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Takada H, Osawa L, Komiyama Y, Muraoka M, Suzuki Y, Sato M, Kobayashi S, Yoshida T, Takano S, Maekawa S, Enomoto N. Imaging-based assessment of muscles and malnutrition predict prognosis in patients with primary hepatocellular carcinoma. PLoS One 2025; 20:e0307458. [PMID: 40273113 PMCID: PMC12021244 DOI: 10.1371/journal.pone.0307458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2024] [Accepted: 02/26/2025] [Indexed: 04/26/2025] Open
Abstract
BACKGROUND The significance of imaging-based assessment of muscles and malnutrition in patients with primary hepatocellular carcinoma (HCC) remains unclear. This study aimed to elucidate the prognostic role of the combination of Low Muscle Volume and Value (LMVV) and malnutrition. METHODS A total of 714 Child-Pugh grade A/ B patients with first-diagnosed HCC were enrolled, and analyzed factors associated with overall survival. LMVV was defined using psoas muscle mass index and computed tomography values of multifidus muscle at the level of the third lumbar vertebra. We used hypoalbuminemia, Child-Pugh grade B, Subjective Global Assessment (SGA) grade B/C, and Royal Free Hospital Nutrition Prioritizing Tool (RFH-NPT) score > 2 as malnutrition factors in this study. RESULTS At baseline, 29% showed LMVV, and 59% met one or more of the malnutrition criteria. No items meeting the criteria of LMVV and malnutrition was observed in 41%, 1 of them was found in 29%, and both were found in 29%. The number of items meeting criteria was an independent factor for a shorter survival. The frequency of liver-related deaths did not differ by presence of LMVV alone, while it was associated with malnutrition. In contrast, the incidence of other types of deaths was influenced by LMVV and malnutrition. CONCLUSIONS The combination of LMVV and malnutrition is a prognostic factor in patients with primary HCC.
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Affiliation(s)
- Hitomi Takada
- Gastroenterology and Hepatology Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Leona Osawa
- Gastroenterology and Hepatology Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Yasuyuki Komiyama
- Gastroenterology and Hepatology Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Masaru Muraoka
- Gastroenterology and Hepatology Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Yuichiro Suzuki
- Gastroenterology and Hepatology Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Mitsuaki Sato
- Gastroenterology and Hepatology Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Shoji Kobayashi
- Gastroenterology and Hepatology Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Takashi Yoshida
- Gastroenterology and Hepatology Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Shinichi Takano
- Gastroenterology and Hepatology Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Shinya Maekawa
- Gastroenterology and Hepatology Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Nobuyuki Enomoto
- Gastroenterology and Hepatology Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
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Miwa T, Hanai T, Nishimura K, Hirata S, Unome S, Nakahata Y, Imai K, Suetsugu A, Takai K, Shimizu M. Nutritional assessment using subjective global assessment identifies energy malnutrition and predicts mortality in patients with liver cirrhosis. Sci Rep 2025; 15:4831. [PMID: 39924549 PMCID: PMC11808070 DOI: 10.1038/s41598-025-89803-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 02/07/2025] [Indexed: 02/11/2025] Open
Abstract
This study aimed to evaluate whether the subjective global assessment (SGA) could effectively predict energy malnutrition, as assessed by indirect calorimetry, and mortality in hospitalized patients with cirrhosis. Energy malnutrition was defined by a nonprotein respiratory quotient (npRQ) < 0.85 using an indirect calorimetry. The usefulness of the SGA in identifying energy malnutrition and predicting mortality was assessed by the logistic regression and Cox proportional hazards models, respectively. Out of the 230 patients analyzed, 43% were found to have energy malnutrition. The distribution of SGA classifications was 54% for SGA-A, 32% for SGA-B, and 14% for SGA-C. Multivariable analysis indicated that both SGA-B (odds ratio, 3.59; 95% confidence interval [CI], 1.59-8.10) and SGA-C (odds ratio, 19.70; 95% CI, 3.46-112.00), along with free fatty acids (FFA), were independently linked to energy malnutrition. Regarding mortality, 125 patients (54%) died over a median follow-up period of 2.8 years. After adjustment, SGA-B (hazard ratio, 1.81; 95% CI, 1.08-3.03) and SGA-C (hazard ratio, 3.35; 95% CI, 1.28-8.76) were predictors of mortality in cirrhosis patients, while energy malnutrition and FFA were not. The SGA is a valuable tool for identifying energy malnutrition and predicting mortality in patients with cirrhosis.
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Affiliation(s)
- Takao Miwa
- Department of Gastroenterology/Internal Medicine, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan.
| | - Tatsunori Hanai
- Department of Gastroenterology/Internal Medicine, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Kayoko Nishimura
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Sachiyo Hirata
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Shinji Unome
- Department of Gastroenterology/Internal Medicine, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Yuki Nakahata
- Department of Gastroenterology/Internal Medicine, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan
- Department of Gastroenterology, Asahi University Hospital, Gifu, Japan
| | - Kenji Imai
- Department of Gastroenterology/Internal Medicine, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Atsushi Suetsugu
- Department of Gastroenterology/Internal Medicine, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Koji Takai
- Department of Gastroenterology/Internal Medicine, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan
- Division for Regional Cancer Control, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Masahito Shimizu
- Department of Gastroenterology/Internal Medicine, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan
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He Y, Hu L, Wu S, Li L, Zhong K, Li J, Liu N, Sun X, Wang Q, Sun C, Wu L. Nutritional screening and assessment tools for patients with cirrhosis based on the Global Leadership Initiative on Malnutrition criteria. J Hum Nutr Diet 2024; 37:430-439. [PMID: 37932103 DOI: 10.1111/jhn.13265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 11/03/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Malnutrition is highly prevalent and associated with complications and mortality in patients with cirrhosis. METHODS This was a prospective observational study. Patients with cirrhosis were screened using the Nutritional Risk Screening 2002, the Royal Free Hospital-Nutritional Prioritizing Tool and the Skeletal Muscle Index. Then, the sensitivity, specificity, positive and negative predictive values, and consistency with the Global Leadership Initiative on Malnutrition criteria results were calculated. We also analysed the association between nutritional status and short-term prognosis. RESULTS We enrolled 125 patients with cirrhosis, of whom 59.20% and 60.00% were malnourished based on the Global Leadership Initiative on Malnutrition criteria and Skeletal Muscle Index. Some 53.60% and 65.60%, respectively, were classified medium-to-high nutritional risk by Nutritional Risk Screening 2002 and the Royal Free Hospital-Nutritional Prioritizing Tool. The Royal Free Hospital-Nutritional Prioritizing Tool had the best predictive value, and it was more sensitive and had a better negative predictive value than the Nutritional Risk Screening 2002 Tool. The Skeletal Muscle Index also had good sensitivity and predictive value. The Royal Free Hospital-Nutritional Prioritizing Tool, Skeletal Muscle Index and Global Leadership Initiative on Malnutrition criteria showed high concordance. The 3- and 6-month mortality rates were significantly higher for patients with moderate-to-high nutritional risk or malnutrition, regardless of the tool. CONCLUSIONS When assessing cirrhosis with the Global Leadership Initiative on Malnutrition criteria, the Royal Free Hospital-Nutritional Prioritizing Tool is best for nutritional screening and the Skeletal Muscle Index is also a good nutritional assessment tool.
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Affiliation(s)
- Yumei He
- North Sichuan Medical College, Nanchong, China
- Department of Gastroenterology, The Third People's Hospital of Chengdu, Chengdu, China
| | - Ling Hu
- Department of Gastroenterology, The Third People's Hospital of Chengdu, Chengdu, China
| | - Shiyan Wu
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Lu Li
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Ke Zhong
- Department of Gastroenterology, The Third People's Hospital of Chengdu, Chengdu, China
| | - Jiazhen Li
- Department of Clinical Nutrition, The Third People's Hospital of Chengdu, Chengdu, China
| | - Na Liu
- Department of Radiology, The Third People's Hospital of Chengdu, Chengdu, China
| | - Xiaobin Sun
- Department of Gastroenterology, The Third People's Hospital of Chengdu, Chengdu, China
| | - Qiong Wang
- Department of Gastroenterology, The Third People's Hospital of Chengdu, Chengdu, China
| | - Chao Sun
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
| | - Liping Wu
- Department of Gastroenterology, The Third People's Hospital of Chengdu, Chengdu, China
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Matsui M, Asai A, Ushiro K, Onishi S, Nishikawa T, Ohama H, Tsuchimoto Y, Kim SK, Nishikawa H. Prognostic Nutritional Index Correlates with Liver Function and Prognosis in Chronic Liver Disease Patients. Diagnostics (Basel) 2023; 14:49. [PMID: 38201358 PMCID: PMC10802838 DOI: 10.3390/diagnostics14010049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 12/23/2023] [Accepted: 12/23/2023] [Indexed: 01/12/2024] Open
Abstract
The Prognostic Nutritional Index (PNI) is widely recognized as a screening tool for nutrition. We retrospectively examined the impact of PNI in patients with chronic liver disease (CLD, n = 319, median age = 71 years, 153 hepatocellular carcinoma (HCC) patients) as an observational study. Factors associated with PNI < 40 were also examined. The PNI correlated well with the albumin-bilirubin (ALBI) score and ALBI grade. The 1-year cumulative overall survival rates in patients with PNI ≥ 40 (n = 225) and PNI < 40 (n = 94) were 93.2% and 65.5%, respectively (p < 0.0001). In patients with (p < 0.0001) and without (p < 0.0001) HCC, similar tendencies were found. In the multivariate analysis, hemoglobin (p = 0.00178), the presence of HCC (p = 0.0426), and ALBI score (p < 0.0001) were independent factors linked to PNI < 40. Receiver operating characteristic (ROC) curve analysis based on survival for the PNI yielded an area under the ROC curve of 0.79, with sensitivity of 0.80, specificity of 0.70, and an optimal cutoff point of 42.35. In conclusion, PNI can be a predictor of nutritional status in CLD patients. A PNI of <40 can be useful in predicting the prognosis of patients with CLD.
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Affiliation(s)
- Masahiro Matsui
- The Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Takatsuki 569-8686, Osaka, Japan
| | - Akira Asai
- The Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Takatsuki 569-8686, Osaka, Japan
- Liver Center, Osaka Medical and Pharmaceutical University, Takatsuki 569-8686, Osaka, Japan
| | - Kosuke Ushiro
- The Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Takatsuki 569-8686, Osaka, Japan
| | - Saori Onishi
- The Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Takatsuki 569-8686, Osaka, Japan
| | - Tomohiro Nishikawa
- The Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Takatsuki 569-8686, Osaka, Japan
| | - Hideko Ohama
- The Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Takatsuki 569-8686, Osaka, Japan
| | - Yusuke Tsuchimoto
- The Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Takatsuki 569-8686, Osaka, Japan
| | - Soo Ki Kim
- Department of Gastroenterology, Kobe Asahi Hospital, Kobe 653-8501, Hyogo, Japan
| | - Hiroki Nishikawa
- The Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Takatsuki 569-8686, Osaka, Japan
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Espinosa-Flores AJ, Guzman-Ortiz E, Melendez-Mier G, Ternovoy SK, Bueno-Hernandez N, Roldan-Valadez E. A scoping review of the methods used in patients with liver cirrhosis to assess body composition and their nutritional findings. Eur J Clin Nutr 2023; 77:845-854. [PMID: 37095222 DOI: 10.1038/s41430-023-01287-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/07/2023] [Accepted: 04/13/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND AND OBJECTIVES Body composition (BC) assessment in cirrhosis has a wide variety of methods with no consensus on the best tools for each body component in patients with Liver Cirrhosis (LC). We aimed to conduct a systematic scoping review of the most frequent body composition analysis methods and nutritional findings published in liver cirrhosis patients. METHODS We searched for articles in PubMed, Scopus, and ISI Web of Science databases. Keywords selected the BC methods and parameters in LC. RESULTS Eleven methods were found. The most frequently used were computed tomography (CT) 47.5%, Bioimpedance Analysis 35%, DXA 32.5%, and anthropometry 32.5%. Up to 15 BC parameters were reported from each method. CONCLUSIONS The vast heterogeneity in the results found during the qualitative analysis and imaging methods must reach a consensus to achieve a better clinical practice and improve nutritional treatment, as the physiopathology in LC compromises the nutritional status directly.
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Affiliation(s)
- Aranza-Jhosadara Espinosa-Flores
- Laboratory for Proteomics and Metabolomics, Research Division, Hospital General de Mexico "Dr Eduardo Liceaga,", 06720, Mexico City, Mexico
| | - Elizabeth Guzman-Ortiz
- Department of Nursing and Obstetrics, Universidad de Guanajuato, 36000, Celaya City, Mexico
| | | | - Sergey K Ternovoy
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Department of Radiology, 119992, Moscow, Russia
- A.L. Myasnikov Research Institute of Clinical Cardiology of National Medical Research Center of Cardiology of the Ministry of Health of Russia, 127005, Moscow, Russia
| | - Nallely Bueno-Hernandez
- Laboratory for Proteomics and Metabolomics, Research Division, Hospital General de Mexico "Dr Eduardo Liceaga,", 06720, Mexico City, Mexico.
| | - Ernesto Roldan-Valadez
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Department of Radiology, 119992, Moscow, Russia.
- Directorate of Research, Hospital General de Mexico "Dr Eduardo Liceaga", 06720, Mexico City, Mexico.
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Yu L, Yousuf S, Yousuf S, Yeh J, Biggins SW, Morishima C, Shyu I, O’Shea-Stone G, Eilers B, Waldum A, Copié V, Burkhead J. Copper deficiency is an independent risk factor for mortality in patients with advanced liver disease. Hepatol Commun 2023; 7:e0076. [PMID: 36809345 PMCID: PMC9949837 DOI: 10.1097/hc9.0000000000000076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 11/17/2022] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND AND AIM Copper is an essential trace metal serving as a cofactor in innate immunity, metabolism, and iron transport. We hypothesize that copper deficiency may influence survival in patients with cirrhosis through these pathways. METHODS We performed a retrospective cohort study involving 183 consecutive patients with cirrhosis or portal hypertension. Copper from blood and liver tissues was measured using inductively coupled plasma mass spectrometry. Polar metabolites were measured using nuclear magnetic resonance spectroscopy. Copper deficiency was defined by serum or plasma copper below 80 µg/dL for women or 70 µg/dL for men. RESULTS The prevalence of copper deficiency was 17% (N=31). Copper deficiency was associated with younger age, race, zinc and selenium deficiency, and higher infection rates (42% vs. 20%, p=0.01). Serum copper correlated positively with albumin, ceruloplasmin, hepatic copper, and negatively with IL-1β. Levels of polar metabolites involved in amino acids catabolism, mitochondrial transport of fatty acids, and gut microbial metabolism differed significantly according to copper deficiency status. During a median follow-up of 396 days, mortality was 22.6% in patients with copper deficiency compared with 10.5% in patients without. Liver transplantation rates were similar (32% vs. 30%). Cause-specific competing risk analysis showed that copper deficiency was associated with a significantly higher risk of death before transplantation after adjusting for age, sex, MELD-Na, and Karnofsky score (HR: 3.40, 95% CI, 1.18-9.82, p=0.023). CONCLUSIONS In advanced cirrhosis, copper deficiency is relatively common and is associated with an increased infection risk, a distinctive metabolic profile, and an increased risk of death before transplantation.
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Affiliation(s)
- Lei Yu
- Department of Medicine, Division of Gastroenterology and Center for Liver Investigation Fostering Discovery, University of Washington, Seattle, Washington, USA
| | - Sarim Yousuf
- College of Medicine, Ziauddin University, Karachi, Pakistan
| | - Shahrukh Yousuf
- Department of Medicine, Division of Gastroenterology and Center for Liver Investigation Fostering Discovery, University of Washington, Seattle, Washington, USA
| | - Jeffrey Yeh
- Department of Medicine, Division of Gastroenterology and Center for Liver Investigation Fostering Discovery, University of Washington, Seattle, Washington, USA
| | - Scott W. Biggins
- Department of Medicine, Division of Gastroenterology and Center for Liver Investigation Fostering Discovery, University of Washington, Seattle, Washington, USA
| | - Chihiro Morishima
- Department of Lab Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Irene Shyu
- Department of Lab Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Galen O’Shea-Stone
- Department of Chemistry, Montana State University, Bozeman, Montana, USA
| | - Brian Eilers
- Department of Chemistry, Montana State University, Bozeman, Montana, USA
| | - Annie Waldum
- Department of Chemistry, Montana State University, Bozeman, Montana, USA
| | - Valérie Copié
- Department of Chemistry, Montana State University, Bozeman, Montana, USA
| | - Jason Burkhead
- Department of Biological Sciences, University of Alaska Anchorage, Anchorage, Alaska, USA
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Chapman B, Goh SK, Parker F, Romero S, Sinclair M, Gow P, Ma R, Angus P, Jones R, Luke J, Muralidharan V, Testro A. Malnutrition and low muscle strength are independent predictors of clinical outcomes and healthcare costs after liver transplant. Clin Nutr ESPEN 2022; 48:210-219. [PMID: 35331494 DOI: 10.1016/j.clnesp.2022.02.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 02/14/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND & AIMS Malnutrition and sarcopenia are associated with increased morbidity and mortality in cirrhosis but conflicting data are reported after liver transplantation (LT), with little known about the economic burden of malnutrition at LT. This study aims to investigate the impact of pre-transplant malnutrition and muscle strength on post-transplant clinical outcomes and healthcare costs. METHODS Pre-transplant nutritional status (via subjective global assessment, SGA) and handgrip strength (HGS) were assessed in patients transplanted from 2009-2017. Descriptive statistics and regression analysis were used to analyse the association between nutrition and muscle function with post-LT clinical outcomes and hospital costs. RESULTS 373 patients (70% male, median age 55 [IQR: 47, 60]) were transplanted, with 79% malnourished and mean HGS 31.4 ± 9.35 kg for males and 17.6 ± 5.78 kg for females. Malnutrition and reduced HGS independently predicted adverse post-transplant outcomes. ICU length of stay (LOS) was associated with severe malnutrition (HR (time to discharge (TTD)) 0.706, p = 0.014) and low HGS (HR (TTD) 0.692, p = 0.003); hospital LOS with severe malnutrition (HR (TTD) 0.759, p = 0.049) and low HGS (HR (TTD) 0.730, p = 0.011), and post-transplant infection with severe malnutrition (OR 1.76, p = 0.042) and low HGS (OR 1.83, p = 0.015). Accordingly, hospital costs were 30% higher in severely malnourished compared to well-nourished recipients (p = 0.012). Neither malnutrition or impaired HGS were associated with post-transplant mortality. CONCLUSIONS This large cohort study demonstrates malnutrition and muscle weakness are independently associated with early post-transplant morbidity, namely infection and ICU and hospital LOS; with significantly increased hospital costs. Strategies to combat malnutrition and deconditioning pre-transplant may improve patient and health system outcomes after LT.
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Affiliation(s)
- Brooke Chapman
- Nutrition and Dietetics Department, Austin Health, Melbourne, Australia; The University of Melbourne, Melbourne, Australia.
| | - Su Kah Goh
- The University of Melbourne, Melbourne, Australia; Liver Transplant Unit, Austin Health, Melbourne, Australia.
| | - Frank Parker
- The University of Melbourne, Melbourne, Australia.
| | - Sarah Romero
- Liver Transplant Unit, Austin Health, Melbourne, Australia.
| | - Marie Sinclair
- The University of Melbourne, Melbourne, Australia; Liver Transplant Unit, Austin Health, Melbourne, Australia.
| | - Paul Gow
- The University of Melbourne, Melbourne, Australia; Liver Transplant Unit, Austin Health, Melbourne, Australia.
| | - Ronald Ma
- The University of Melbourne, Melbourne, Australia.
| | - Peter Angus
- The University of Melbourne, Melbourne, Australia; Liver Transplant Unit, Austin Health, Melbourne, Australia.
| | - Robert Jones
- The University of Melbourne, Melbourne, Australia; Liver Transplant Unit, Austin Health, Melbourne, Australia.
| | - Jacqueline Luke
- Physiotherapy Department, Austin Health, Melbourne, Australia.
| | - Vijayaragavan Muralidharan
- The University of Melbourne, Melbourne, Australia; Liver Transplant Unit, Austin Health, Melbourne, Australia.
| | - Adam Testro
- The University of Melbourne, Melbourne, Australia; Liver Transplant Unit, Austin Health, Melbourne, Australia.
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JAVAID N, KHAN Z, ALI MA, TAHIR SK. EVALUATING THE IMPACT OF EARLY NUTRITIONAL ASSESSMENT AND INTERVENTION IN HOSPITALIZED LIVER CIRRHOSIS PATIENTS. ARQUIVOS DE GASTROENTEROLOGIA 2022; 59:22-28. [PMID: 35442331 DOI: 10.1590/s0004-2803.202200001-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 08/03/2021] [Indexed: 11/22/2022]
Abstract
ABSTRACT Background Malnutrition is common in liver cirrhosis patients that is correlated with early complications, morbidity and mortality. Objective The purpose of the study was to assess nutritional status, impact of nutritional screening and intervention in liver cirrhosis patients by evaluating their actual energy and protein intake during hospital stay. Methods A cross sectional study was conducted wherein all patients’ nutritional status was defined by Subjective Global Assessment tool. Adequate energy and protein supply were planned and executed by using individualized nutritional plan for patients with dietitian’s collaboration. Anthropometric measurements included height, weight, body mass index, mid upper arm circumference, hand grip strength and triceps skin-fold thickness. Biochemical tests included haemoglobin, mean corpuscular haemoglobin, volume and concentration, albumin and liver function tests. To record the daily food intake, a 24-hour dietary recall was used. Results Overall 83 patients (mean age 55) were included, among them 46% of patients were moderately malnourished, 12% were normal, while 42% of cirrhotic patients were severely depleted according to Subjective Global Assessment. The mean intake of calories and protein was improved during stay in hospital after nutritional intervention and critical monitoring (P<0.05). Anthropometric measurements at baseline and discharge showed significant differences (P <0.05) in weight, body mass index, triceps skin fold thickness and mid upper arm circumference values, but not in hand grip strength that was associated with malnourishment among patients. Conclusion Providing individualized nutritional intervention and its monitoring by qualified dietitians during hospital stay helps to improve intake in patients that prevent further risk of malnutrition and related complications.
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Affiliation(s)
| | - Zahra KHAN
- University of Veterinary and Animal Sciences, Pakistan
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Grover I, Singh N, Gunjan D, Pandey RM, Chandra Sati H, Saraya A. Comparison of Anthropometry, Bioelectrical Impedance, and Dual-energy X-ray Absorptiometry for Body Composition in Cirrhosis. J Clin Exp Hepatol 2022; 12:467-474. [PMID: 35535105 PMCID: PMC9077186 DOI: 10.1016/j.jceh.2021.05.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 05/29/2021] [Indexed: 12/12/2022] Open
Abstract
Background & aims This study was planned to evaluate triceps skinfold thickness (TSFT), mid-arm muscle circumference (MAMC) and bioelectrical impedance analysis (BIA) for assessing body composition using dual-energy X-ray absorptiometry (DEXA) (reference) and to predict fat mass (FM) and fat-free mass (FFM) in patients with cirrhosis. Methods FM and FFM were assessed by using DEXA and BIA. Skin-fold calliper was used for measuring TSFT, and MAMC was calculated. Bland-Altman plot was used to determine agreement and linear regression analysis for obtaining equations to predict FM and FFM. Results Patients with cirrhosis (n = 302, 241 male, age 43.7 ± 12.0 years) were included. Bland-Altman plot showed very good agreement between BIA and DEXA for the estimation of FM and FFM. Majority of patients were within the limit of agreement: FM (98%) and FFM (96.4%). BIA shows a positive correlation with DEXA:FM (r = 0.73, P ≤ 0.001) and FFM (r = 0.86, P ≤ 0.001). DEXA (FM and FFM) shows a positive correlation with TSFT (r = 0.69, P ≤ 0.01) and MAMC (r = 0.61, P ≤ 0.01). The mean difference between the observed and predicted value of FM and FFM by BIA in the developmental set was 0.01 and 0.05, respectively; whereas in the validation set, it was -0.13 and 0.86, respectively. The mean difference between the observed and predicted value of TSFT and MAMC in the developmental set was 0.43 and 0.07; whereas, in the validation set, it was 0.16 and 0.48, respectively. Conclusion Anthropometry (TSFT and MAMC) and BIA are simple and easy to use and can be a substitute of DEXA for FM and FFM assessment in routine clinical settings in patients with cirrhosis.
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Key Words
- ALP, alkaline phosphatise
- ALT, alanine aminotransferase
- ANA, anti-nuclear antibody
- ASMA, anti-smooth muscle antibody
- AST, aspartate aminotransferase
- BIA, bioelectrical impedance analysis
- BMC, bone mineral content
- BMI, body mass index
- CTP, Child–Turcotte–Pugh score
- DEXA, dual-energy X-ray absorptiometry
- FFM, fat-free mass
- FM, fat mass
- HBsAg, hepatitis B surface antigen
- MAMC, mid-arm muscle circumference
- TSFT, triceps skinfold thickness
- anthropometric measurements
- anti-HCV, anti-hepatitis C virus
- anti-LKM1, anti-liver kidney microsomal antibody type 1
- bioelectrical impedance analysis
- cirrhosis
- dual-energy X-ray absorptiometry
- nutritional assessment
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Affiliation(s)
- Indu Grover
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, N. Delhi, India
| | - Namrata Singh
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, N. Delhi, India
| | - Deepak Gunjan
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, N. Delhi, India
| | - Ravindra M. Pandey
- Department of Biostatistics, All India Institute of Medical Sciences, N. Delhi, India
| | - Hem Chandra Sati
- Department of Biostatistics, All India Institute of Medical Sciences, N. Delhi, India
| | - Anoop Saraya
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, N. Delhi, India,Address for correspondence: Anoop Saraya, Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, N. Delhi, India.
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10
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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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11
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Agoulnik D, Lewis S. Nutrition Parameters for Assessing Malnutrition in a Population of US Veterans With Hepatitis C Virus. Nutr Clin Pract 2020; 35:1053-1060. [PMID: 32946674 DOI: 10.1002/ncp.10576] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Chronic liver disease often leads to malnutrition in patients. Patients with hepatitis C virus (HCV) are at greater risk for misclassification due to disease-specific changes in fluid, muscle, and fat status. Tools traditionally used to diagnose malnutrition may not be applicable in the HCV population, and delaying malnutrition diagnosis may contribute to disease progression. The aim of the present study is to determine and compare the incidence of malnutrition in US veterans with HCV by using 3 different malnutrition assessment tools (subjective global assessment [SGA], American Society for Parenteral and Enteral Nutrition and the Academy of Nutrition and Dietetics [ASPEN-AND], and Royal Free Hospital Global Assessment [RFH-GA]). METHODS Thirty-three US veterans were evaluated for malnutrition according to SGA, ASPEN-AND, and RFH-GA protocols using a prospective, descriptive study design. RESULTS Fifteen participants (45.5%) were classified with malnutrition using any criteria (SGA, ASPEN, or RFH-GA). All 3 tools had good agreement, with ASPEN-AND to RFH-GA having the highest specificity and sensitivity. Of those classified with malnutrition using any assessment tool, mean body mass index was 26.6 (P = .014), subjective muscle loss was the most frequently encountered parameter, and 6 (40%) of 15 also had fluid accumulation. CONCLUSIONS The results indicate that malnutrition and particularly muscle wasting is common in US veterans with HCV. All 3 tools had good agreement and the most commonly used nutrition parameter was muscle loss (subjective). In a malnutrition assessment tool for the HCV population, both subjective and objective measures of body composition should be included.
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Affiliation(s)
- Dorothy Agoulnik
- James A. Haley Veterans' Hospital, and Clinics, Tampa, Florida, USA
| | - Sherri Lewis
- James A. Haley Veterans' Hospital, and Clinics, Tampa, Florida, USA
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12
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Royal Free Hospital-Nutritional Prioritizing Tool improves the prediction of malnutrition risk outcomes in liver cirrhosis patients compared with Nutritional Risk Screening 2002. Br J Nutr 2020; 124:1293-1302. [PMID: 32600494 PMCID: PMC7656665 DOI: 10.1017/s0007114520002366] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines recommend the Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT) to identify malnutrition risk in patients with liver disease. However, little is known about the application of the RFH-NPT to screen for the risk of malnutrition in China, where patients primarily suffer from hepatitis virus-related cirrhosis. A total of 155 cirrhosis patients without liver cancer or uncontrolled co-morbid illness were enrolled in this prospective study. We administered the Nutritional Risk Screening 2002 (NRS-2002), RFH-NPT, Malnutrition Universal Screening Tool (MUST) and Liver Disease Undernutrition Screening Tool (LDUST) to the patients within 24 h after admission and performed follow-up observations for 1·5 years. The RFH-NPT and NRS-2002 had higher sensitivities (64·8 and 52·4 %) and specificities (60 and 70 %) than the other tools with regard to screening for malnutrition risk in cirrhotic patients. The prevalence of nutritional risk was higher under the use of the RFH-NPT against the NRS-2002 (63 v. 51 %). The RFH-NPT tended more easily to detect malnutrition risk in patients with advanced Child–Pugh classes (B and C) and lower Model for End-stage Liver Disease scores (<15) compared with NRS-2002. RFH-NPT score was an independent predictive factor for mortality. Patients identified as being at high malnutrition risk with the RFH-NPT had a higher mortality rate than those at low risk; the same result was not obtained with the NRS-2002. Therefore, we suggest that using the RFH-NPT improves the ability of clinicians to predict malnutrition risk in patients with cirrhosis primarily caused by hepatitis virus infection at an earlier stage.
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13
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Lindqvist C, Slinde F, Majeed A, Bottai M, Wahlin S. Nutrition impact symptoms are related to malnutrition and quality of life – A cross-sectional study of patients with chronic liver disease. Clin Nutr 2020; 39:1840-1848. [DOI: 10.1016/j.clnu.2019.07.024] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 06/19/2019] [Accepted: 07/31/2019] [Indexed: 02/08/2023]
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Abstract
Patients with chronic liver disease have a very high lifetime risk of malnourishment. It has been increasingly identified in literature that the severity of liver disease affects severity of malnutrition and vice versa. The objective of this review article is to recognize the severity of complications associated with malnutrition in patients with cirrhosis and ways to overcome these obstacles.
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Affiliation(s)
- Aiman Ghufran
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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15
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Cortez AF, de Almeida VP, Corrêa BB, Costa Reis BC, dos Reis GS, Barreto FS, Bastos PR, Brandão Mello CE. Nutritional assessment, handgrip strength and adductor pollicis muscle thickness in patients with chronic viral hepatitis. CLINICAL NUTRITION EXPERIMENTAL 2020. [DOI: 10.1016/j.yclnex.2019.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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16
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Moctezuma-Velazquez C, Ebadi M, Bhanji RA, Stirnimann G, Tandon P, Montano-Loza AJ. Limited performance of subjective global assessment compared to computed tomography-determined sarcopenia in predicting adverse clinical outcomes in patients with cirrhosis. Clin Nutr 2019; 38:2696-2703. [DOI: 10.1016/j.clnu.2018.11.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 10/10/2018] [Accepted: 11/16/2018] [Indexed: 02/08/2023]
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Plauth M, Bernal W, Dasarathy S, Merli M, Plank LD, Schütz T, Bischoff SC. ESPEN guideline on clinical nutrition in liver disease. Clin Nutr 2019; 38:485-521. [PMID: 30712783 DOI: 10.1016/j.clnu.2018.12.022] [Citation(s) in RCA: 392] [Impact Index Per Article: 65.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 12/18/2018] [Indexed: 02/06/2023]
Abstract
This update of evidence-based guidelines (GL) aims to translate current evidence and expert opinion into recommendations for multidisciplinary teams responsible for the optimal nutritional and metabolic management of adult patients with liver disease. The GL was commissioned and financially supported by ESPEN. Members of the guideline group were selected by ESPEN. We searched for meta-analyses, systematic reviews and single clinical trials based on clinical questions according to the PICO format. The evidence was evaluated and used to develop clinical recommendations implementing the SIGN method. A total of 85 recommendations were made for the nutritional and metabolic management of patients with acute liver failure, severe alcoholic steatohepatitis, non-alcoholic fatty liver disease, liver cirrhosis, liver surgery and transplantation as well as nutrition associated liver injury distinct from fatty liver disease. The recommendations are preceded by statements covering current knowledge of the underlying pathophysiology and pathobiochemistry as well as pertinent methods for the assessment of nutritional status and body composition.
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Affiliation(s)
- Mathias Plauth
- Department of Internal Medicine, Municipal Hospital of Dessau, Dessau, Germany.
| | - William Bernal
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Srinivasan Dasarathy
- Division of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Manuela Merli
- Gastroenterology and Hepatology Unit, Sapienza University of Rome, Rome, Italy
| | - Lindsay D Plank
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Tatjana Schütz
- IFB Adiposity Diseases, Leipzig University Medical Centre, Leipzig, Germany
| | - Stephan C Bischoff
- Department for Clinical Nutrition, University of Hohenheim, Stuttgart, Germany
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Merli M, Berzigotti A, Zelber-Sagi S, Dasarathy S, Montagnese S, Genton L, Plauth M, Parés A. EASL Clinical Practice Guidelines on nutrition in chronic liver disease. J Hepatol 2019; 70:172-193. [PMID: 30144956 PMCID: PMC6657019 DOI: 10.1016/j.jhep.2018.06.024] [Citation(s) in RCA: 650] [Impact Index Per Article: 108.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 06/28/2018] [Indexed: 12/11/2022]
Abstract
A frequent complication in liver cirrhosis is malnutrition, which is associated with the progression of liver failure, and with a higher rate of complications including infections, hepatic encephalopathy and ascites. In recent years, the rising prevalence of obesity has led to an increase in the number of cirrhosis cases related to non-alcoholic steatohepatitis. Malnutrition, obesity and sarcopenic obesity may worsen the prognosis of patients with liver cirrhosis and lower their survival. Nutritional monitoring and intervention is therefore crucial in chronic liver disease. These Clinical Practice Guidelines review the present knowledge in the field of nutrition in chronic liver disease and promote further research on this topic. Screening, assessment and principles of nutritional management are examined, with recommendations provided in specific settings such as hepatic encephalopathy, cirrhotic patients with bone disease, patients undergoing liver surgery or transplantation and critically ill cirrhotic patients.
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19
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Shergill R, Syed W, Rizvi SA, Singh I. Nutritional support in chronic liver disease and cirrhotics. World J Hepatol 2018; 10:685-694. [PMID: 30386461 PMCID: PMC6206154 DOI: 10.4254/wjh.v10.i10.685] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 08/04/2018] [Accepted: 08/06/2018] [Indexed: 02/06/2023] Open
Abstract
The liver is a major organ and an essential component in maintaining an appropriate nutritional status in healthy individuals through metabolism of protein, carbohydrates, and fat. In individuals with chronic liver disease (CLD), along with a number of other essential functions that the liver serves, its role in nutrition maintenance is severely impaired. Common causes of CLD include hepatitis C, alcoholic liver disease, and non-alcoholic liver disease. Amongst this population, the most common manifestation of impaired nutritional maintenance is protein-calorie malnutrition. Aside from inherent abnormalities in metabolism, such as malabsorption and maldigestion, CLD can be associated with anorexia as well as increased metabolic requirements, all of which contribute to a state of malnutrition. Given the systemic implications and impact on prognosis of malnutrition, proper nutritional assessment is essential and can be achieved through a thorough history and physical, as well as biochemical investigations and anthropometry as needed. Following an appropriate assessment of a patient’s nutritional status, an approach to management can be decided upon and is based on the extent of malnutrition which directly reflects the severity of disease. Management options can be grossly separated into enteral and parenteral nutrition. The former is usually sufficient in the form of oral supplements in less severe cases of malnutrition, but as the CLD worsens, parenteral nutrition becomes necessary. With appropriate assessment and early intervention, many of the complications of CLD can be avoided, and ultimately better outcomes can be achieved.
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Affiliation(s)
- Ravi Shergill
- Radiology Department, McMaster University, Hamilton, ON L8S4L8, Canada
| | - Wajahat Syed
- Undergraduate Medicine, McMaster University, Hamilton, ON L8S4L8, Canada
| | - Syed Ali Rizvi
- Undergraduate Medicine, McMaster University, Hamilton, ON L8S4L8, Canada
| | - Ikjot Singh
- Undergraduate Medicine, McMaster University, Hamilton, ON L8S4L8, Canada
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20
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Ebadi M, Tandon P, Moctezuma-Velazquez C, Ghosh S, Baracos VE, Mazurak VC, Montano-Loza AJ. Low subcutaneous adiposity associates with higher mortality in female patients with cirrhosis. J Hepatol 2018; 69:608-616. [PMID: 29709682 DOI: 10.1016/j.jhep.2018.04.015] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 04/03/2018] [Accepted: 04/18/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Two major body compartments, skeletal muscle and adipose tissue, exhibit independent functions. We aimed to explore the prognostic significance of skeletal muscle, visceral and subcutaneous adipose tissue, according to sex, in patients with cirrhosis assessed for liver transplantation (LT). METHODS CT images taken at the 3rd lumbar vertebra from 677 patients were quantified for three body composition indexes (cm2/m2), visceral adipose tissue index, subcutaneous adipose tissue index (SATI), and skeletal muscle index (SMI). Cox proportional and competing-risk analysis hazard models were conducted to assess associations between mortality and body composition. RESULTS The majority of patients were male (67%) with a mean age of 57 ± 7 years, model for end-stage liver disease (MELD) score of 14 ± 8 and mean body mass index of 27 ± 6 kg/m2. Despite similar body mass index between the sexes, male patients had greater SMI (53 ± 12 vs. 45 ± 9 cm2/m2), whereas SATI (67 ± 52 vs. 48 ± 37 cm2/m2) was higher in females (p <0.001 for each). In sex stratified multivariate analyses after adjustment for MELD score and other confounding variables, SATI in females (hazard ratio [HR] 0.99; 95% CI 0.98-1.00; p = 0.01) and SMI in males (HR 0.98; 95% CI 0.96-1.00; p = 0.02) were significant predictors of mortality. Female patients with low SATI (<60 cm2/m2) had a higher risk of mortality (HR 2.06; 95% CI 1.08-3.91; p = 0.03). Using competitive risk analysis in female patients listed for LT, low SATI was also an independent predictor of mortality (subdistribution HR 2.80; 95% CI 1.28-6.12; p = 0.01) after adjusting for MELD, and other confounding factors. CONCLUSIONS A lower SATI is associated with higher mortality in female patients with cirrhosis. Subcutaneous adipose tissue has a favorable metabolic profile - low SATI may reflect depletion of this major energy reservoir, leading to poor clinical outcomes. LAY SUMMARY We looked at the importance of two of the main body compartments, skeletal muscle and adipose tissue (fat) on the prognosis of males and females with end-stage liver disease. Lower amounts of subcutaneous fat but not visceral fat (around internal organs), are associated with higher mortality in female patients with end-stage liver disease. However, low skeletal muscle predicts mortality in male patients with end-stage liver disease.
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Affiliation(s)
- Maryam Ebadi
- Division of Gastroenterology & Liver Unit, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Puneeta Tandon
- Division of Gastroenterology & Liver Unit, University of Alberta Hospital, Edmonton, Alberta, Canada
| | | | - Sunita Ghosh
- Department of Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Vickie E Baracos
- Department of Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Vera C Mazurak
- Division of Human Nutrition, University of Alberta, Edmonton, Alberta, Canada
| | - Aldo J Montano-Loza
- Division of Gastroenterology & Liver Unit, University of Alberta Hospital, Edmonton, Alberta, Canada.
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21
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Marroni CA, Fleck Jr ADM, Fernandes SA, Galant LH, Mucenic M, de Mattos Meine MH, Mariante-Neto G, Brandão ABDM. Liver transplantation and alcoholic liver disease: History, controversies, and considerations. World J Gastroenterol 2018; 24:2785-2805. [PMID: 30018475 PMCID: PMC6048431 DOI: 10.3748/wjg.v24.i26.2785] [Citation(s) in RCA: 106] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 05/23/2018] [Accepted: 06/16/2018] [Indexed: 02/06/2023] Open
Abstract
Alcohol consumption accounts for 3.8% of annual global mortality worldwide, and the majority of these deaths are due to alcoholic liver disease (ALD), mainly alcoholic cirrhosis. ALD is one of the most common indications for liver transplantation (LT). However, it remains a complicated topic on both medical and ethical grounds, as it is seen by many as a "self-inflicted disease". One of the strongest ethical arguments against LT for ALD is the probability of relapse. However, ALD remains a common indication for LT worldwide. For a patient to be placed on an LT waiting list, 6 mo of abstinence must have been achieved for most LT centers. However, this "6-mo rule" is an arbitrary threshold and has never been shown to affect survival, sobriety, or other outcomes. Recent studies have shown similar survival rates among individuals who undergo LT for ALD and those who undergo LT for other chronic causes of end-stage liver disease. There are specific factors that should be addressed when evaluating LT patients with ALD because these patients commonly have a high prevalence of multisystem alcohol-related changes. Risk factors for relapse include the presence of anxiety or depressive disorders, short pre-LT duration of sobriety, and lack of social support. Identification of risk factors and strengthening of the social support system may decrease relapse among these patients. Family counseling for LT candidates is highly encouraged to prevent alcohol consumption relapse. Relapse has been associated with unique histopathological changes, graft damage, graft loss, and even decreased survival in some studies. Research has demonstrated the importance of a multidisciplinary evaluation of LT candidates. Complete abstinence should be attempted to overcome addiction issues and to allow spontaneous liver recovery. Abstinence is the cornerstone of ALD therapy. Psychotherapies, including 12-step facilitation therapy, cognitive-behavioral therapy, and motivational enhancement therapy, help support abstinence. Nutritional therapy helps to reverse muscle wasting, weight loss, vitamin deficiencies, and trace element deficiencies associated with ALD. For muscular recovery, supervised physical activity has been shown to lead to a gain in muscle mass and improvement of functional activity. Early LT for acute alcoholic hepatitis has been the subject of recent clinical studies, with encouraging results in highly selected patients. The survival rates after LT for ALD are comparable to those of patients who underwent LT for other indications. Patients that undergo LT for ALD and survive over 5 years have a higher risk of cardiorespiratory disease, cerebrovascular events, and de novo malignancy.
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Affiliation(s)
- Claudio Augusto Marroni
- Graduate Program in Medicine: Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre 90430-080, RS, Brazil
- Liver Transplant Adult Group, Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre 90035-072, RS, Brazil
| | - Alfeu de Medeiros Fleck Jr
- Liver Transplant Adult Group, Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre 90035-072, RS, Brazil
| | - Sabrina Alves Fernandes
- Graduate Program in Medicine: Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre 90430-080, RS, Brazil
- Liver Transplant Adult Group, Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre 90035-072, RS, Brazil
- Nutrition at the Centro Universitário Metodista (IPA), Porto Alegre 90420-060, RS, Brazil
| | - Lucas Homercher Galant
- Graduate Program in Medicine: Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre 90430-080, RS, Brazil
- Liver Transplant Adult Group, Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre 90035-072, RS, Brazil
| | - Marcos Mucenic
- Liver Transplant Adult Group, Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre 90035-072, RS, Brazil
| | - Mario Henrique de Mattos Meine
- Liver Transplant Adult Group, Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre 90035-072, RS, Brazil
| | - Guilherme Mariante-Neto
- Graduate Program in Medicine: Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre 90430-080, RS, Brazil
- Liver Transplant Adult Group, Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre 90035-072, RS, Brazil
| | - Ajacio Bandeira de Mello Brandão
- Graduate Program in Medicine: Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre 90430-080, RS, Brazil
- Liver Transplant Adult Group, Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre 90035-072, RS, Brazil
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Combined nutritional assessment methods to predict clinical outcomes in patients on the waiting list for liver transplantation. Nutrition 2018; 47:21-26. [DOI: 10.1016/j.nut.2017.09.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 07/24/2017] [Accepted: 09/16/2017] [Indexed: 02/06/2023]
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Mathew A, Marzio DHD, Reddy S, Wong SY, Cheung M, Mosca H, Guglielmo F, Halpern E, Sass DA, Doria C. Pre-Liver Transplant Muscle Loss Is a Risk Factor for Post-Liver Transplantation Left Ventricular Systolic Dysfunction. Ann Transplant 2017; 22:759-764. [PMID: 29269723 PMCID: PMC6248012 DOI: 10.12659/aot.905610] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The development of left ventricular systolic dysfunction (LVSD) after liver transplant (LT) can result in increased morbidity and mortality in the immediate period following liver transplant. The aim of this study was to evaluate low muscle mass due to chronic liver disease, as a potential risk factor for LVSD after LT. MATERIAL AND METHODS A retrospective chart review was completed for all adult patients who received a liver transplant between January 2002 and January 2015 at a single academic LT center. Collected data included patient demographics, medical history, laboratory data, radiology results, and pathology. Echocardiograms were reviewed for patients identified as having LVSD diagnosed within 1 year after LT (left ventricular ejection fraction <55%). The total psoas area (TPA), a marker of low muscle mass, was determined by measuring the average cross-sectional area of the psoas muscle on MRI or CT scans before transplant at the level of L4 vertebra. RESULTS Of the 503 post-LT patients reviewed, 144 (28.6%) had pre-and post-LT echocardiograms. Of these 144 patients, 17 developed LVSD, of which 15 (88.2%) occurred within 1 year after LT. The average age at transplant of those with LVSD was 58.9±6 years, with a mean MELD score of 30.7±6. The mean TPA normalized for height for patients with LVSD was 297.68±86.99 mm²/m² compared to 382.1±104.2 mm²/m² for those with normal EF (p= 0.002). BMI, MELD score, and etiology of cirrhosis were not significant risk factors for post-LT LVSD in our study population. During the study period, 35.2% (n=6) of LVSD patients died within 1 year after LT. CONCLUSIONS Although LVSD is thought to be a rare complication after LT, those with muscle loss as predicted by mean TPA measurements normalized for height may be at highest risk.
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Affiliation(s)
- Arun Mathew
- Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, U.S.A
| | - Dina Halegoua-De Marzio
- Division of Gastroenterology and Hepatology, Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, U.S.A
| | - Sheela Reddy
- Division of Gastroenterology and Hepatology, Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, U.S.A
| | - She-Yan Wong
- Division of Gastroenterology and Hepatology, Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, U.S.A
| | - Michael Cheung
- Department of Medicine, Division of Cardiovascular Diseases, Lankenau Medical Center, Wynnewood, PA, U.S.A
| | - Heather Mosca
- Department of Radiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, U.S.A
| | - Flavius Guglielmo
- Department of Radiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, U.S.A
| | - Ethan Halpern
- Department of Radiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, U.S.A
| | - David A. Sass
- Division of Gastroenterology and Hepatology, Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, U.S.A
| | - Cataldo Doria
- Division of Transplant Surgery, Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, U.S.A
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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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Comparing assessment tools for detecting undernutrition in patients with liver cirrhosis. Clin Nutr ESPEN 2017; 23:156-161. [PMID: 29460792 DOI: 10.1016/j.clnesp.2017.10.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 08/01/2017] [Accepted: 10/20/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND AIMS Undernutrition in cirrhotic patients is often poorly recognised until late-stages. The current UK screening tool, the Malnutrition Universal Screening Tool, can miss undernutrition in patients with ascites/fluid retention. A 6-question Liver Disease Undernutrition Screening Tool (LDUST) has been developed in America. METHODS We sought to compare LDUST with MUST in the detection of undernutrition in 50 inpatients and 50 outpatients with liver cirrhosis in a secondary care setting. This was then validated by a dietitian assessment. RESULTS Similar patient demographics and liver disease aetiologies were found in the two cohorts. Mean Child-Pugh scores were higher for inpatients, 8.3 (SD 1.9) vs 5.9 (SD 1.2). LDUST detected undernutrition in 45/50 inpatients (90%) and 34/50 outpatients (68%). MUST scores ≥2 were present in 19/50 (38%) inpatients and 9/50 (18%) outpatients. In those with a MUST score <2, LDUST detected undernutrition in 26/31 (84%) inpatients and 27/41 (66%) outpatients. 26 inpatients had undernutrition using LDUST but had a MUST score <2, 20 (76%) of these were deemed to be undernourished by dietetics assessment. LDUST was mostly completed independently or with minimal assistance (80% inpatients, 100% outpatients), with mean completion times of 4 and 3 min for in- and outpatients respectively. CONCLUSION LDUST is a quick and easy screening tool, which appears better able than MUST to detect undernutrition in cirrhotic patients, including undernutrition missed by MUST. Importantly the tool was validated against dietitian assessments. The high rates of undernutrition among cirrhotic inpatients suggest that screening this cohort is unnecessary, and instead all should undergo dietitian review, with LDUST utilised in an outpatient setting.
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Nishikawa H, Enomoto H, Ishii A, Iwata Y, Miyamoto Y, Ishii N, Yuri Y, Takata R, Hasegawa K, Nakano C, Nishimura T, Yoh K, Aizawa N, Sakai Y, Ikeda N, Takashima T, Iijima H, Nishiguchi S. Development of a simple predictive model for decreased skeletal muscle mass in patients with compensated chronic liver disease. Hepatol Res 2017; 47:1223-1234. [PMID: 28019060 DOI: 10.1111/hepr.12857] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 12/15/2016] [Accepted: 12/21/2016] [Indexed: 02/08/2023]
Abstract
AIM To develop and validate a simple predictive model using easily obtained clinical parameters to predict decreased skeletal muscle mass (DSMM) in chronic liver disease (CLD) patients (n = 652). METHODS Study subjects were divided into a training set (n = 326) and a validation set (n = 326). Decreased skeletal muscle mass was diagnosed based on skeletal muscle mass index measured by bioimpedance analysis. Variables significantly associated with DSMM were identified using univariate and multivariate analyses in the training set and used to construct a predictive formula. Receiver operating characteristic (ROC) curve analysis was carried out and the predictive model was validated in the validation set. Subgroup analyses were undertaken based on gender, age, or cirrhosis status of patients. RESULTS Body mass index (BMI), age, serum albumin, and branched-chain amino acid to tyrosine ratio (BTR) were determined to be significant predictive factors for DSMM. A composite formula "BALB score" was constructed [-7.740 + (0.539 × BMI) + (-0.112 × age) + (1.358 × albumin) + (-0.264 × BTR)]. The BALB score had the best predictive characteristics among all variables in both population sets (area under the ROC curve, 0.877-0.898). Patients with DSMM were stratified into three BALB score categories (>4, 0-4, and <0). Subgroup analyses also showed that BALB scoring was predictive of DSMM irrespective of gender, age, or cirrhosis status. The BALB score significantly correlated with psoas muscle index on computed tomography (rs = 0.6083 for men; rs = 0.6814 for women). CONCLUSION The BALB scoring system based on routinely used clinical parameters offers a convenient and non-invasive method for predicting DSMM in compensated CLD patients with high accuracy.
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Affiliation(s)
- Hiroki Nishikawa
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hirayuki Enomoto
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Akio Ishii
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yoshinori Iwata
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yuho Miyamoto
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Noriko Ishii
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yukihisa Yuri
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Ryo Takata
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kunihiro Hasegawa
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Chikage Nakano
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Takashi Nishimura
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kazunori Yoh
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Nobuhiro Aizawa
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yoshiyuki Sakai
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Naoto Ikeda
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Tomoyuki Takashima
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hiroko Iijima
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Shuhei Nishiguchi
- Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
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Subjective Global Assessment and Handgrip Strength as Predictive Factors in Patients with Liver Cirrhosis. Gastroenterol Res Pract 2017; 2017:8348390. [PMID: 28804497 PMCID: PMC5540494 DOI: 10.1155/2017/8348390] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 06/11/2017] [Indexed: 12/25/2022] Open
Abstract
Background and Aims Malnutrition is common in patients with chronic liver disease. We aimed to evaluate malnutrition assessment tools in predicting severity and survival of patients with liver cirrhosis. Material and Methods We examined patients with liver cirrhosis. Nutritional evaluation was performed on admission, using subjective global assessment (SGA), handgrip strength (HGS), and anthropometry. Patients were followed up for 6 months. Results We included 100 patients, 72 men, with mean age of 59.2 years. According to disease severity, patients were 23% Child-Pugh A, 46% Child-Pugh B, and 31% Child-Pugh C. SGA and HGS significantly correlated with Child-Pugh, MELD, and MELD-Na scores on admission. At 6 months follow-up, 80.4% (78 of 97) of patients survived, while 3 patients were lost from observation. Survival was predicted by SGA (1 death in 32 patients SGA A, 8 deaths in 46 patients SGA B, and 9 deaths in 19 patients SGA C, p = 0.001) and HGS (25.1 ± 8.5 in deceased versus 30.6 ± 10.9 in survivors, p = 0.046). The mean BMI and MAMC values did not significantly differ between patients who survived or were deceased at 6 months. Conclusion HGS and SGA may predict severity and short-term survival in cirrhotic patients.
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Belarmino G, Gonzalez MC, Sala P, Torrinhas RS, Andraus W, D’Albuquerque LAC, Pereira RMR, Caparbo VF, Ferrioli E, Pfrimer K, Damiani L, Heymsfield SB, Waitzberg DL. Diagnosing Sarcopenia in Male Patients With Cirrhosis by Dual-Energy X-Ray Absorptiometry Estimates of Appendicular Skeletal Muscle Mass. JPEN J Parenter Enteral Nutr 2017; 42:24-36. [DOI: 10.1177/0148607117701400] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 02/21/2017] [Indexed: 12/17/2022]
Affiliation(s)
- Giliane Belarmino
- Department of Gastroenterology (LIM 35), Surgical Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Maria Cristina Gonzalez
- Postgraduate Program in Health and Behavior, Universidade Católica de Pelotas, Rio Grande do Sul, Brazil
- Pennington Biomedical Research Center, Baton Rouge, Louisiana, USA
| | - Priscila Sala
- Department of Gastroenterology (LIM 35), Surgical Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Raquel Susana Torrinhas
- Department of Gastroenterology (LIM 35), Surgical Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Wellington Andraus
- Department of Gastroenterology (LIM 35), Surgical Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Rosa Maria R. Pereira
- Laboratory of Bone Metabolism, Rheumatology Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Valéria F. Caparbo
- Laboratory of Bone Metabolism, Rheumatology Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Eduardo Ferrioli
- Department of Medical Clinic, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, São Paulo, Brazil
| | - Karina Pfrimer
- Department of Medical Clinic, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, São Paulo, Brazil
| | - Lucas Damiani
- Research Institute, Hospital do Coração de São Paulo, São Paulo, Brazil
| | | | - Dan L. Waitzberg
- Department of Gastroenterology (LIM 35), Surgical Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Belarmino G, Gonzalez MC, Torrinhas RS, Sala P, Andraus W, D'Albuquerque LAC, Pereira RMR, Caparbo VF, Ravacci GR, Damiani L, Heymsfield SB, Waitzberg DL. Phase angle obtained by bioelectrical impedance analysis independently predicts mortality in patients with cirrhosis. World J Hepatol 2017; 9:401-408. [PMID: 28321276 PMCID: PMC5340995 DOI: 10.4254/wjh.v9.i7.401] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Revised: 12/22/2016] [Accepted: 01/11/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the prognostic value of the phase angle (PA) obtained from bioelectrical impedance analysis (BIA) for mortality prediction in patients with cirrhosis. METHODS In total, 134 male cirrhotic patients prospectively completed clinical evaluations and nutritional assessment by BIA to obtain PAs during a 36-mo follow-up period. Mortality risk was analyzed by applying the PA cutoff point recently proposed as a malnutrition marker (PA ≤ 4.9°) in Kaplan-Meier curves and multivariate Cox regression models. RESULTS The patients were divided into two groups according to the PA cutoff value (PA > 4.9°, n = 73; PA ≤ 4.9°, n = 61). Weight, height, and body mass index were similar in both groups, but patients with PAs > 4.9° were younger and had higher mid-arm muscle circumference, albumin, and handgrip-strength values and lower severe ascites and encephalopathy incidences, interleukin (IL)-6/IL-10 ratios and C-reactive protein levels than did patients with PAs ≤ 4.9° (P ≤ 0.05). Forty-eight (35.80%) patients died due to cirrhosis, with a median of 18 mo (interquartile range, 3.3-25.6 mo) follow-up until death. Thirty-one (64.60%) of these patients were from the PA ≤ 4.9° group. PA ≤ 4.9° significantly and independently affected the mortality model adjusted for Model for End-Stage Liver Disease score and age (hazard ratio = 2.05, 95%CI: 1.11-3.77, P = 0.021). In addition, Kaplan-Meier curves showed that patients with PAs ≤ 4.9° were significantly more likely to die. CONCLUSION In male patients with cirrhosis, the PA ≤ 4.9° cutoff was associated independently with mortality and identified patients with worse metabolic, nutritional, and disease progression profiles. The PA may be a useful and reliable bedside tool to evaluate prognosis in cirrhosis.
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Affiliation(s)
- Giliane Belarmino
- Giliane Belarmino, Raquel S Torrinhas, Priscila Sala, Wellington Andraus, Luiz Augusto Carneiro D'Albuquerque, Graziela R Ravacci, Dan L Waitzberg, Department of Gastroenterology, Surgical Division, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-000, Brazil
| | - Maria Cristina Gonzalez
- Giliane Belarmino, Raquel S Torrinhas, Priscila Sala, Wellington Andraus, Luiz Augusto Carneiro D'Albuquerque, Graziela R Ravacci, Dan L Waitzberg, Department of Gastroenterology, Surgical Division, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-000, Brazil
| | - Raquel S Torrinhas
- Giliane Belarmino, Raquel S Torrinhas, Priscila Sala, Wellington Andraus, Luiz Augusto Carneiro D'Albuquerque, Graziela R Ravacci, Dan L Waitzberg, Department of Gastroenterology, Surgical Division, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-000, Brazil
| | - Priscila Sala
- Giliane Belarmino, Raquel S Torrinhas, Priscila Sala, Wellington Andraus, Luiz Augusto Carneiro D'Albuquerque, Graziela R Ravacci, Dan L Waitzberg, Department of Gastroenterology, Surgical Division, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-000, Brazil
| | - Wellington Andraus
- Giliane Belarmino, Raquel S Torrinhas, Priscila Sala, Wellington Andraus, Luiz Augusto Carneiro D'Albuquerque, Graziela R Ravacci, Dan L Waitzberg, Department of Gastroenterology, Surgical Division, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-000, Brazil
| | - Luiz Augusto Carneiro D'Albuquerque
- Giliane Belarmino, Raquel S Torrinhas, Priscila Sala, Wellington Andraus, Luiz Augusto Carneiro D'Albuquerque, Graziela R Ravacci, Dan L Waitzberg, Department of Gastroenterology, Surgical Division, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-000, Brazil
| | - Rosa Maria R Pereira
- Giliane Belarmino, Raquel S Torrinhas, Priscila Sala, Wellington Andraus, Luiz Augusto Carneiro D'Albuquerque, Graziela R Ravacci, Dan L Waitzberg, Department of Gastroenterology, Surgical Division, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-000, Brazil
| | - Valéria F Caparbo
- Giliane Belarmino, Raquel S Torrinhas, Priscila Sala, Wellington Andraus, Luiz Augusto Carneiro D'Albuquerque, Graziela R Ravacci, Dan L Waitzberg, Department of Gastroenterology, Surgical Division, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-000, Brazil
| | - Graziela R Ravacci
- Giliane Belarmino, Raquel S Torrinhas, Priscila Sala, Wellington Andraus, Luiz Augusto Carneiro D'Albuquerque, Graziela R Ravacci, Dan L Waitzberg, Department of Gastroenterology, Surgical Division, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-000, Brazil
| | - Lucas Damiani
- Giliane Belarmino, Raquel S Torrinhas, Priscila Sala, Wellington Andraus, Luiz Augusto Carneiro D'Albuquerque, Graziela R Ravacci, Dan L Waitzberg, Department of Gastroenterology, Surgical Division, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-000, Brazil
| | - Steven B Heymsfield
- Giliane Belarmino, Raquel S Torrinhas, Priscila Sala, Wellington Andraus, Luiz Augusto Carneiro D'Albuquerque, Graziela R Ravacci, Dan L Waitzberg, Department of Gastroenterology, Surgical Division, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-000, Brazil
| | - Dan L Waitzberg
- Giliane Belarmino, Raquel S Torrinhas, Priscila Sala, Wellington Andraus, Luiz Augusto Carneiro D'Albuquerque, Graziela R Ravacci, Dan L Waitzberg, Department of Gastroenterology, Surgical Division, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-000, Brazil
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Marr KJ, Shaheen AA, Lam L, Stapleton M, Burak K, Raman M. Nutritional status and the performance of multiple bedside tools for nutrition assessment among patients waiting for liver transplantation: A Canadian experience. Clin Nutr ESPEN 2017; 17:68-74. [DOI: 10.1016/j.clnesp.2016.10.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 09/12/2016] [Accepted: 10/21/2016] [Indexed: 12/29/2022]
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Fernandes SA, de Mattos AA, Tovo CV, Marroni CA. Nutritional evaluation in cirrhosis: Emphasis on the phase angle. World J Hepatol 2016; 8:1205-1211. [PMID: 27803765 PMCID: PMC5067440 DOI: 10.4254/wjh.v8.i29.1205] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 08/02/2016] [Accepted: 08/17/2016] [Indexed: 02/06/2023] Open
Abstract
Protein-calorie malnutrition (PCM) is a common condition in cirrhotic patients, leading to a worse prognosis, complications, poor quality of life and lower survival rates. Among ways of assessing nutritional status, there are anthropometric methods such as the evaluation of the triceps skinfold, the arm circumference, the arm muscle circumference and the body mass index, and non-anthropometric methods such as the subjective global assessment, the handgrip strength of non-dominant hand, and the bioelectrical impedance analysis (BIA). PCM is frequently under-diagnosed in clinical settings in patients with cirrhosis due to the limitations of nutritional evaluation methods in this population. BIA is a useful method, but cannot be indicated in patients with abnormal body composition. In these situations, the phase angle (PA) has been used, and can become an important tool in assessing nutritional status in any situation. The PA is superior to anthropometric methods and might be considered as a nutritional indicator in cirrhosis. The early characterization of the nutritional status in patients with cirrhosis means an early nutritional intervention, with a positive impact on patients' overall prognosis. Among the usually accepted methods for nutritional diagnosis, the PA provides information in a quick and objective manner.
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Affiliation(s)
- Sabrina Alves Fernandes
- Sabrina Alves Fernandes, Angelo Alves de Mattos, Cristiane Valle Tovo, Claudio Augusto Marroni, Postgraduate Program at Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS 90420-060, Brazil
| | - Angelo Alves de Mattos
- Sabrina Alves Fernandes, Angelo Alves de Mattos, Cristiane Valle Tovo, Claudio Augusto Marroni, Postgraduate Program at Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS 90420-060, Brazil
| | - Cristiane Valle Tovo
- Sabrina Alves Fernandes, Angelo Alves de Mattos, Cristiane Valle Tovo, Claudio Augusto Marroni, Postgraduate Program at Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS 90420-060, Brazil
| | - Claudio Augusto Marroni
- Sabrina Alves Fernandes, Angelo Alves de Mattos, Cristiane Valle Tovo, Claudio Augusto Marroni, Postgraduate Program at Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS 90420-060, Brazil
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Tandon P, Low G, Mourtzakis M, Zenith L, Myers RP, Abraldes JG, Shaheen AAM, Qamar H, Mansoor N, Carbonneau M, Ismond K, Mann S, Alaboudy A, Ma M. A Model to Identify Sarcopenia in Patients With Cirrhosis. Clin Gastroenterol Hepatol 2016; 14:1473-1480.e3. [PMID: 27189915 DOI: 10.1016/j.cgh.2016.04.040] [Citation(s) in RCA: 160] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Revised: 04/25/2016] [Accepted: 04/28/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The severe depletion of muscle mass at the third lumbar vertebral level (sarcopenia) is a marker of malnutrition and is independently associated with mortality in patients with cirrhosis. Instead of monitoring sarcopenia by cross-sectional imaging, we investigated whether ultrasound-based measurements of peripheral muscle mass, measures of muscle function, along with nutritional factors, are associated with severe loss of muscle mass. METHODS We performed a prospective study of 159 outpatients with cirrhosis (56% male; mean age, 58 ± 10 years; mean model for end-stage liver disease score, 10 ± 3; 60% Child-Pugh class A) evaluated at the Cirrhosis Care Clinic at the University of Alberta Hospital from March 2011 through September 2012. Lumbar skeletal muscle indices were determined by computed tomography or magnetic resonance imaging. We collected clinical data and data on patients' body composition, nutrition, and thigh muscle thickness (using ultrasound analysis). We also measured mid-arm muscle circumference, mid-arm circumference, hand grip, body mass index, and serum level of albumin; patients were evaluated using the subjective global assessment scale. Findings from these analyses were compared with those from cross-sectional imaging, for each sex, using logistic regression analysis. RESULTS Based on cross-sectional imaging analysis, 43% of patients had sarcopenia (57% of men and 25% of women). Results from the subjective global assessment, serum level of albumin, and most nutritional factors were significantly associated with sarcopenia. We used multivariate analysis to develop a model to identify patients with sarcopenia, and developed a nomogram based on body mass index and thigh muscle thickness for patients of each sex. Our model identified men with sarcopenia with an area under the receiver operating characteristic curve value of 0.78 and women with sarcopenia with an area under the receiver operating characteristic curve value of 0.89. CONCLUSIONS In a prospective study of patients with cirrhosis, we found that the combination of body mass index and thigh muscle thickness (measured by ultrasound) can identify male and female patients with sarcopenia almost as well as cross-sectional imaging (area under the receiver operating characteristic curve values of 0.78 and 0.89, respectively). These factors might be used in screening and routine nutritional monitoring of patients with cirrhosis.
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Affiliation(s)
- Puneeta Tandon
- Cirrhosis Care Clinic, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
| | - Gavin Low
- Department of Radiology, University of Alberta, Edmonton, Alberta, Canada
| | - Marina Mourtzakis
- Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada
| | - Laura Zenith
- Cirrhosis Care Clinic, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Robert P Myers
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Juan G Abraldes
- Cirrhosis Care Clinic, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Hina Qamar
- Cirrhosis Care Clinic, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Nadia Mansoor
- Cirrhosis Care Clinic, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Michelle Carbonneau
- Cirrhosis Care Clinic, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Kathleen Ismond
- Cirrhosis Care Clinic, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Sumeer Mann
- Department of Radiology, University of Alberta, Edmonton, Alberta, Canada
| | - Alshimaa Alaboudy
- Cirrhosis Care Clinic, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Mang Ma
- Cirrhosis Care Clinic, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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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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Lalama MA, Saloum Y. Nutrition, fluid, and electrolytes in chronic liver disease. Clin Liver Dis (Hoboken) 2016; 7:18-20. [PMID: 31041020 PMCID: PMC6490252 DOI: 10.1002/cld.526] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 11/04/2015] [Accepted: 12/13/2015] [Indexed: 02/04/2023] Open
Affiliation(s)
- Miguel A. Lalama
- Division of Digestive Diseases and Nutrition, Morsani College of MedicineUniversity of South FloridaTampaFL
| | - Yasser Saloum
- Division of Digestive Diseases and Nutrition, Morsani College of MedicineUniversity of South FloridaTampaFL
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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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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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Fialla AD, Israelsen M, Hamberg O, Krag A, Gluud LL. Nutritional therapy in cirrhosis or alcoholic hepatitis: a systematic review and meta-analysis. Liver Int 2015; 35:2072-8. [PMID: 25645300 DOI: 10.1111/liv.12798] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 01/29/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Patients with cirrhosis and alcoholic hepatitis are often malnourished and have a superimposed stress metabolism, which increases nutritional demands. We performed a systematic review on the effects of nutritional therapy vs. no intervention for patients with cirrhosis or alcoholic hepatitis. METHODS We included trials on nutritional therapy designed to fulfil at least 75% of daily nutritional demand. Authors extracted data in an independent manner. Random-effects and fixed-effect meta-analyses were performed and the results expressed as risk ratios (RR) with 95% confidence intervals (CI). Sequential analyses were performed to evaluate the risk of spurious findings because of random and systematic errors. Subgroup and sensitivity analyses were performed to evaluate the risk of bias and sources of between trial heterogeneity. RESULTS Thirteen randomized controlled trials with 329 allocated to enteral (nine trials) or intravenous (four trials) nutrition and 334 controls. All trials were classed as having a high risk of bias. Random-effects meta-analysis showed that nutritional therapy reduced mortality 0.80 (95% CI, 0.64 to 0.99). The result was not confirmed in sequential analysis. Fixed-effect analysis suggested that nutrition prevented overt hepatic encephalopathy (0.73; 95% CI, 0.55 to 0.96) and infection (0.66; 95% CI, 0.45 to 0.98, respectively), but the results were not confirmed in random-effects analyses. CONCLUSION Our review suggests that nutritional therapy may have beneficial effects on clinical outcomes in cirrhosis and alcoholic hepatitis. High-quality trials are needed to verify our findings.
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Affiliation(s)
- Annette D Fialla
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark
| | - Mads Israelsen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark
| | - Ole Hamberg
- Department of Hepatology, Copenhagen University Hospital Rigshospitalet, Koebenhavn, Denmark
| | - Aleksander Krag
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark
| | - Lise Lotte Gluud
- Gastrounit, Medical Division, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
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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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Ee LC, Hill RJ, Beale K, Noble C, Fawcett J, Cleghorn GJ. Long-term effect of childhood liver transplantation on body cell mass. Liver Transpl 2014; 20:922-9. [PMID: 24753196 DOI: 10.1002/lt.23891] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2013] [Accepted: 04/09/2014] [Indexed: 02/07/2023]
Abstract
Malnutrition is common in end-stage liver disease, but a correction after transplantation is expected. Body cell mass (BCM) assessment using total body potassium (TBK) measurements is considered the gold standard for assessing nutritional status. The aim of this study was to examine the BCM and, therefore, nutritional status of long-term survivors after childhood liver transplantation. This was a longitudinal nested cohort study of patients undergoing transplantation at <18 years of age and surviving >3 years with ongoing review at our center. TBK measurements were obtained before transplantation and during long-term follow-up. BCM was calculated from TBK and was adjusted for the height raised to power p, which depended on sex (BCM/height(p)). The effects of the age at transplant, linear growth impairment, a diagnosis of biliary atresia, and steroid use were assessed. Thirty-two patients (20 males) participated; 59% had biliary atresia. The median age at transplant was 2.11 years (range = 0.38-10.92 years). Posttransplant testing was performed at a median of 7.23 years (range = 3.28-14.99 years) when they were 10.12 years old (range = 4.56-20.77 years). This cohort attained mean z scores for height, weight, and body mass index of -0.41 ± 1.36, -0.26 ± 1.14, and 0.04 ± 0.99, respectively. BCM/height(p) was reduced before transplantation but was further reduced after transplantation (P < 0.001) despite the normalization of height and weight. Weight recovery, therefore, likely came from increased fat mass and not BCM. Linear growth impairment was associated with a greater reduction in posttransplant BCM/height(p) (P = 0.02). In multivariate analyses, only an older age at transplant predicted reduced posttransplant BCM/height(p) (P = 0.02). The age at transplant, sex, steroid use, and underlying diagnosis did not predict changes in BCM/height(p) after transplantation. In conclusion, weight recovery in long-term survivors of childhood liver transplantation is likely due to increased fat mass because BCM remains reduced. Nutritional compromise persists in long-term survivors of childhood liver transplantation.
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Affiliation(s)
- Looi Cheng Ee
- Queensland Liver Transplant Service, Royal Children's Hospital, Brisbane, Australia; School of Medicine, University of Queensland, Brisbane, Australia
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Yosry A, Omran D, Said M, Fouad W, Fekry O. Impact of nutritional status of Egyptian patients with end-stage liver disease on their outcomes after living donor liver transplantation. J Dig Dis 2014; 15:321-6. [PMID: 24593282 DOI: 10.1111/1751-2980.12141] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Malnutrition is prevalent among patients with end-stage liver disease (ESLD) awaiting liver transplantation. Our aim was to examine prospectively the impact of patients' nutritional status on their outcomes after living donor liver transplantation (LDLT). METHODS In all, 30 patients scheduled for LDLT were subjected to a preoperative nutritional status assessment through subjective global assessment (SGA), nutritional risk screening (NRS 2002) and anthropometric measurements. All patients were followed up for 3 months after LDLT for mortality, graft rejection, number of clinically significant infective episodes, time spent in hospital (ward and intensive care unit [ICU]) and graft failure or dysfunction. RESULTS All patients were nutritionally compromised (evaluated by SGA and NRS 2002), and were divided into two groups: moderately and severely malnourished. Compared with moderately malnourished patients, severely malnourished patients showed significant postoperative hyperbilirubinemia, higher number of infective episodes and longer ICU stay. Preoperative triceps skinfold and mid-arm circumference were negatively correlated with the number of infective episodes (r = -0.33, P = 0.03 and r = -0.377, P = 0.04, respectively). Moreover, skeletal muscle mass was negatively correlated with postoperative serum alanine aminotransferase level (r = -0.52, P = 0.003) and the number of postoperative infective episodes (r = -0.3, P = 0.04). CONCLUSION Poor nutritional status of Egyptian patients with ESLD negatively affects the patients' outcomes after LDLT.
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Affiliation(s)
- Ayman Yosry
- Department of Endemic Medicine and Hepatology, Faculty of Medicine, Cairo University, Cairo, Egypt
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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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Kwarta E, Nagle S, Welstead L. Update on Malnutrition in Liver Cirrhosis: Assessment and Treatment. ACTA ACUST UNITED AC 2014. [DOI: 10.1007/s11901-014-0230-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Wu SN, Qi YM, Chen YJ, Xiao HJ, Hao CM, Wang X. Intracellular and extracellular water distribution in patients with liver cirrhosis. Shijie Huaren Xiaohua Zazhi 2013; 21:4170-4174. [DOI: 10.11569/wcjd.v21.i36.4170] [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] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate intracellular water (ICW) and extracellular water (ECW) distribution in patients with cirrhosis.
METHODS: One hundred and four cirrhotic patients were divided into three groups based on Child-Pugh class (A, B, C), and 24 healthy volunteers were used as controls (n). Total body water (TBW), ICW and ECW were measured by multi-frequency bioelectrical impedance. ICW% was calculated as ICW/TBW × 100%, and ECW% as ECW/TBW × 100%.
RESULTS: Intracellular and extracellular fluid distribution changed in patients with cirrhosis. With the increase in Child-Pugh class, ECW and ECW% increased and ICW% and ICW/TBW decreased (ECW: 13.011 ± 2.517 L, 14.463 ± 2.720 L, 14.587 ± 2.976 L vs 13.300 ± 2.073 L; ECW%: 38.93% ± 1.10%, 39.87% ± 1.00%, 40.52% ± 1.32% vs 38.52% ± 0.95%; ICW%: 61.07% ± 1.10%, 60.03% ± 1.00%, 59.48% ± 1.32% vs 61.48% ± 0.95%; ICW/ECW: 1.571 ± 0.072, 1.510 ± 0.063, 1.470 ± 0.789, 1.598 ± 0.065).
CONCLUSION: Intracellular and extracellular fluid distribution has changed at the beginning of the disease in cirrhotic patients, which manifests as increased ECW and ECW% and decreased ICW% and ICW/TBW.
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DiMartini A, Cruz RJ, Dew MA, Myaskovsky L, Goodpaster B, Fox K, Kim KH, Fontes P. Muscle mass predicts outcomes following liver transplantation. Liver Transpl 2013; 19:1172-80. [PMID: 23960026 PMCID: PMC4382961 DOI: 10.1002/lt.23724] [Citation(s) in RCA: 177] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Accepted: 07/08/2013] [Indexed: 12/12/2022]
Abstract
For patients with end-stage liver disease, commonly used indices of nutritional status (ie, body weight and body mass index) are often inflated because of fluid overload (ie, ascites and peripheral edema), and this results in an underdiagnosis of malnutrition. Because muscle is the largest protein reservoir in the body, an estimate of the muscle mass may be a more reliable and valid estimate of nutritional status. Therefore, we used pretransplant computed tomography data for 338 liver transplantation (LT) candidates to identify muscle and fat mass on the basis of a specific abdominal transverse section commonly used in body composition analyses, and we investigated the contribution of this measure to specific post-LT outcomes. We found that the majority of our patients (68%) could be defined as cachectic. For men, muscle mass predicted many important posttransplant outcomes, including intensive care unit (ICU) stay, total length of stay (LOS), and days of intubation. Muscle mass was a significant predictor of survival and also predicted disposition to home versus another facility. For women, muscle mass predicted ICU stay, total LOS, and days of intubation, but the effect was modest. Muscle mass did not predict survival or disposition for women. In conclusion, because pretransplant muscle mass is associated with many important postoperative outcomes, we discuss these findings in the context of possible pretransplant interventions for either improving or sustaining muscle mass before surgery.
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Affiliation(s)
- Andrea DiMartini
- Department of Transplantation Surgery, University of Pittsburgh Medical Center,Department of Psychiatry, University of Pittsburgh Medical Center,Starzl Transplant Institute
| | - Ruy J. Cruz
- Department of Transplantation Surgery, University of Pittsburgh Medical Center,Starzl Transplant Institute
| | - Mary Amanda Dew
- Department of Psychiatry, University of Pittsburgh Medical Center,Department of Psychology, University of Pittsburgh Medical Center,Department of Epidemiology, University of Pittsburgh Medical Center,Department of Biostatistics, University of Pittsburgh Medical Center
| | - Larissa Myaskovsky
- Department of Psychiatry, University of Pittsburgh Medical Center,Department of Medicine, University of Pittsburgh Medical Center,Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System
| | - Bret Goodpaster
- Department of Medicine, University of Pittsburgh Medical Center,Department of Health and Physical Education, University of Pittsburgh Medical Center
| | - Kristen Fox
- Department of Psychiatry, University of Pittsburgh Medical Center
| | - Kevin H. Kim
- Department of Psychology in Education, University of Pittsburgh Medical Center,University of Pittsburgh Joseph M. Katz Graduate School of Business
| | - Paulo Fontes
- Department of Transplantation Surgery, University of Pittsburgh Medical Center,Starzl Transplant Institute
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Amodio P, Bemeur C, Butterworth R, Cordoba J, Kato A, Montagnese S, Uribe M, Vilstrup H, Morgan MY. The nutritional management of hepatic encephalopathy in patients with cirrhosis: International Society for Hepatic Encephalopathy and Nitrogen Metabolism Consensus. Hepatology 2013; 58:325-36. [PMID: 23471642 DOI: 10.1002/hep.26370] [Citation(s) in RCA: 289] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Accepted: 02/25/2013] [Indexed: 12/12/2022]
Abstract
UNLABELLED Nitrogen metabolism plays a major role in the development of hepatic encephalopathy (HE) in patients with cirrhosis. Modulation of this relationship is key to the management of HE, but is not the only nutritional issue that needs to be addressed. The assessment of nutritional status in patients with cirrhosis is problematic. In addition, there are significant sex-related differences in body composition and in the characteristics of tissue loss, which limit the usefulness of techniques based on measures of muscle mass and function in women. Techniques that combine subjective and objective variables provide reasonably accurate information and are recommended. Energy and nitrogen requirements in patients with HE are unlikely to differ substantially from those recommended in patients with cirrhosis per se viz. 35-45 kcal/g and 1.2-1.5g/kg protein daily. Small meals evenly distributed throughout the day and a late-night snack of complex carbohydrates will help minimize protein utilization. Compliance is, however, likely to be a problem. Diets rich in vegetables and dairy protein may be beneficial and are therefore recommended, but tolerance varies considerably in relation to the nature of the staple diet. Branched chain amino acid supplements may be of value in the occasional patient intolerant of dietary protein. Increasing dietary fiber may be of value, but the utility of probiotics is, as yet, unclear. Short-term multivitamin supplementation should be considered in patients admitted with decompensated cirrhosis. Hyponatremia may worsen HE; it should be prevented as far as possible and should always be corrected slowly. CONCLUSION Effective management of these patients requires an integrated multidimensional approach. However, further research is needed to fill the gaps in the current evidence base to optimize the nutritional management of patients with cirrhosis and HE.
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Affiliation(s)
- Piero Amodio
- Department of Medicine University Hospital of Padua Padova Italy.
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48
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Abstract
Cirrhosis results from repeated hepatocellular injury over time, leading to portal hypertension and the development of ascites, hepatic encephalopathy, and varices. Despite improvements in medical care for patients with cirrhosis, mortality from infection, renal failure, and hepatocellular carcinoma remain high.
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Affiliation(s)
- Christopher Fowler
- Transplant Clinical Operations at Methodist Dallas Medical Center, Dallas, TX, USA
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49
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Ney M, Vandermeer B, van Zanten SJV, Ma MM, Gramlich L, Tandon P. Meta-analysis: oral or enteral nutritional supplementation in cirrhosis. Aliment Pharmacol Ther 2013; 37:672-9. [PMID: 23421379 DOI: 10.1111/apt.12252] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2012] [Revised: 01/03/2013] [Accepted: 01/28/2013] [Indexed: 12/15/2022]
Abstract
BACKGROUND Malnutrition is a common and clinically significant problem in patients with cirrhosis. The impact of nutritional therapy remains unclear. AIM To provide an up-to-date systematic review and meta-analysis of RCTs of oral or enteral nutritional supplementation (ONS or ENS) on nutritional and clinical outcomes in adult patients with cirrhosis. METHODS The primary outcome measure was survival. Included: full-text English language RCTs investigating ONS or ENS vs. a standard nonsupplemented diet in patients with cirrhosis. Excluded: parenteral or branched chain amino acids intervention; treatment duration ≤7 days, exclusive evaluation of posttransplant, postsurgical or quality of life outcomes. RESULTS Six trials (4 ONS/2 ENS) and 470 patients were included with 71% males and median age 53 years. When all studies were combined, there was no reduction in mortality [Relative risk (RR): 0.75 (0.42, 1.32), P = 0.31]. Subgroup analysis of 3 of the 4 ONS studies did demonstrate a mortality reduction [RR: 0.40 (0.18, 0.90), P = 0.03]. Of the 2 ENS studies, one included the sickest patients in the meta-analysis (82% Child Pugh C) and the other had the shortest mean intervention duration (8.6 days), possibly impacting the potential for benefit. Study quality was suboptimal (median Jadad = 2). CONCLUSIONS Although there is insufficient evidence to definitively state that oro-enteral nutritional supplementation impacts clinical outcomes, on the basis of this analysis, one can be cautiously optimistic that there is the potential for benefit without an increase in adverse events. Adequately powered, Child Pugh stratified studies of at least 1 month in duration are needed to clarify the impact on relevant clinical outcomes.
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Affiliation(s)
- M Ney
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
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Hayashi F, Momoki C, Yuikawa M, Simotani Y, Kawamura E, Hagihara A, Fujii H, Kobayashi S, Iwai S, Morikawa H, Enomoto M, Tamori A, Kawada N, Ohfuji S, Fukusima W, Habu D. Nutritional status in relation to lifestyle in patients with compensated viral cirrhosis. World J Gastroenterol 2012; 18:5759-5770. [PMID: 23155318 PMCID: PMC3484346 DOI: 10.3748/wjg.v18.i40.5759] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Revised: 06/20/2012] [Accepted: 06/28/2012] [Indexed: 02/06/2023] Open
Abstract
AIM To assess the nourishment status and lifestyle of non-hospitalized patients with compensated cirrhosis by using noninvasive methods. METHODS The subjects for this study consisted of 27 healthy volunteers, 59 patients with chronic viral hepatitis, and 74 patients with viral cirrhosis, from urban areas. We assessed the biochemical blood tests, anthropometric parameters, diet, lifestyle and physical activity of the patients. A homeostasis model assessment-insulin resistance (HOMA-IR) value of ≥ 2.5 was considered to indicate insulin resistance. We measured height, weight, waist circumference, arm circumference, triceps skin-fold thickness, and handgrip strength, and calculated body mass index, arm muscle circumference (AMC), and arm muscle area (AMA). We interviewed the subjects about their dietary habits and lifestyle using health assessment computer software. We surveyed daily physical activity using a pedometer. Univariate and multivariate logistic regression modeling were used to identify the relevant factors for insulin resistance. RESULTS The rate of patients with HOMA-IR ≥ 2.5 (which was considered to indicate insulin resistance) was 14 (35.9%) in the chronic hepatitis and 17 (37.8%) in the cirrhotic patients. AMC (%) (control vs chronic hepatitis, 111.9% ± 10.5% vs 104.9% ± 10.7%, P = 0.021; control vs cirrhosis, 111.9% ± 10.5% vs 102.7% ± 10.8%, P = 0.001) and AMA (%) (control vs chronic hepatitis, 128.2% ± 25.1% vs 112.2% ± 22.9%, P = 0.013; control vs cirrhosis, 128.2% ± 25.1% vs 107.5% ± 22.5%, P = 0.001) in patients with chronic hepatitis and liver cirrhosis were significantly lower than in the control subjects. Handgrip strength (%) in the cirrhosis group was significantly lower than in the controls (control vs cirrhosis, 92.1% ± 16.2% vs 66.9% ± 17.6%, P < 0.001). The results might reflect a decrease in muscle mass. The total nutrition intake and amounts of carbohydrates, protein and fat were not significantly different amongst the groups. Physical activity levels (kcal/d) (control vs cirrhosis, 210 ± 113 kcal/d vs 125 ± 74 kcal/d, P = 0.001), number of steps (step/d) (control vs cirrhosis, 8070 ± 3027 step/d vs 5789 ± 3368 step/d, P = 0.011), and exercise (Ex) (Ex/wk) (control vs cirrhosis, 12.4 ± 9.3 Ex/wk vs 7.0 ± 7.7 Ex/wk, P = 0.013) in the cirrhosis group was significantly lower than the control group. The results indicate that the physical activity level of the chronic hepatitis and cirrhosis groups were low. Univariate and multivariate logistic regression modeling suggested that Ex was associated with insulin resistance (odds ratio, 6.809; 95% CI, 1.288-36.001; P = 0.024). The results seem to point towards decreased physical activity being a relevant factor for insulin resistance. CONCLUSION Non-hospitalized cirrhotic patients may need to maintain an adequate dietary intake and receive lifestyle guidance to increase their physical activity levels.
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