Prospective Study
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Mar 8, 2017; 9(7): 401-408
Published online Mar 8, 2017. doi: 10.4254/wjh.v9.i7.401
Phase angle obtained by bioelectrical impedance analysis independently predicts mortality in patients with cirrhosis
Giliane Belarmino, Maria Cristina Gonzalez, Raquel S Torrinhas, Priscila Sala, Wellington Andraus, Luiz Augusto Carneiro D’Albuquerque, Rosa Maria R Pereira, Valéria F Caparbo, Graziela R Ravacci, Lucas Damiani, Steven B Heymsfield, 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
Maria Cristina Gonzalez, Postgraduate Program in Health and Behavior, Universidade Católica de Pelotas, Pelotas 96015-560, Brazil
Maria Cristina Gonzalez, Steven B Heymsfield, Pennington Biomedical Research Center, Baton Rouge, LA 70808, United States
Rosa Maria R Pereira, Valéria F Caparbo, Laboratory of Bone Metabolism, Rheumatology Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-000, Brazil
Lucas Damiani, Research Institute, Hospital do Coração de São Paulo, São Paulo 04004-030, Brazil
Author contributions: Belarmino G, Gonzalez MC, Waitzberg DL, Heymsfield SB, Pereira RMR and D’Albuquerque LAC contributed to the conception and design and/or coordination of the study; Belarmino G, Gonzalez MC, Torrinhas RS, Waitzberg DL, Sala P, Andraus W, Heymsfield SB and Caparbo VF were responsible for the acquisition, analysis, and/or interpretation and discussion of data; Belarmino G, Torrinhas RS, Gonzalez MC and Ravacci GR drafted the manuscript; Damiani L performed statistical analyses; all authors read and approved the final manuscript.
Supported by The Fundação de Amparo à Pesquisa do Estado de São Paulo, Nos. 2011/13243-3, 2012/15677-3 [GB].
Institutional review board statement: The study was reviewed and approved by the Institutional Ethics Review Board (0646/11) of the Hospital das Clínicas (São Paulo, SP, Brazil).
Clinical trial registration statement: This clinical trial was registered at with the identifier NCT02421848. Details can be found at
Informed consent statement: All study participants, or their legal guardians, provided written consent prior to study enrollment.
Conflict-of-interest statement: The authors of this manuscript have no conflict of interest to disclose.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Dr. Giliane Belarmino, Department of Gastroenterology, Surgical Division, Faculdade de Medicina da Universidade de São Paulo, Avenida Dr. Arnaldo, 455, Cerqueira César, Sao Paulo 05403-000, Brazil.
Telephone: +55-11-30617459 Fax: +55-11-30617459
Received: July 30, 2016
Peer-review started: August 2, 2016
First decision: September 8, 2016
Revised: December 22, 2016
Accepted: January 11, 2017
Article in press: January 14, 2017
Published online: March 8, 2017

To evaluate the prognostic value of the phase angle (PA) obtained from bioelectrical impedance analysis (BIA) for mortality prediction in patients with cirrhosis.


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.


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.


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.

Keywords: Bioelectrical impedance analysis, Body composition, Phase angle, Nutritional assessment, Liver disease, Cirrhosis, Mortality

Core tip: This article provides original data displaying the good performance of the phase angle (PA) obtained by bioelectrical impedance analysis in the evaluation of mortality prognosis in patients with cirrhosis. The findings suggest that the PA is a safe, practical, and inexpensive tool for the prediction of mortality potentially associated with malnutrition.