2014] [Accepted: 06/05/2014] [Indexed: 02/06/2023] Open
Abstract
Patients with liver cirrhosis exhibit several features of gut dysfunction which may contribute to the development of cirrhosis complications as well as have an impact on nutritional status and health-related quality of life. Gastrointestinal symptoms are common in cirrhosis and their pathophysiology probably involves factors related to liver disease severity, psychological distress, and gut dysfunction (e.g., increased gastric sensitivity to distension and delayed gut transit). They may lead to reduced food intake and, thus, may contribute to the nutritional status deterioration in cirrhotic patients. Although tense ascites appears to have a negative impact on meal-induced accommodation of the stomach, published data on gastric accommodation in cirrhotics without significant ascites are not unanimous. Gastric emptying and small bowel transit have generally been shown to be prolonged. This may be related to disturbances in postprandial glucose, insulin, and ghrelin levels, which, in turn, appear to be associated to insulin resistance, a common finding in cirrhosis. Furthermore, small bowel manometry disturbances and delayed gut transit may be associated with the development of small bowel bacterial overgrowth. Finally, several studies have reported intestinal barrier dysfunction in patients with cirrhosis (especially those with portal hypertension), which is related to bacterial translocation and permeation of intestinal bacterial products, e.g., endotoxin and bacterial DNA, thus potentially being involved in the pathogenesis of complications of liver cirrhosis.
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Abstract
Liver transplantation (LT) is a major surgery performed on patients with end stage liver disease. Nutrition is an integral part of patient care, and protein-energy malnutrition is almost universally present in patients suffering from liver disease undergoing LT. Nutrition assessment of preliver transplant phase helps to make a good nutrition care plan for the patients. Nutrition status has been associated with various factors which are related to the success of liver transplant such as morbidity, mortality, and length of hospital stay. To assess the nutritional status of preliver transplant patients, combinations of nutrition assessment methods should be used like subjective global assessment, Anthropometry mid arm-muscle circumference, Bioelectrical impedance analysis (BIA) and handgrip strength.
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Affiliation(s)
- Neha Bakshi
- Lady Irwin College, Department of Foods and Nutrition, University of Delhi, New Delhi, India
| | - Kalyani Singh
- Lady Irwin College, Department of Foods and Nutrition, University of Delhi, New Delhi, India
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Vulcano DSB, Carvalhaes MADBL, Bakonyi Neto A. Evaluation of nutritional indicators and body composition in patients with advanced liver disease enrolled for liver transplantation. Acta Cir Bras 2014; 28:733-9. [PMID: 24114303 DOI: 10.1590/s0102-86502013001000008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 09/10/2013] [Indexed: 01/12/2023] Open
Abstract
PURPOSE Malnutrition is prevalent in patients with advanced liver disease (LD) related to multifactorial causes. Fluid retention can underestimate the nutritional status based on anthropometric measures. We evaluated nutritional indicators and body composition (BC) in patients with liver cirrhosis and correlated them with LD severity. METHODS Forty three patients with LD enrolled for liver transplantation were evaluated by Anthropometric measures, subjective evaluation (Global Assessment of Nutritional Status - SGA) and biochemical indicators. Single-frequency electrical bioimpedance (SFE-BIA) was used to evaluate body composition (BC). It measured resistance (R), reactance (Xc) and the phase angle (PA). LD severity was estimated by Child-Pugh and Meld criteria (Model for End-Stage Liver Disease). RESULTS Child-Pugh index between patients was 7.11 ± 1.70 and Meld was 12.23 ± 4.22. Arm Circumference, Arm Muscle Circumference and Arm Muscle Area, SGA, hemoglobin, hematocrit and albumin showed better correlation with disease severity. Xc and PA showed correlation both with Meld and Child-Pugh score when BC were evaluated. PA was depleted in 55.8% of the patients. CONCLUSIONS Diagnosis of malnutrition varied according to the method. Global assessment of nutritional status showed better correlation with disease severity than with objective methods. Single-frequency electrical bioimpedance for body composition analysis in cirrhotic patients must be cautiously used; however, primary vectors seems to be valid and promising in clinical practice.
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Bémeur C, Butterworth RF. Nutrition in the management of cirrhosis and its neurological complications. J Clin Exp Hepatol 2014; 4:141-50. [PMID: 25755550 PMCID: PMC4116712 DOI: 10.1016/j.jceh.2013.05.008] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 05/19/2013] [Indexed: 12/12/2022] Open
Abstract
Malnutrition is a common feature of chronic liver diseases that is often associated with a poor prognosis including worsening of clinical outcome, neuropsychiatric complications as well as outcome following liver transplantation. Nutritional assessment in patients with cirrhosis is challenging owing to confounding factors related to liver failure. The objectives of nutritional intervention in cirrhotic patients are the support of liver regeneration, the prevention or correction of specific nutritional deficiencies and the prevention and/or treatment of the complications of liver disease per se and of liver transplantation. Nutritional recommendations target the optimal supply of adequate substrates related to requirements linked to energy, protein, carbohydrates, lipids, vitamins and minerals. Some issues relating to malnutrition in chronic liver disease remain to be addressed including the development of an appropriate well-validated nutritional assessment tool, the identification of mechanistic targets or therapy for sarcopenia, the development of nutritional recommendations for obese cirrhotic patients and liver-transplant recipients and the elucidation of the roles of vitamin A hepatotoxicity, as well as the impact of deficiencies in riboflavin and zinc on clinical outcomes. Early identification and treatment of malnutrition in chronic liver disease has the potential to lead to better disease outcome as well as prevention of the complications of chronic liver disease and improved transplant outcomes.
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Key Words
- AAAs, aromatic amino acids
- BCAAs, branched-chain amino acids
- BMI, body mass index
- CNS, central nervous system
- CONUT, controlling nutritional status
- HE, hepatic encephalopathy
- ISHEN, International Society for Hepatic Encephalopathy and Nitrogen metabolism
- NAFLD, non-alcoholic fatty liver disease
- NASH, non-alcoholic steato-hepatitis
- PNI, prognostic nutritional index
- complications
- hepatic encephalopathy
- liver disease
- liver transplantation
- nutritional status
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Affiliation(s)
- Chantal Bémeur
- Département de nutrition, Faculté de médecine, Université de Montréal, Montréal, Canada ; Unité de recherche en sciences neurologiques, Hôpital Saint-Luc (CHUM), Université de Montréal, Montréal, Canada
| | - Roger F Butterworth
- Unité de recherche en sciences neurologiques, Hôpital Saint-Luc (CHUM), Université de Montréal, Montréal, Canada
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Dasarathy S. Treatment to improve nutrition and functional capacity evaluation in liver transplant candidates. ACTA ACUST UNITED AC 2014; 12:242-55. [PMID: 24691782 DOI: 10.1007/s11938-014-0016-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OPINION STATEMENT Liver transplantation is the definitive therapy for cirrhosis, and malnutrition is the most frequent complication in these patients. Sarcopenia or loss of muscle mass is the major component of malnutrition in cirrhotics and adversely affects their outcome. In addition to the metabolic consequences, functional consequences of sarcopenia include reduced muscle strength and deconditioning. Despite nearly universal occurrence of sarcopenia and its attendant complications, there are no established therapies to prevent or reverse the same. Major reasons for this deficiency include the lack of established standardized definitions or measures to quantify muscle mass, as well as paucity of mechanistic studies or identified molecular targets to develop specific therapeutic interventions. Anthropometric evaluation, bioelectrical impedance analysis, and DEXA scans are relatively imprecise measures of muscle mass, and recent data on imaging measures to determine muscle mass accurately are likely to allow well-defined outcome responses to treatments. Resurgence of interest in the mechanisms of muscle loss in liver disease has been directly related to the rapid advances in the field of muscle biology. Metabolic tracer studies on whole body kinetics have been complemented by direct studies on the skeletal muscle of cirrhotics. Hypermetabolism and anabolic resistance contribute to sarcopenia. Reduced protein synthesis and increased autophagy have been reported in cirrhotic skeletal muscle, while the contribution of the ubiquitin-proteasome pathway is controversial. Increased plasma concentration and skeletal muscle expression of myostatin, a TGFβ superfamily member that causes reduction in muscle mass, have been reported in cirrhosis. Hyperammonemia and TNFα have been reported to increase myostatin expression and may be responsible for sarcopenia in cirrhosis. Nutriceutical interventions with leucine enriched amino acid mixtures, myostatin antagonists and physical activity hold promise as measures to reverse sarcopenia. There is even less data on muscle function and deconditioning in cirrhosis and studies in this area are urgently needed. Even though macronutrient replacement is a major therapeutic goal, micronutrient supplementation, specifically vitamin D, is expected to improve outcomes.
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Affiliation(s)
- Srinivasan Dasarathy
- Lerner Research Institute, NE4 208, 9500 Euclid Avenue, Cleveland, OH, 44195, USA,
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Thapaliya S, Runkana A, McMullen MR, Nagy LE, McDonald C, Naga Prasad SV, Dasarathy S. Alcohol-induced autophagy contributes to loss in skeletal muscle mass. Autophagy 2014; 10:677-90. [PMID: 24492484 DOI: 10.4161/auto.27918] [Citation(s) in RCA: 115] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Patients with alcoholic cirrhosis and hepatitis have severe muscle loss. Since ethanol impairs skeletal muscle protein synthesis but does not increase ubiquitin proteasome-mediated proteolysis, we investigated whether alcohol-induced autophagy contributes to muscle loss. Autophagy induction was studied in: A) Human skeletal muscle biopsies from alcoholic cirrhotics and controls, B) Gastrocnemius muscle from ethanol and pair-fed mice, and C) Ethanol-exposed murine C2C12 myotubes, by examining the expression of autophagy markers assessed by immunoblotting and real-time PCR. Expression of autophagy genes and markers were increased in skeletal muscle from humans and ethanol-fed mice, and in myotubes following ethanol exposure. Importantly, pulse-chase experiments showed suppression of myotube proteolysis upon ethanol-treatment with the autophagy inhibitor, 3-methyladenine (3MA) and not by MG132, a proteasome inhibitor. Correspondingly, ethanol-treated C2C12 myotubes stably expressing GFP-LC3B showed increased autophagy flux as measured by accumulation of GFP-LC3B vesicles with confocal microscopy. The ethanol-induced increase in LC3B lipidation was reversed upon knockdown of Atg7, a critical autophagy gene and was associated with reversal of the ethanol-induced decrease in myotube diameter. Consistently, CT image analysis of muscle area in alcoholic cirrhotics was significantly reduced compared with control subjects. In order to determine whether ethanol per se or its metabolic product, acetaldehyde, stimulates autophagy, C2C12 myotubes were treated with ethanol in the presence of the alcohol dehydrogenase inhibitor (4-methylpyrazole) or the acetaldehyde dehydrogenase inhibitor (cyanamide). LC3B lipidation increased with acetaldehyde treatment and increased further with the addition of cyanamide. We conclude that muscle autophagy is increased by ethanol exposure and contributes to sarcopenia.
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Affiliation(s)
| | - Ashok Runkana
- Department of Pathobiology; Cleveland Clinic; Cleveland, OH USA; Department of Internal Medicine; Fairview Hospital; Cleveland, OH USA
| | | | - Laura E Nagy
- Department of Pathobiology; Cleveland Clinic; Cleveland, OH USA; Department of Gastroenterology and Hepatology; Cleveland Clinic; Cleveland, OH USA
| | | | | | - Srinivasan Dasarathy
- Department of Pathobiology; Cleveland Clinic; Cleveland, OH USA; Department of Gastroenterology and Hepatology; Cleveland Clinic; Cleveland, OH USA
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Deved V, Jette N, Quan H, Tonelli M, Manns B, Soo A, Barnabe C, Hemmelgarn BR, for the Alberta Kidney Disease Network. Quality of care for First Nations and non-First Nations People with diabetes. Clin J Am Soc Nephrol 2013; 8:1188-94. [PMID: 23449766 PMCID: PMC3700698 DOI: 10.2215/cjn.10461012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Accepted: 01/28/2013] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Compared with non-First Nations, First Nations People with diabetes experience higher rates of kidney failure and death, which may be related to disparities in care. This study examined First Nations and non-First Nations People with diabetes for differences in quality indicators and their association with kidney failure and death. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Adults with diabetes and an outpatient creatinine in Alberta from 2005 to 2008 were identified. Logistic regression was used to determine the likelihood of process of care indicators (measurement of urine albumin/creatinine ratio [ACR], LDL, and hemoglobin A1C [A1C]) and surrogate outcome indicators (achievement of LDL and A1C targets). Cox regression was used to determine the association between lack of achievement of indicator targets and each of kidney failure and death. RESULTS This study identified 140,709 non-First Nations and 6574 First Nations People with diabetes. There was a significant interaction between First Nations status and CKD for the outcomes (P<0.01); therefore, results are stratified by CKD. Among participants without CKD, First Nations People were less likely to receive process of care indicators and achieve target A1C compared with non-First Nations People. For those with CKD, First Nations People were as likely to receive these indicators (other than LDL) and achieve LDL and A1C targets. Lack of LDL and A1C assessment and achievement of targets were associated with increased risk of kidney failure and death similarly for both groups. CONCLUSIONS Compared with non-First Nations, First Nations People with diabetes but without CKD experience disparities in assessment of quality indicators and achievement of A1C target.
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Affiliation(s)
- Vinay Deved
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; and
| | - Nathalie Jette
- Departments of Clinical Neurosciences
- Community Health Sciences, and
| | | | - Marcello Tonelli
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; and
| | - Braden Manns
- Community Health Sciences, and
- Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Cheryl Barnabe
- Community Health Sciences, and
- Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Brenda R. Hemmelgarn
- Community Health Sciences, and
- Medicine, University of Calgary, Calgary, Alberta, Canada
| | - for the Alberta Kidney Disease Network
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; and
- Departments of Clinical Neurosciences
- Community Health Sciences, and
- Medicine, University of Calgary, Calgary, Alberta, Canada
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