Malnutrition in cirrhosis: contribution and consequences of sarcopenia on metabolic and clinical responses

Pre-transplant Psoas Muscle Density as a Ready-to-Use and Low-cost Predictor of Patient Survival After Liver Transplant

Background: Sarcopenia, defined as low muscle mass with reduced function, is frequently encountered in cirrhotic patients and is a major predictor of adverse events, including post-liver transplant (LT) outcome. Objectives: This study assessed the impact of sarcopenia using computed tomography (CT)-based measurements on post-LT mortality and complications. Methods: From January 2008 to June 2016, 646 adult patients underwent 613 LTs at our institution. We analyzed the postoperative outcome of 287 patients who had pathologically proven cirrhosis on the explanted liver and who had performed a CT examination three months before LT. Psoas muscle density (PMD) was detected for every patient using standard instruments present in the radiological workstation and was related to postoperative survival rates and complications. Statistical analysis was carried out using the appropriate tests. Results: Postoperative mortality was 6.3%. At least one grade III-IV postoperative complication was experienced by 121 patients. Respiratory and infective complications occurred in 30 and 32 patients, respectively. Also, PMD was an independent predictor of postoperative mortality (P = 0.021), respiratory complications (P = 0.015), and infections (P = 0.010). The ROC analysis identified a PMD ≤ 43.72 HU as the best cutoff value for predicting 90-day mortality after LT. Conclusions: Psoas muscle density accurately predicted post-LT mortality and complications. Its ease and low-cost determination can allow widespread use of this parameter to improve clinical care and help with the decision to give these patients some priority on the transplant waiting list.

Extracellular water to total body water ratio obtained by bioelectrical impedance analysis determines the dose intensity of lenvatinib for the treatment of patients with advanced hepatocellular carcinoma

BACKGROUND AND AIM

The aim of this study was to identify the factors that contribute to the maintenance of relative dose intensity (RDI) of lenvatinib in hepatocellular carcinoma (HCC) patients.

METHODS

Thirty-two patients with advanced HCC treated with lenvatinib were enrolled. We evaluated the relationship between maintenance of RDI and various clinical data, parameters obtained by body composition measurements with bioelectrical impedance analysis (BIA) and grip strength at the start of lenvatinib treatment.

RESULTS

Multivariate analysis showed that only the extracellular water to total body water ratio (ECW/TBW) ≤ 0.400 at initiation of treatment was associated with RDI ≥ 50% (odds ratio, 6.94; 95% confidence interval [CI], 1.00-48.00; P = 0.049). When the RDI was compared between ECW/TBW ≤ 0.400 group and ECW/TBW > 0.400 group, the RDI was significantly higher in the ECW/TBW ≤ 0.400 group at each of 0-4W, 4-6W, and 6-8W points. The P value at each point was 0.003, 0.003, and 0.005, respectively. On the other hand, multivariate analysis showed that only the ECW/TBW ≤ 0.400 at initiation of treatment was associated with the extension of duration until reduction or withdrawal of lenvatinib (hazard ratio, 4.86; 95% CI, 1.52-15.50; P = 0.007).

CONCLUSION

The extracellular water to total body water ratio, a parameter of body composition measurement by BIA, was significantly associated with the maintenance of RDI and the duration until reduction or withdrawal of lenvatinib in HCC patients. In addition to standard predictors such as Child-Pugh score and modified albumin-bilirubin grade that have been used to date, ECW/TBW might be a new predictor of RDI in HCC patients treated with lenvatinib.

Impact of Liver and Pancreas Diseases on Nutritional Status

Liver and pancreatic diseases have significant consequences on nutritional status, with direct effects on clinical outcomes, survival, and quality of life. Maintaining and preserving an adequate nutritional status is crucial and should be one of the goals of patients with liver or pancreatic disease. Thus, the nutritional status of such patients should be systematically assessed at follow-up. Recently, great progress has been made in this direction, and the relevant pathophysiological mechanisms have been better established. While the spectrum of these diseases is wide, and the mechanisms of the onset of malnutrition are numerous and interrelated, clinical and nutritional manifestations are common. The main consequences include an impaired dietary intake, altered macro and micronutrient metabolism, energy metabolism disturbances, an increase in energy expenditure, nutrient malabsorption, sarcopenia, and osteopathy. In this review, we summarize the factors contributing to malnutrition, and the effects on nutritional status and clinical outcomes of liver and pancreatic diseases. We explain the current knowledge on how to assess malnutrition and the efficacy of nutritional interventions in these settings.

Clinical impact of sarcopenia assessment in patients with liver cirrhosis

Introduction: Sarcopenia is defined as loss of skeletal muscle mass, strength, and function, and it is associated with increased morbidity and mortality in patients with chronic liver disease.Areas covered: The aim of this review is to provide a detailed report on the pathophysiological mechanisms underlying sarcopenia in cirrhotic patients, the several imaging methods available for the assessment of sarcopenia and the clinical studies evaluating the prognostic role of sarcopenia presence in cirrhotic patients.Expert opinion: Sarcopenia pathogenesis is complex and multifaceted, as chronic catabolic conditions, increased energy expenditure, reduced appetite, side effects of multiple therapies, alterations in circulating levels of hormones, low protein synthesis, presence of ascites or portosystemic shunts are all factors contributing to muscle atrophy in cirrhotic patients. Computed tomography scan is the most validated method to evaluate muscle mass and quality. Sarcopenia is associated with a higher rate waitlist mortality, hepatic encephalopathy, and lower quality of life in patients with liver cirrhosis. Future studies should make an effort to unify and validate liver disease-specific cutoffs for the definition of sarcopenia.

Sarcopenia in chronic liver disease: mechanisms and countermeasures

Sarcopenia, a condition of low muscle mass, quality, and strength, is commonly found in patients with cirrhosis and is associated with adverse clinical outcomes including reduction in quality of life, increased mortality, and posttransplant complications. In chronic liver disease (CLD), sarcopenia is most commonly defined through the measurement of the skeletal muscle index of the third lumbar spine. A major contributor to sarcopenia in CLD is the imbalance in muscle protein turnover, which likely occurs due to a decrease in muscle protein synthesis and an elevation in muscle protein breakdown. This imbalance is assumed to arise due to several factors including accelerated starvation, hyperammonemia, amino acid deprivation, chronic inflammation, excessive alcohol intake, and physical inactivity. In particular, hyperammonemia is a key mediator of the liver-gut axis and is known to contribute to mitochondrial dysfunction and an increase in myostatin expression. Currently, the use of nutritional interventions such as late-evening snacks, branched-chain amino acid supplementation, and physical activity have been proposed to help the management and treatment of sarcopenia. However, little evidence exists to comprehensively support their use in clinical settings. Several new pharmacological strategies, including myostatin inhibition and the nutraceutical Urolithin A, have recently been proposed to treat age-related sarcopenia and may also be of use in CLD. This review highlights the potential molecular mechanisms contributing to sarcopenia in CLD alongside a discussion of existing and potential new treatment strategies.

Compound Sarcopenia in Hospitalized Patients with Cirrhosis Worsens Outcomes with Increasing Age

Background: There are limited data on outcomes of older patients with chronic diseases. Skeletal muscle loss of aging (primary sarcopenia) has been extensively studied but the impact of secondary sarcopenia of chronic disease is not as well evaluated. Older patients with chronic diseases have both primary and secondary sarcopenia that we term compound sarcopenia. We evaluated the clinical impact of compound sarcopenia in hospitalized patients with cirrhosis given the increasing number of patients and high prevalence of sarcopenia in these patients. Design: The Nationwide Inpatients Sample (NIS) database (years 2010–2014) was analyzed to study older patients with cirrhosis. Since there is no universal hospital diagnosis code for “muscle loss”, we used a comprehensive array of codes for “muscle loss phenotype” in the international classification of diseases-9 (ICD-9). A randomly selected 2% sample of hospitalized general medical population (GMP) and inpatients with cirrhosis were stratified into 3 age groups based on age-related changes in muscle mass. In-hospital mortality, length of stay (LoS), cost of hospitalization (CoH), comorbidities and discharge disposition were analyzed. Results. Of 517,605 hospitalizations for GMP and 106,835 hospitalizations for treatment of cirrhosis or a cirrhosis-related complication, 207,266 (40.4%) GMP and 29,018 (27.7%) patients with cirrhosis were >65 years old, respectively. Muscle loss phenotype in both GMP and inpatients with cirrhosis 51–65 years old and >65 years old was significantly (p < 0.001 for all) associated with higher mortality, LoS, and CoH compared to those ≤50 years old. Patients >65 years old with cirrhosis and muscle loss phenotype had higher mortality (adjusted OR: 1.06, 95% CI [1.04, 1.08] and CoH (adjusted odds ratio (OR): 1.10, 95% confidence interval (CI) [1.04, 1.08])) when compared to >65 years old GMP with muscle loss phenotype. Muscle loss in younger patients with cirrhosis (≤50 years old) was associated with worse outcomes compared to GMP >65 years old. Non-home discharges (nursing, skilled, long-term care) were more frequent with increasing age to a greater extent in patients with cirrhosis with muscle loss phenotype for each age stratum. Conclusion: Muscle loss is more frequent in older patients with cirrhosis than younger patients with cirrhosis and older GMP. Younger patients with cirrhosis had clinical outcomes similar to those of older GMP, suggesting an accelerated senescence in cirrhosis. Compound sarcopenia in older patients with cirrhosis is associated with higher inpatient mortality, increased LoS, and CoH compared to GMP with sarcopenia.

Resting energy expenditure in cirrhotic patients with and without hepatocellular carcinoma

BACKGROUND

The diagnosis of malnutrition in patients with independent hepatocellular carcinoma (HCC) varies from 20% to 50%, is related to important complications and has a direct impact on the prognosis. Determination of the resting energy expenditure (REE) has become an important parameter in this population, as it allows therapeutic adjustments to recover their nutritional status. The REE in cirrhosis, with and without HCC, is not clearly defined, and requires the identification and definition of the best nutritional approach.

AIM

To evaluate the REE of patients with cirrhosis, with and without HCC.

METHODS

This is a prospective observational study evaluating the REE of 118 patients, 33 with cirrhosis and hepatocellular carcinoma and a control group of 85 patients with cirrhosis without HCC, using indirect calorimetry (IC), bioimpedance, and predictive formulas.

RESULTS

The REE determined by IC in cirrhotic patients with HCC was 1643 ± 364 and in those without HCC was 1526 ± 277 (P = 0.064). The REE value as assessed by bioimpedance was 1529 ± 501 for those with HCC and 1660 ± 385 for those without HCC (P = 0.136). When comparing the values of REE determined by IC and predictive formulas in cirrhotics with HCC, it was observed that only the formulas of the Food and Agriculture Organization (FAO)/World Health Organization (WHO) (1985) and Cunningham (1980) presented values similar to those determined by IC. When comparing the REE values determined by IC and predictive formulas in cirrhotics without HCC, it was observed that the formulas of Schofield (1985), FAO/WHO (1985), WHO (2000), Institute of Medicine (IOM) (2005) and Katch and McArdie (1996) presented values similar to those determined by IC.

CONCLUSION

The FAO/WHO formula (1985) could be used for cirrhotic patients with or without HCC; as it is the one with the values closest to those obtained by IC in these cirrhotic patients.

Imaging Software-Based Sarcopenia Assessment in Gastroenterology: Evolution and Clinical Meaning

Sarcopenia is gaining attention as a negative prognostic factor in different fields of medicine, including chronic liver failure. However, the assessment of sarcopenia in patients with liver diseases is often neglected due to unawareness of reliable tools and methods and thus is limited to research studies. Cross-sectional imaging is a diffuse diagnostic tool and is commonly performed in patients with chronic liver failure. The last advancements in radiology image analysis using dedicated software allow an easy and standardized method to assess skeletal muscle volume. Several measures can be obtained from cross-sectional imaging analysis to evaluate sarcopenia in patients affected by chronic liver disease. We aimed to review the recent advances in imaging-based sarcopenia assessment, in particular in patients with chronic liver diseases. As a result, we found that the skeletal muscle index (SMI) seems to be a reliable method to assess sarcopenia in cirrhotic patients. Even if further studies are needed to validate proper cut-offs for each clinical endpoint, physicians are invited to consider the assessment of sarcopenia in the work-up of patients with chronic liver disease.

Effect of Body Mass Index on the Prognosis of Liver Cirrhosis

Objective: At present, the association of body mass index (BMI) with the prognosis of liver cirrhosis is controversial. Our retrospective study aimed to evaluate the impact of BMI on the outcome of liver cirrhosis. Methods: In the first part, long-term death was evaluated in 436 patients with cirrhosis and without malignancy from our prospectively established single-center database. In the second part, in-hospital death was evaluated in 379 patients with cirrhosis and with acute gastrointestinal bleeding (AGIB) from our retrospective multicenter study. BMI was calculated and categorized as underweight (BMI <18.5 kg/m²), normal weight (18.5 ≤ BMI < 23.0 kg/m²), and overweight/obese (BMI ≥ 23.0 kg/m²). Results: In the first part, Kaplan-Meier curve analyses demonstrated a significantly higher cumulative survival rate in the overweight/obese group than the normal weight group (p = 0.047). Cox regression analyses demonstrated that overweight/obesity was significantly associated with decreased long-term mortality compared with the normal weight group [hazard ratio (HR) = 0.635; 95% CI: 0.405-0.998; p = 0.049] but not an independent predictor after adjusting for age, gender, and Child-Pugh score (HR = 0.758; 95%CI: 0.479-1.199; p = 0.236). In the second part, Kaplan-Meier curve analyses demonstrated no significant difference in the cumulative survival rate between the overweight/obese and the normal weight groups (p = 0.094). Cox regression analyses also demonstrated that overweight/obesity was not significantly associated with in-hospital mortality compared with normal weight group (HR = 0.349; 95%CI: 0.096-1.269; p = 0.110). In both of the two parts, the Kaplan-Meier curve analyses demonstrated no significant difference in the cumulative survival rate between underweight and normal weight groups. Conclusion: Overweight/obesity is modestly associated with long-term survival in patients with cirrhosis but not an independent prognostic predictor. There is little effect of overweight/obesity on the short-term survival of patients with cirrhosis and with AGIB.

Nutrition in Chronic Liver Disease: Consensus Statement of the Indian National Association for Study of the Liver

Malnutrition and sarcopenia are common in patients with chronic liver disease and are associated with increased risk of decompensation, infections, wait-list mortality and poorer outcomes after liver transplantation. Assessment of nutritional status and management of malnutrition are therefore essential to improve outcomes in patients with chronic liver disease. This consensus statement of the Indian National Association for Study of the Liver provides a comprehensive review of nutrition in chronic liver disease and gives recommendations for nutritional screening and treatment in specific clinical scenarios of malnutrition in cirrhosis in adults as well as children with chronic liver disease and metabolic disorders.

Effect of non-alcoholic beer, diet and exercise on endothelial function, nutrition and quality of life in patients with cirrhosis

BACKGROUND

The implementation of nutritional strategies targeting several variables at once could benefit patients with cirrhosis. Non-alcoholic beer has different compounds that exert antioxidant, anti-inflammatory and nutritional properties.

AIM

To evaluate the effect of diet + exercise and non-alcoholic beer on nutritional status, endothelial function and quality of life in patients with cirrhosis.

METHODS

In this randomized open clinical trial, patients with cirrhosis were randomized into two groups: The intervention (non-alcoholic beer + diet + exercise) and control (water + diet + exercise) group. Treatment consisted of 330 mL non-alcoholic beer/day or the same amount of water, plus an individualized dietary plan and an exercise program with a pedometer-based bracelet to reach at least 5000 steps/d and > 2500 above the baseline during 8 wk. Endothelial function (flow-mediated dilation, plethysmography), biochemical and nutritional variables and quality of life (CLDQ) were evaluated.

RESULTS

Forty-three patients were included in the study, 21 in the control group and 22 in the intervention group. The mean age was 53.5 ± 7.8 years, 60% were women, the median MELD score was 8 (7-10) and most patients were Child-Pugh A (88%). Adherence to the interventions was > 90% in both groups, there were no adverse events and all biochemical parameters remained stable in both groups. Endothelial function improved in both groups. All measured nutritional parameters improved in the intervention group, compared to only 2 in the control group and quality of life improved in both groups; however, more domains improved in the intervention group.

CONCLUSION

The intervention consisting of non-alcoholic beer, diet and exercise seems to be safe and well tolerated in patients with cirrhosis, and shows improvement in nutritional status, endothelial function, and quality of life. These results need to be further confirmed.

Treatment on the Spleen Prevents the Progression of Secondary Sarcopenia in Patients With Liver Cirrhosis

Hyperammonemia is an important stimulator of myostatin expression, a negative regulator of muscle growth. After splenectomy or partial splenic artery embolization (PSE), hyperammonemia often improves. Thus, we investigated changes in skeletal muscle index (SMI) in patients following an operation on the spleen and in patients who did not undergo an operation on their spleen. The study was designed retrospectively, in which we analyzed data collected between January 2000 and December 2015. Patients were assigned to the splenectomy/PSE or nontreatment group. Changes in SMI (ΔSMI), ammonia (Δammonia), myostatin (Δmyostatin), irisin (Δirisin), and branched‐chain amino acids/tyrosine molar ratio (ΔBTR) were analyzed between baseline and 5‐year follow‐up both before and after inverse probability of treatment weighting adjustment (IPTW). Patients (102) were enrolled (splenectomy/PSE, n = 45; nontreatment group, n = 57) before IPTW adjustment: ΔSMI (2.6 cm²/m² vs. −8.8 cm²/m², respectively) (P < 0.001), Δmyostatin (−867 vs. −568, respectively) (P < 0.001), Δammonia (−34 and 16, respectively) (P < 0.001), and ΔBTR (0.89 and −0.665, respectively) (P < 0.001). There were no differences between splenectomy and PSE regarding these factors. Moreover, after IPTW adjustment, significant differences were observed between the splenectomy/PSE and nontreatment group for the median ΔBTR (0.89 and −0.64, respectively) (P < 0.001), Δammonia (−33 and 16, respectively) (P < 0.001), Δmyostatin (−894 and 504, respectively) (P < 0.001), and ΔSMI (1.8 cm²/m² and −8.2 cm²/m², respectively) (P < 0.001). Conclusions: Both splenectomy and PSE were associated with the prevention of secondary sarcopenia in patients with LC. Moreover, it can be expected that muscle volume loss is reduced by splenectomy or PSE in patients with hyperammonemia.

Malnutrition in cirrhosis: More food for thought

Malnutrition is highly prevalent in liver cirrhosis and its presence carries important prognostic implications. The clinical conditions and pathophysiological mechanisms that cause malnutrition in cirrhosis are multiple and interrelated. Anorexia and liver decompensation symptoms lead to poor dietary intake; metabolic changes characterised by elevated energy expenditure, reduced glycogen storage, an accelerated starvation response and protein catabolism result in muscle and fat wasting; and, malabsorption renders the cirrhotic patient unable to fully absorb or utilise food that has been consumed. Malnutrition is therefore a considerable challenge to manage effectively, particularly as liver disease progresses. A high energy, high protein diet is recognised as standard of care, yet patients struggle to follow this recommendation and there is limited evidence to guide malnutrition interventions in cirrhosis and liver transplantation. In this review, we seek to detail the factors which contribute to poor nutritional status in liver disease, and highlight complexities far greater than "poor appetite" or "reduced oral intake" leading to malnutrition. We also discuss management strategies to optimise nutritional status in this patient group, which target the inter-related mechanisms unique to advanced liver disease. Finally, future research requirements are suggested, to develop effective treatments for one of the most common and debilitating complications afflicting cirrhotic patients.

Serial Observations of Muscle and Fat Mass as Prognostic Factors for Deceased Donor Liver Transplantation

Objective

Muscle depletion in patients undergoing liver transplantation affects the recipients' prognosis and therefore cannot be overlooked. We aimed to evaluate whether changes in muscle and fat mass during the preoperative period are associated with prognosis after deceased donor liver transplantation (DDLT).

Materials and Methods

This study included 72 patients who underwent DDLT and serial computed tomography (CT) scans. Skeletal muscle index (SMI) and fat mass index (FMI) were calculated using the muscle and fat area in CT performed 1 year prior to surgery (1 yr Pre-LT), just before surgery (Pre-LT), and after transplantation (Post-LT). Simple aspects of serial changes in muscle and fat mass were analyzed during three measurement time points. The rate of preoperative changes in body composition parameters were calculated (preoperative ΔSMI [%] = [SMI at Pre-LT − SMI at 1 yr Pre-LT] / SMI at Pre-LT × 100; preoperative ΔFMI [%] = [FMI at Pre-LT − FMI at 1 yr Pre-LT] / FMI at Pre-LT × 100) and assessed for correlation with patient survival.

Results

SMI significantly decreased during the preoperative period (mean preoperative ΔSMI, −13.04%, p < 0.001). In the multivariable analysis, preoperative ΔSMI (p = 0.016) and model for end-stage liver disease score (p = 0.011) were independent prognostic factors for overall survival. The mean survival time for patients with a threshold decrease in the preoperative ΔSMI (≤ −30%) was significantly shorter than for other patients (p = 0.007). Preoperative ΔFMI was not a prognostic factor but FMI increased during the postoperative period (p = 0.009) in all patients.

Conclusion

A large reduction in preoperative SMI was significantly associated with reduced survival after DDLT. Therefore, changes in muscle mass during the preoperative period can be considered as a prognostic factor for survival after DDLT.

Impact of Malnutrition on Outcomes in Patients Undergoing Transjugular Intrahepatic Portosystemic Shunt Insertion

BACKGROUND

Malnutrition is common in patients with cirrhosis and is associated with poor outcomes after hepatic resection and liver transplantation. Transjugular intrahepatic portosystemic shunt (TIPS) is performed for complications of cirrhosis.

AIM

To assess the impact of malnutrition on TIPS outcomes.

METHODS

A retrospective analysis was performed using the Healthcare Cost and Utilization Project: National Inpatient Sample database for TIPS procedures from 2005 to 2014. The primary end point was in-hospital mortality. The association of specific malnutrition diagnostic codes and race-ethnicity on mortality was evaluated with survey-weighted logistic regression adjusted for age, gender, admission type, insurance payer, hospital region, comorbidities, and length of stay (LOS).

RESULTS

From 2005 to 2014, an estimated 53,207 (95% CI 49,330-57,085) admissions with TIPS occurred. A diagnosis of malnutrition was present in 11%. In-hospital death post-TIPS occurred in 15.0% versus 10.7% (p value < 0.001) of patients with and without malnutrition, respectively. Patients with malnutrition had longer post-procedural LOS (median 6.7 vs. 2.9 days, p value < 0.001) and greater total hospital charges (median $144,752 vs. $79,781, p value < 0.001) and were more likely to be discharged to a skilled nursing facility (21.6% vs. 9.7%) than patients without malnutrition. Patients with malnutrition had increased odds of mortality (OR 1.31, 95% CI 1.07, 1.59) compared to patients with no malnutrition.

CONCLUSION

Malnutrition was associated with worse outcomes after TIPS. Further research is needed to understand the mechanism of malnutrition in post-procedure outcomes and the ability of interventions for nutritional optimization to improve outcomes.

Feasibility of Serial Ultrasound Measurements of the Rectus Femoris Muscle Area to Assess Muscle Loss in Patients Awaiting Liver Transplantation in the Intensive Care Unit

End-stage liver disease (ESLD) patients requiring intensive care unit (ICU) care before liver transplantation (LT) often experience significant muscle mass loss, which has been associated with mortality. In this exploratory study, we primarily aimed to assess the feasibility of serial ultrasound (US) rectus femoris muscle area (RFMA) measurements for the evaluation of progressive muscle loss in ICU-bound potential LT candidates and describe the rate of muscle loss as assessed by sequential US RFMA measurements. Secondarily, we sought to identify patient characteristics associated with muscle loss and determine how muscle loss is associated with survival.

Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update

More than five decades after it was originally conceptualized as rescue therapy for patients with intractable variceal bleeding, the transjugular intrahepatic portosystemic shunt (TIPS) procedure continues to remain a focus of intense clinical and biomedical research. By the impressive reduction in portal pressure achieved by this intervention, coupled with its minimally invasive nature, TIPS has gained increasing acceptance in the treatment of complications of portal hypertension. The early years of TIPS were plagued by poor long-term patency of the stents and increased incidence of hepatic encephalopathy. Moreover, the diversion of portal flow after placement of TIPS often resulted in derangement of hepatic functions, which was occasionally severe. While the incidence of shunt dysfunction has markedly reduced with the advent of covered stents, hepatic encephalopathy and instances of early liver failure continue to remain a significant issue after TIPS. It has emerged over the years that careful selection of patients and diligent post-procedural care is of paramount importance to optimize the outcome after TIPS. The past twenty years have seen multiple studies redefining the role of TIPS in the management of variceal bleeding and refractory ascites while exploring its application in other complications of cirrhosis like hepatic hydrothorax, portal hypertensive gastropathy, ectopic varices, hepatorenal and hepatopulmonary syndromes, non-tumoral portal vein thrombosis and chylous ascites. It has also been utilized to good effect before extrahepatic abdominal surgery to reduce perioperative morbidity and mortality. The current article aims to review the updated literature on the status of TIPS in the management of patients with liver cirrhosis.

Clinical implications, diagnosis, and management of diabetes in patients with chronic liver diseases

Diabetes mellitus (DM) negatively affects the development and progression of chronic liver diseases (CLD) of various etiologies. Concurrent DM and CLD are also associated with worse clinical outcomes with respect to mortality, the occurrence of hepatic decompensation, and the development of hepatocellular carcinoma (HCC). Unfortunately, early diagnosis and optimal treatment of DM can be challenging, due to the lack of established clinical guidelines as well as the medical complexity of this patient population. We conducted an exploratory review of relevant literature to provide an up-to-date review for internists and hepatologists caring for this patient population. We reviewed the epidemiological and pathophysiological associations between DM and CLD, the impact of insulin resistance on the progression and manifestations of CLD, the pathogenesis of hepatogenic diabetes, as well as the practical challenges in diagnosis and monitoring of DM in this patient population. We also reviewed the latest clinical evidence on various pharmacological antihyperglycemic therapies with an emphasis on liver disease-related clinical outcomes. Finally, we proposed an algorithm for managing DM in patients with CLD and discussed the clinical and research questions that remain to be addressed.

Nutrition Parameters for Assessing Malnutrition in a Population of US Veterans With Hepatitis C Virus

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.

Transcriptomic profile of semitendinosus muscle of bulls of different breed and performance

The aim of the study was to compare the transcriptomic profiles of fully differentiated skeletal muscle derived from bulls belonging to different breeds of varying performance. Microarray analyses were performed to determine the differences in the expression profiles of genes between semitendinosus muscles of 15-month-old beef-breed bulls (Limousin—LIM and Hereford—HER) and dairy-breed bulls (Holstein Friesian—HF). These analyses allowed for the identification of those genes the expression of which is similar and characteristic of fully differentiated muscle in beef breeds, but differs in skeletal muscle of a typical dairy breed. The analysis revealed 463 transcripts showing similar expression in the semitendinosus muscle of beef breeds (LIM/HER), in comparison with the dairy breed (HF). Among the identified genes, 227 were upregulated and 236 were downregulated in beef breeds. The ontological analyses revealed that the largest group of genes similarly expressed in LIM and HER was involved in the processes of protein metabolism and development of muscle organ. In beef breeds, some genes involved in protein synthesis and proteolysis showed an upregulation, including ctsd, ctsf, fhl2, fhl3, fst, sirt1, and trim63, whereas some were downregulated, including bmpr1a, bmpr2, mstn, smad2, hspa8, gsk3β, and tgfβ2. The expression of the chosen genes was confirmed by RT-qPCR technique. Thus, it can be assumed that the identified genes involved in the regulation of growth and development of muscle tissue and the processes of protein metabolism in the examined cattle breeds may be responsible for the greater gain of muscle mass in beef-breed bulls.

Excess Weight Gain After Cure of Hepatitis C Infection with Direct-Acting Antivirals

BACKGROUND

Cure from chronic hepatitis C virus (HCV) infection is readily achievable with direct-acting antivirals (DAA), but little is known about optimal management after treatment. Weight gained after DAA treatment may mitigate benefits or increase risk for liver disease progression. As the single largest sample of HCV-infected individuals receiving DAA treatment in the United States, the Veterans Affairs (VA) Birth Cohort is an ideal setting to assess weight gain after DAA treatment.

METHODS

We performed a prospective study of patients dispensed DAA therapy from January 2014 to June 2015. Weight change was calculated as the difference in weight from sustained virologic response (SVR) determination to 2 years later. Demographic, weight, height, prescription, laboratory, and diagnosis code data were used for covariate definitions. We used multiple logistic regression to assess the association between candidate predictors and excess weight gain (≥ 10 lbs) after 2 years.

RESULTS

Among 11,469 patients, 78.0% of patients were already overweight or obese at treatment initiation. Overall, SVR was achieved in 97.0% of patients. After 2 years, 52.6% of patients gained weight and 19.8% gained excess weight. In those with SVR, weight gain was as high as 38.2 lbs, with the top 10% gaining ≥ 16.5 lbs. Only 1% of those with obesity at treatment initiation normalized their weight class after 2 years. Significant predictors of post-SVR weight gain were SVR achievement, lower age, high FIB-4 score, cirrhosis, and weight class at treatment initiation.

CONCLUSION

Weight gain is common after DAA treatment, even among those who are overweight or obese prior to treatment. Major predictors include age, baseline weight, alcohol, cirrhosis, and SVR. Everyone receiving DAAs should be counseled against weight gain with a particular emphasis among those at higher risk.

Nutrition in alcohol-related liver disease: Physiopathology and management

Malnutrition encompassing both macro- and micro-nutrient deficiency, remains one of the most frequent complications of alcohol-related liver disease (ArLD). Protein-energy malnutrition can cause significant complications including sarcopenia, frailty and immunodepression in cirrhotic patients. Malnutrition reduces patient’s survival and negatively affects the quality of life of individuals with ArLD. Moreover, nutritional deficit increases the likelihood of hepatic decompensation in cirrhosis. Prompt recognition of at-risk individuals, early diagnosis and treatment of malnutrition remains a key component of ArLD management. In this review, we describe the pathophysiology of malnutrition in ArLD, review the screening tools available for nutritional assessment and discuss nutritional management strategies relevant to the different stages of ArLD, ranging from acute alcoholic hepatitis through to decompensated end stage liver disease.

Resistance Training Increases Muscle Strength and Muscle Size in Patients With Liver Cirrhosis

BACKGROUND & AIMS

Cirrhosis is often complicated by reduced muscle mass and strength, which limits the ability to perform daily activities and affects quality of life. Resistance training can increase muscle strength and mass in elderly and chronically ill patients. We performed a randomized controlled trial to investigate whether resistance training increases muscle strength and size in patients with compensated cirrhosis.

METHODS

We performed a prospective study of 39 patients with cirrhosis (Child-Pugh class A or B) seen at an outpatient clinic in Denmark from January 2015 through March 2017. Participants protein intake and activity levels were registered daily. Participants were randomly assigned (1:1) to a group that performed 36 1-hour sessions of physical exercise (supervised progressive resistance training for 1 hour, 3 times weekly for 12 weeks) or a control group (no change in daily activity level). Maximal muscle strength was measured as the peak torque in isokinetic knee extension and muscle size was measured as the cross-sectional area of the quadriceps muscle, assessed by magnetic resonance imaging of the thigh.

RESULTS

The exercise group increased their muscle strength by 13% (from a mean 119 Nm to 134 Nm)-an 11 Nm greater gain in mean strength than that of the control group (P = .05). The exercise group increased their quadriceps cross-sectional area by 10% (from a mean 58.5 cm² to 64.6 cm²)-a 4.4 cm² greater gain than that of the control group (P < .01). The exercise group had significant increases in whole-body lean mass and body cell mass, and significant increases in 6-minute walking distance and the mental component summary of the short form-36 questionnaire. Adverse events were minor and equal between groups.

CONCLUSIONS

In a randomized trial of patients with compensated cirrhosis, we found that 12 weeks of supervised progressive resistance training increased muscle strength and size and had beneficial effects on general performance measures, compared with patients who did not change their daily activity routine (control subjects). ClinicalTrials.gov no: NCT02343653.

Continued muscle loss increases mortality in cirrhosis: Impact of aetiology of liver disease

BACKGROUND AND AIMS

Sarcopenia or skeletal muscle loss adversely affects outcomes in cirrhosis. The impact of aetiology of liver disease on the severity or the rate of muscle loss is not known.

METHODS

Consecutive, well-characterized adult patients with cirrhosis due to viral hepatitis (VH), alcoholic liver disease (ALD) or non-alcoholic fatty liver disease (NAFLD) and non-diseased controls with at least two temporally distinct abdominal CT (computed tomography) scans were evaluated. Psoas, paraspinal and abdominal wall muscle areas at the L3 vertebra level were quantified on the CT scans. Standardized rate of change in muscle area was expressed as change in area/100 days. Univariate and multivariable analyses were performed to identify contributors to rate of muscle loss and survival.

RESULTS

Among 83 cirrhotics (NAFLD n = 26, ALD n = 39, VH n = 18), there were 20 (24.1%) deaths over 62.7 ± 41.3 months. The mean percentage change in psoas area was -0.03 ± 0.05/100d in controls and -3.52 ± 0.45/100d in cirrhosis (P < .001). The mean percentage change in psoas area was -1.72 ± 0.27/100d in NAFLD, -5.28 ± 0.86/100d in ALD and -2.29 ± 0.28/100d in VH. Among cirrhotics, patients with ALD had the lowest initial muscle area and most rapid rate of reduction in muscle area. Aetiology of liver disease, model for end-stage liver disease (MELD) and the rate of loss of muscle area were independent risk factors for survival.

CONCLUSIONS

Aetiology of liver disease is an independent risk factor for sarcopenia with the greatest rate of muscle loss noted in ALD. Survival in cirrhosis was dependent on initial muscle mass, rate of muscle loss and MELD score.

Skeletal muscle loss phenotype in cirrhosis: A nationwide analysis of hospitalized patients

BACKGROUND & AIMS

There are very limited data on the healthcare burden of muscle loss, the most frequent complication in hospitalized cirrhotics. We determined the healthcare impact of a muscle loss phenotype in hospitalized cirrhotics.

METHODS

The Nationwide Inpatient Sample (NIS) database (years 2010-2014) was analyzed. Search terms included cirrhosis and its complications, and an expanded definition of a muscle loss phenotype that included all conditions associated with muscle loss. In-hospital mortality, length of stay (LOS), post-discharge disposition, co-morbidities and cost during admission were analyzed. Univariate and multivariate analyses were performed to identify associations between a muscle loss phenotype and outcomes. Impact of muscle loss in cirrhotics was compared to that in a random sample (2%) of general medical inpatients.

RESULTS

A total of 162,694 hospitalizations for cirrhosis were reported, of which 18,261 (11.2%) included secondary diagnosis codes for a muscle loss phenotype. A diagnosis of muscle loss was associated with a significantly (p < 0.001 for all) higher mortality (19.3% vs 8.2%), LOS (14.2 ± 15.8 vs. 4.6 ± 6.9 days), and median hospital charge per admission ($21,400 vs. $8573) and a lower likelihood of discharge to home (30.1% vs. 60.2%). All evaluated outcomes were more severe in cirrhotics than general medical patients (n = 534,687). Multivariate regression analysis showed that a diagnosis of muscle loss independently increased mortality by 130%, LOS by 80% and direct cost of care by 119% (p < 0.001 for all). Alcohol use, female gender, malignancies and other organ dysfunction were independently associated with muscle loss.

CONCLUSIONS

Muscle loss contributed to higher mortality, LOS, and direct healthcare costs in hospitalized cirrhotics.

Exercise and physical activity in cirrhosis: opportunities or perils

Reduced exercise capacity and impaired physical performance are observed in nearly all patients with liver cirrhosis. Physical activity and exercise are physiological anabolic stimuli that can reverse dysregulated protein homeostasis or proteostasis and potentially increase muscle mass and contractile function in healthy subjects. Cirrhosis is a state of anabolic resistance, and unlike the beneficial responses to exercise reported in physiological states, there are few systematic studies evaluating the response to exercise in cirrhosis. Hyperammonemia is a mediator of the liver-muscle axis with net skeletal muscle ammonia uptake in cirrhosis causing signaling perturbations, mitochondrial dysfunction with decreased ATP content, modifications of contractile proteins, and impaired ribosomal function, all of which contribute to anabolic resistance in cirrhosis and have the potential to impair the beneficial responses to exercise. English language-publications in peer-reviewed journals that specifically evaluated the impact of exercise in cirrhosis were reviewed. Most studies evaluated responses to endurance exercise, and readouts included peak or maximum oxygen utilization, grip strength, and functional capacity. Endurance exercise for up to 12 wk is clinically tolerated in well-compensated cirrhosis. Data on the safety of resistance exercise are conflicting. Nutritional supplements enhance the benefits of exercise in healthy subjects but have not been evaluated in cirrhosis. Whether the beneficial physiological responses with endurance exercise and increase in muscle mass with resistance exercise that occur in healthy subjects also occur in cirrhotics is not known. Specific organ-system responses, changes in body composition, or improved long-term clinical outcomes with exercise in cirrhosis need evaluation.

Nutrition in Chronic Liver Disease: A Point-of-Care Review

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.

Sarcopenia in Cirrhosis: Looking Beyond the Skeletal Muscle Loss to See the Systemic Disease

Sarcopenia is a common complication of cirrhosis and is defined as a progressive and generalized loss of skeletal muscle mass, strength, and function. Sarcopenia is associated with poor prognosis and increased mortality. How sarcopenia and muscle wasting relate to such poor outcomes requires looking beyond the overt muscle loss and at this entity as a systemic disease that affects muscles of vital organs including cardiac and respiratory muscles. This review explores the pathophysiological pathways and mechanisms that culminate in poor outcomes associated with sarcopenia. This provides a launching pad to identify potential targets for therapeutic intervention and optimization to improve patient outcomes.

Impact of Bacterial Translocation on Sarcopenia in Patients with Decompensated Cirrhosis

Advanced liver disease is associated with a persistent inflammatory state, derived from abnormal bacterial translocation from the gut, which may contribute to the development of sarcopenia in cirrhosis. We aim to document the association of chronic inflammation and bacterial translocation with the presence of sarcopenia in cirrhosis. We prospectively followed cirrhotic patients aged 18-70 years with medically refractory ascites at a single tertiary care center in Toronto, Canada. The baseline data included patient demographic variables, the presence of bacterial DNA in serum/ascitic fluid, systemic inflammatory response syndrome (SIRS) status, and nutritional assessment. Thirty-one patients were enrolled, 18 (58.1%) were sarcopenic, 9 (29%) had bacterial DNA in serum and ascites fluid. The mean MELD score was 11.5 ± 4.0 (6-23). Sarcopenic and non-sarcopenic patients did not differ significantly in their baseline MELD scores, caloric intake, resting energy expenditure, the incidence of bacterial translocation, or SIRS. While sarcopenia was not linked to increased hospital admissions or death, it was strongly associated with increased episodes of acute kidney injury (3 vs. 0, p = 0.05). This pilot study did not demonstrate an association between sarcopenia and SIRS or bacterial translocation. These results should be confirmed in future larger studies, encompassing a greater number of chronic inflammation events and quantifying levels of bacterial DNA.

Nutritional management of cirrhosis patients: A qualitative study exploring perceptions of patients and health workers in Ghana

BACKGROUND AND AIMS

Malnutrition is common among patients with end stage liver disease including liver cirrhosis and liver cancer. Optimal nutrition is important to reduce morbidity and mortality of these patients. There is limited qualitative data on nutritional status and management of chronic liver disease patients. We aimed to explore the knowledge, opinions and practices of cirrhosis patients and health workers in nutritional management of cirrhosis in Ghana, in order to determine whether there is a need to improve nutritional care for cirrhosis patients.

METHODS

We conducted a qualitative study using semi-structured interviews of cirrhotic patients (n = 16) and healthcare providers (n = 27) in three academic centers in Accra, Kumasi and Cape Coast (Ghana). Recruitment was by purposive sampling of patients attending specialist liver disease clinics. The recorded data were analyzed using NVivo 11 software, with generation of codes, themes and subthemes.

RESULTS

The major themes that emerged from the data included nutrition as part of care delivery during the hospital visit, nutritional recommendations, dietary changes and long-term practice improvement. The results showed that patients and health workers felt dietary recommendations for patients were frequently addressed, but could be significantly improved. We found that in the opinion of study participants, local guidelines are important and necessary in nutritional management of cirrhosis patients, and that participants felt it was difficult to change dietary habits following cirrhosis diagnosis.

CONCLUSIONS

These results suggest that nutritional management of cirrhosis patients in Ghana requires improvement. Strategies to improve this could include a multi-disciplinary approach to nutritional management, development of local guidelines and continued nutritional assessment, monitoring and follow-up.

The Relationship of Obesity, Nutritional Status and Muscle Wasting in Patients Assessed for Liver Transplantation

INTRODUCTION

Obesity co-exists with malnutrition and muscle atrophy in patients with cirrhosis. Muscle wasting is a feature of sarcopenia, a known determinant of patient outcomes. This is the first description of a relationship between obesity, subjective global assessment (SGA) of nutritional status and muscle wasting in patients with cirrhosis.

METHODS

The relationship between body mass index (BMI with obesity defined as ≥ 30 kg/m2), nutritional status (assessed by liver-specific subjective global assessment-SGA) and muscle wasting (assessed by corrected total cross-sectional psoas muscle area-cTPA) was analysed in patients with cirrhosis considered for liver transplantation between 1 January 2012 and 31 December 2014.

RESULTS

There were 205 patients, of whom 70% were males. The mean age was 52 ± 0.7 years and the Model for End-Stage Liver Disease (MELD) score was 16.8 ± 0.5. Overall, 31% of patients were obese and 56% of well-nourished (SGA A) individuals were obese. Muscle wasting was identified in 86% of all patients, irrespective of their nutritional status (A, B, C). All obese males classified as well-nourished (SGA A) were sarcopenic and 62% of obese females classified as SGA A were sarcopenic. Muscle wasting was worse in obese individuals (cTPA 230.9 mm2/m2 ± 12.9, p < 0.0001) and more likely to be associated with hepatic encephalopathy (p = 0.03). Univariate and multivariate analysis demonstrated testosterone deficiency was significantly associated with muscle wasting (p = 0.007) but not obesity (p = 0.8).

CONCLUSION

Obesity combined with muscle wasting is common in patients with cirrhosis. Muscle wasting is common in well-nourished (SGA A) obese patients. Consequently, all patients assessed for liver transplantation should undergo additional screening for malnutrition and muscle wasting irrespective of BMI.

Is rectus abdominis thickness associated with survival among patients with liver cirrhosis? A prospective cohort study

BACKGROUND

Sarcopenia may affect patients with liver cirrhosis and worsen disease outcomes.

OBJECTIVES

To evaluate ultrasound-measured psoas major (PM) and rectus abdominis (RA) thickness for predicting survival among patients with liver cirrhosis.

DESIGN AND SETTING

Prospective cohort study in a tertiary-level hospital.

METHODS

61 patients with liver cirrhosis were prospectively included during a 15-month period and followed up for at least six months. Cirrhosis was classified using the Child-Pugh score. Sarcopenia was assessed using surrogate parameters: handgrip strength (HGS), mid-arm muscle circumference (MAMC) and SGA (subjective global assessment). We used ultrasound to measure RA and PM thickness at admission.

RESULTS

There were 41 men. The patients' mean age was 58.03 ± 10.8 years. 26.22% of them were Child-Pugh A, 45.9% B and 27.86% C. The patients were followed up for 11.9 ± 5.63 months. RA thickness correlated moderately with MAMC (r = 0. 596; P < 0.0001) and HGS (r = 0.515; P < 0.0001) and decreased with increasing SGA class (A, 10.6 ± 2.8 mm; B, 8.3 ± 1.9 mm; C, 6.5 ± 1.9 mm; P < 0.0001). Survival at six months was independently predicted by using the model for end-stage liver disease-serum sodium score (odds ratio, OR 1.305; 95% OR confidence interval 1.083-1.572; P = 0.005). Survival during follow-up was independently predicted by RA thickness (hazard ratio, HR 0.701; 95% HR confidence interval 0.533-0.922; P = 0.011) and ascites (HR 1.876; 95% HR confidence interval 1.078-3.267; P = 0.026). PM thickness did not have any predictive value.

CONCLUSIONS

As a surrogate marker of sarcopenia, RA thickness may predict survival among patients with liver cirrhosis.

Nutritional support in cirrhotic patients with sarcopenia

Sarcopenia has been linked to oncologic and chronic diseases such as liver cirrhosis. In fact, sarcopenia is present in 25-70% of patients with liver cirrhosis. Furthermore, sarcopenia is an independent predictor of poor prognosis in many diseases. Currently cirrhotic patients are recommended to adopt a high protein diet (1.5 g/kg/day) with 30-40 kcal/kg/day and several meals throughout the day, being late evening snack intake with at least 50 g of carbohydrates of special importance. Despite the growing interest in the impact of sarcopenia in cirrhotic patients, there are still gaps in knowledge in the appropriate diagnostic criteria for this syndrome, the role of gut microbiota, as well as the most appropriate nutritional therapy.

Recipient body mass index and infectious complications following liver transplantation

BACKGROUND

Nutritional problems are common in patients requiring liver transplantation. Recipient obesity or malnutrition are thought to increase postoperative complications. Body mass index (BMI) is commonly used prior to major surgery but its value specifically in liver transplant assessment has not been established. This is a retrospective study assessing the correlation between the BMI of individuals undergoing liver transplant and the development of postoperative infectious complications.

METHODS

Data were collected from a prospectively maintained database regarding all consecutive patients over a period of 23 years. Preoperative recipient BMI was correlated with the number, nature and outcome of postoperative infective complications.

RESULTS

Of a total of 1156 consecutive patients, 13.2% developed infectious complications. Thirty-day mortality was 7.2% and 90-day mortality was 10%. Higher BMI was associated with higher risk of infections (p = 0.002). Wound infections occurred predominantly in obese patients (p = 0.001) while other types of infections were more common in malnourished patients (p < 0.001).

CONCLUSION

Extremes of BMI are associated with increased infectious complications following liver transplantation. Patients with lower BMI had a higher rate of overall infectious complications whereas those with a higher BMI had increased general and wound complications.

Nutrition in Cirrhosis

PURPOSE OF REVIEW

This review discusses the prevalence of malnutrition in cirrhosis, metabolic functions of the liver and alterations in cirrhosis, malnutrition screening tools, and common macronutrient and micronutrient deficiencies encountered in individuals with chronic liver disease and their impact on morbidity and mortality.

RECENT FINDINGS

Several meta-analyses and international society guidelines recommend malnutrition screening and nutrition interventions to improve outcomes in all patients with chronic liver disease given their high risk of malnutrition which is often under recognized. Malnutrition is common in individuals with chronic liver disease and has a significant impact on patient outcomes. Thus, it is critical that validated malnutrition screening tools are used routinely in this patient population in order to identify high-risk patients and implement nutrition and exercise interventions early.

Semiautomatic software for measurement of abdominal muscle and adipose areas using computed tomography: A STROBE-compliant article

The aim of the study was to introduce our in-house software to measure the muscle and adipose area on axial computed tomography (CT) scans and to compare with various quantification methods.Our institutional review board approved this retrospective study and informed consent was waived. We developed in-house software to identify body composition analysis on CT scan, which semiautomatically operates 3 image processing steps. Abdominal images were obtained using multidetector row CT (MDCT). Two radiologists analyzed the same cross-sectional areas of subcutaneous fat, muscle, and visceral fat using the following techniques: manual measurements, Aquarius, ImageJ, and our newly developed software. We calculated an intraclass correlation coefficient (ICC) for comparison of muscle and fat areas quantified by various measurement methods using a 2-way random model. Interobserver agreement between the radiologists was also evaluated.Agreements in the measurement of subcutaneous fat and muscle areas were excellent among the methods (ICC = 0.962 and 0.897, respectively), and that of the visceral fat area was good (ICC = 0.822). In the subgroup analysis, ICC of the visceral fat area in the female group and in subjects with ascites was slightly lower than the other group (ICC = 0.742 and 0.787, respectively). The correlation coefficients between our software and other methods were relatively high (r = 0.854-0.996). Additionally, ICCs between both observers of our program for quantification of subcutaneous fat, muscle, and visceral fat areas were 0.999, 0.980, and 0.999, respectively.In conclusion, our method showed be reliable in quantifying muscle and adipose tissue using cross-sectional areas of MDCT with high reproducibility.

Nutrition in Patients With Cirrhosis

Malnutrition is a common complication of cirrhosis, increases in frequency with Child-Turcotte-Pugh (CTP) score, and is associated with an increased morbidity and mortality. Although malnutrition is easily recognized in chronically ill patients with CTP class C cirrhosis, it is present but often unrecognized in up to 50% of patients with CTP class A cirrhosis; thus, all patients with cirrhosis, regardless of etiology or severity, should be screened for malnutrition. A nutritional screening should be incorporated into the routine clinical care of patients with cirrhosis, with a more extensive nutritional assessment that includes a detailed history, dietary recall, baseline nutrition laboratory tests, and evaluation of sarcopenia using imaging modalities or strength testing to determine the degree of frailty. A thorough assessment will allow for a personalized treatment plan that provides the patient with total daily caloric intake goals with an emphasis on quality protein, education on timing of oral intake with a reduction in periods of fasting, identification and treatment of micronutrient deficiencies, and recommendation of safe and realistic exercise programs to help prevent and/or reduce sarcopenia and improve frailty.

L-Ornithine L-Aspartate for the Treatment of Sarcopenia in Chronic Liver Disease: The Taming of a Vicious Cycle

Sarcopenia is a common complication of cirrhosis with a negative impact on posttransplant outcome, health-related quality of life (HRQOL), and patient survival. Studies in experimental animals and in patients demonstrate that ammonia is directly implicated in the pathogenesis of sarcopenia in cirrhosis via mechanisms involving increased expression of myostatin and of autophagy markers such as LC3 lipidation and p62 leading to muscle dysmetabolism and sarcopenia. Paradoxically, skeletal muscle replaces liver as the primary ammonia-detoxifying site as a result of the modification of genes coding for key proteins implicated in ammonia-lowering pathways in cirrhosis. Thus, a vicious cycle occurs whereby hyperammonemia causes severe muscle damage and sarcopenia that, in turn, limits the capacity of muscle to remove excess blood-borne ammonia and the cycle continues. Randomized clinical trials and meta-analyses confirm that L-ornithine L-aspartate (LOLA) is an effective ammonia-lowering agent currently employed for the treatment of hepatic encephalopathy (HE) that stimulates both urea synthesis by residual hepatocytes and muscle glutamine synthesis together with putative hepatoprotective actions. Treatment of cirrhotic patients with LOLA limits ammonia-induced sarcopenia by improving muscle protein synthesis and function. It is conceivable that the antisarcopenic action of LOLA contributes to its efficacy for the treatment of HE in cirrhosis.

The evolution and impact of sarcopenia pre- and post-liver transplantation

BACKGROUND

Sarcopenia is associated with both increased wait-list mortality and mortality following liver transplantation.

AIMS

To determine the course of sarcopenia from transplant evaluation until 1 year post-transplant, and its implications on hospitalisation and mortality following liver transplantation.

METHODS

Two hundred and ninety-three transplant recipients from 2002 to 2006 had pre-transplant CT scans analysed at the third lumbar region for sarcopenia, myosteatosis and abdominal visceral fat content. Half the recipients had post-transplant CT scan for interpretation (161/293).

RESULTS

Sarcopenia was present in 146/293 (50%) of the patients pre-transplant. There was a significant decrease in muscle mass (loss 2.0 ± 4.9 cm² /m² ; P < 0.001), and an increase in myosteatosis while awaiting liver transplantation. There was no significant change in abdominal visceral fat. For every 1 cm² /m² decrease in muscle mass there was an increase in post-transplant length of stay by 0.36 days (P = 0.005). Post-transplant, 98/161 (61%) of patients with CT imaging had sarcopenia (25 de novo and 73 persistent), with continued increase in myosteatosis, lower Hounsfield units (-5.0 [IQR -8.6 to 0.1]; P < 0.001) and an increase in abdominal visceral fat (4.9 [IQR -4.4 to 15.6] cm² /m² ; P < 0.001). There was no statistically significant difference in 1-year mortality in patients with de novo sarcopenia compared to patients with sarcopenia both pre- and post-transplant (HR 1.88; P = 0.088).

CONCLUSIONS

Sarcopenia progresses up to 1 year following liver transplantation and is associated with an increase in post-transplant length of stay.

Advances in ultrasound diagnosis in chronic liver diseases

Chronic liver disease is a major disorder worldwide. A better understanding of anatomy, blood flow, and pathophysiology may be a key issue for their proper management. Ultrasound (US) is a simple and non-invasive diagnostic tool in the abdominal field. Doppler mode offers real-time hemodynamic evaluation, and the contrast-enhanced US is one of the most frequently used modalities for the detailed assessment. Further development in digital technology enables threedimensional (3D) visualization of target images with high resolution. This article reviews the wide ranges of application in the abdominal US and describes the recent progress in the diagnosis of chronic liver diseases.

Interventions to improve sarcopenia in cirrhosis: A systematic review

BACKGROUND

Sarcopenia, i.e., muscle loss is now a well-recognized complication of cirrhosis and in cases of non-alcoholic fatty liver disease can contribute to accelerate liver fibrosis leading to cirrhosis. Hence, it is imperative to study interventions which targets to improve sarcopenia in cirrhosis.

AIM

To examine the relationship between interventions such nutritional supplementation, exercise, combined life style intervention, testosterone replacement and trans jugular intrahepatic portosystemic shunt (TIPS) to improve muscle mass in cirrhosis.

METHODS

We search PubMed, EMBASE and Cochrane between June-August 2018, without a limiting period and the types of articles (RCTs, clinical trial, comparative study) in adult patients with sarcopenia and cirrhosis. The primary outcome of interest was improvement in muscle mass, strength and physical function interventions mentioned above. In the screening process, 154 full text articles were included in the review and 129 studies were excluded.

RESULTS

We identified 24 studies that met review inclusion criteria. The studies were diverse in terms of the design, setting, interventions, and outcome measurements. We performed only qualitative synthesis of evidence due to heterogeneity amongst studies. Risk of bias was medium in most of the included studies and low quality of evidence showed improvement in the muscle mass, strength and physical function following aerobic exercise. 60% of the included studies on the nutritional intervention, 100% of the studies on testosterone replacement in hypogonadal men and trans-jugular portosystemic shunt were proved to be effective in improving sarcopenia in cirrhosis.

CONCLUSION

Although the quality of evidence is low, the findings of our systematic review suggest improvement in the sarcopenia in cirrhosis with exercise, nutritional interventions, hormonal and TIPS interventions. High quality randomized controlled trials needed to further strengthen these findings.

Differing Impact of Sarcopenia and Frailty in Nonalcoholic Steatohepatitis and Alcoholic Liver Disease

Sarcopenia and frailty are commonly encountered in patients with end-stage liver disease and are associated with adverse clinical outcomes, including decompensation and wait-list mortality. The impact of these entities in patients with differing disease etiologies has not been elucidated. We aim to ascertain the change in their prevalence over time on the wait list and determine their impact on hospitalization, delisting, and wait-list survival, specifically for patients with nonalcoholic steatohepatitis (NASH) and alcoholic liver disease (ALD). Adult patients who were evaluated for their first liver transplant from 2014 to 2016 with a primary diagnosis of NASH (n = 136) or ALD (n = 129) were included. Computed tomography scans were used to determine the presence of sarcopenia and myosteatosis. Frailty was diagnosed using the Rockwood frailty index. Patients with NASH had a significantly lower prevalence of sarcopenia (22% versus 47%; P < 0.001) but a significantly higher prevalence of frailty (49% versus 34%; P = 0.03) when compared with patients with ALD at the time of listing. In patients with NASH, sarcopenia was not associated with adverse events, but a higher frailty score was associated with an increased length of hospitalization (P = 0.05) and an increased risk of delisting (P = 0.02). In patients with ALD, univariate analysis showed the presence of sarcopenia was associated with an increased risk of delisting (P = 0.01). In conclusion, sarcopenia and frailty occur with differing prevalence with variable impact on outcomes in wait-listed patients with NASH and ALD.

Effect of loop diuretics on skeletal muscle depletion in patients with liver cirrhosis

AIM

Sarcopenia, the loss of skeletal muscle mass, impairs prognosis of patients with liver cirrhosis. The aim of this study was to investigate the effect of loop diuretics, which are frequently used to treat hepatic edema/ascites, on skeletal muscle depletion and the prognosis in patients with liver cirrhosis.

METHODS

This retrospective study evaluated 226 patients with liver cirrhosis. The skeletal muscle cross-sectional area at the level of the third lumbar vertebra was measured using computed tomography. The relative change in skeletal muscle area per year (ΔSMA) was calculated, and the association between ΔSMA and therapeutic dosage of loop diuretics was examined.

RESULTS

The therapeutic dosage of loop diuretics was inversely correlated with ΔSMA by simple (r = -0.27, P < 0.0001) and multiple regression analyses (t = -3.07, P = 0.002). During a median follow-up period of 49 months, 82 patients died. Overall survival rates were lower in patients treated with loop diuretics at >20 mg than in those who received ≤20 mg (median, 66 vs. 97 months; P = 0.002). Multivariate analysis revealed that loop diuretics of >20 mg (hazard ratio [HR], 1.86; 95% confidence interval [CI], 1.03-3.24; P = 0.039) and ΔSMA of ≤-3.1% (HR, 3.87; 95% CI, 2.32-6.60; P < 0.0001) were independently associated with mortality.

CONCLUSIONS

A higher dose of loop diuretic use was associated with more rapid skeletal muscle depletion and poor survival in patients with liver cirrhosis, independent of the severity of liver disease.

EASL Clinical Practice Guidelines on nutrition in chronic liver disease

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.

Physical exercise for people with cirrhosis

BACKGROUND

Loss of muscle mass and muscle weakness are common complications to cirrhosis and are associated with increased morbidity and mortality. Therefore, physical exercise may benefit people with cirrhosis.

OBJECTIVES

To assess the beneficial and harmful effects of physical exercise versus sham exercise or no exercise for people with cirrhosis.

SEARCH METHODS

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Ovid, Embase Ovid, and three other databases, including manual searches through reference lists, abstracts, and presentations at conferences and meetings, Google Scholar, and online trial registers in February 2018.

SELECTION CRITERIA

We included randomised clinical trials regardless of publication status or language. Inclusion criteria were cirrhosis irrespective of the aetiology or stage. Interventions were physical exercise compared with sham exercise or no intervention.

DATA COLLECTION AND ANALYSIS

Three review authors independently extracted data. We undertook meta-analyses and presented results using risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, both with 95% confidence intervals (CI) and I² values as markers of imprecision and heterogeneity. We assessed bias control using the Cochrane Hepato-Biliary Group domains and determined the credibility of the evidence using GRADE.

MAIN RESULTS

We included six randomised clinical trials with 173 participants. All participants had Child-Pugh stage A or B cirrhosis. The intervention groups participated in eight to 14 weeks of physical exercise (aerobic: three trials; resistance: one trial; or aerobic plus resistance training: two trials). Control groups underwent sham exercise (supervised relaxation: one trial) or no intervention (five trials). None of the 89 participants allocated to exercise versus two of 84 participants in the control group died (RR 0.19, 95% CI 0.01 to 3.73; moderate-quality evidence). The cause of death was acute-on-chronic liver disease for both participants. Nine participants in the exercise group and 13 in the control group experienced serious adverse events (RR 0.61, 95% CI 0.19 to 1.94; low-quality evidence).Physical exercise showed no beneficial or detrimental effect on health-related quality of life assessed by the Chronic Liver Disease Questionnaire (MD 0.11, 95% CI -0.44 to 0.67; low-quality evidence). Likewise, physical exercise had no clear effect on physical fitness measured by peak exercise oxygen uptake (MD 0.3 mL/kg/minute, 95 % CI -2.74 to 3.35; low-quality evidence) and Six-Minute Walk Test (MD 56.06 min, 95% CI -9.14 to 121.26; very low-quality evidence). Physical exercise showed no clear effect on mid-thigh circumference (MD 1.76 cm, 95% CI -0.26 to 3.77; low-quality evidence), but showed an increase in mid-arm circumference (MD 2.61 cm, 95% CI 0.36 to 4.85; low-quality evidence).

AUTHORS' CONCLUSIONS

We found no clear beneficial or harmful effect of physical exercise on mortality, morbidity, or health-related quality of life. Further evidence is needed to evaluate the beneficial and harmful effects of physical exercise on clinical outcomes.

Apparent Diffusion Coefficient Is a Novel Imaging Biomarker of Myopathic Changes in Liver Cirrhosis

Diffusion weighted imaging can provide information regarding tissue composition and can quantitatively characterize different pathological changes by means of apparent diffusion coefficient (ADC). The study comprised of 114 patients with liver cirrhosis-22 women and 92 men with a mean age of 56.5 ± 9.0 years. In all patients, the Model for End Stage-Liver Disease (MELD) score was calculated. Furthermore, 12 healthy persons (5 women, 7 men), mean age, 42.1 ± 16.2 years, were investigated as a control group. In all cases, magnetic resonance imaging of the liver/trunk was performed using different 3T scanners and diffusion weighted images were obtained with a multi-shot SE-EPI sequence. In all cases, polygonal regions of interest were manually drawn on the ADC maps along the contours of the iliopsoas and paravertebral muscles. The comparison of ADC values in groups was performed by Mann-Whitney-U tests. The association between ADC and MELD score was calculated by Spearman's rank correlation coefficient. ADC values of the skeletal musculature were statistically much higher in comparison to those in the control group: 1.85 ± 0.46 × 10^-3 mm² s^-1 vs. 1.23 ± 0.12 × 10^-3 mm² s^-1, p = 0.001. ADC values showed statistically significant correlation with the MELD score (r = 0.473, p = 0.0001). Furthermore, ADC values differed between the subgroups with different values of the MELD score. ADC values correlated slightly with lactate dehydrogenase (LDH) (r = 0.381, p = 0.0001) and tended to correlate with C-reactive protein (CRP) (r = 0.171, p = 0.07) and alanine aminotransferase (ALAT) (r = -0.167, p = 0.076). ADC can reflect muscle changes in liver cirrhosis and shows statistically significant correlation with the MELD score. Therefore, ADC can be used as an imaging biomarker of myopathic changes in liver cirrhosis.

Dietary management and supplementation with branched-chain amino acids in cirrhosis of the liver

One of the most important characteristics of malnutrition is the loss of muscle mass and the severe depletion of the protein reserve, secondarily affecting energy metabolism. That impacts nutritional status and the progression of disease-related complications. Nutritional treatment is one of the main factors in the comprehensive management of those patients. Achieving adequate energy intake that provides the macronutrients and micronutrients necessary to prevent or correct malnutrition is attempted through dietary measures. ESPEN, the European Society for Clinical Nutrition and Metabolism, recommends a caloric intake of 30-40kcal/kg/day, in which carbohydrates provide 45-60% of the daily energy intake and proteins supply 1.0-1.5g/kg/day. The remaining portion of the total energy expenditure should be covered by lipids. The administration of branched-chain amino acids has been shown to be beneficial not only in counteracting malnutrition, but also as a coadjuvant treatment in specific complications, thus playing a favorable role in outcome and quality of life. Therefore, branched-chain amino acids should be considered part of nutritional treatment in patients with advanced stages of cirrhosis of the liver, particularly in the presence of complications.