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

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.

Sarcopenic obesity in cirrhosis-The confluence of 2 prognostic titans

Sarcopenia and obesity are 2 major health conditions with a growing prevalence in cirrhosis. The concordance of these 2 conditions, sarcopenic obesity, is associated with higher rates of mortality and impact on the metabolic profile and physical function than either condition alone. To date, there is little consensus surrounding the diagnostic criteria for sarcopenia, obesity or as a result, sarcopenic obesity in patients with cirrhosis. Cross-sectional imaging, although the most accurate diagnostic technique, has practical limitations for routine use in clinical practice. Management strategies are focused on increasing muscle mass and strength. The present review provides an overview of the diagnosis, pathophysiology, prognostic implications and management strategies available for sarcopenic obesity in cirrhosis. We also discuss the associated condition myosteatosis, the pathological accumulation of fat in skeletal muscle. Much work needs to be done to advance both clinical care and research in this area. Future directions require consensus definitions for sarcopenia, obesity and sarcopenic obesity, an expansion of our understanding of the complex pathogenesis of the muscle-liver-adipose tissue axis in cirrhosis and evidence to support management recommendations for nutrition, exercise and pharmacological therapies.

A 5-Year Follow-Up of The Benefits of an Exercise Training Program in Liver Recipients Transplanted Due to Familial Amyloidotic Polyneuropathy

BACKGROUND

Supervised (SE) and home-based exercise (HBE) training regimes are effective on reconditioning patients with familial amyloidotic polyneuropathy (FAP) after liver transplantation, but research of the long-term retention of the benefits attained in patients with FAP has not yet been conducted.

PURPOSE

In this 5-year follow-up study, we aimed to determine whether the exercise training gains in body composition, physical activity, and function promoted by a 24-week SE or HBE training regimes are retained in patients with FAP who resume normal activity.

METHODOLOGY

Sixteen liver-transplanted patients with FAP were reassessed for body composition (dual X-ray absorptiometry), physical activity (questionnaire), and function (handgrip strength and 6-minute walk test).

RESULTS

Total body fat increased with both exercise regimes during follow-up ( P < .05; η² = 0.432-0.625) as well as femoral neck bone density ( P = .048; η² = 0.119). However, gains in upper limbs muscle quality during follow-up ( P < .001; η² = 0.597) were only found in the SE group ( P = .042; η² = 0.245). Both exercise regimes showed retaining aptitudes in walking capacity ( P < .05; η² = 0.329-0.460) and muscle mass ( P = .05; η² = 0.245). Still, none could retain the physical activity levels.

CONCLUSION

Long-term resumption of normal activity following a 24-week SE or HBE regime in patients with FAP resulted in loss of exercise induced increases in physical activity but counterweighted postoperative losses in bone mineral density and substantially retained the benefits in walking capacity, muscle mass, and quality, in particular, in the SE group.

The metabolic and molecular mechanisms of hyperammonaemia- and hyperethanolaemia-induced protein catabolism in skeletal muscle cells

Hyperammonaemia and hyperethanolaemia are thought to be driving factors behind skeletal muscle myopathy in liver disease, that is, cirrhosis. Despite this, the singular and combined impacts of ethanol‐ and ammonia‐induced protein catabolism are poorly defined. As such, we aimed to dissect out the effects of ammonia and ethanol on muscle catabolism. Murine C2C12 myotubes were treated with ammonium acetate (10 mM) and ethanol (100 mM) either alone or in combination for 4 hr and/or 24 hr. Myotube diameter, muscle protein synthesis and anabolic and catabolic signalling pathways were assessed. In separate experiments, cells were cotreated with selected inhibitors of protein breakdown to assess the importance of proteolytic pathways in protein loss with ammonia and ethanol. Ammonia and ethanol in combination resulted in a reduction in myotube width and total protein content, which was greater than the reduction observed with ammonia alone. Both ammonia and ethanol caused reductions in protein synthesis, as assessed by puromycin incorporation. There was also evidence of impairments in regulation of protein translation, and increased protein expression of markers of muscle protein breakdown. Myotube protein loss with ammonia plus ethanol was not affected by autophagy inhibition, but was completely prevented by proteasome inhibition. Thus, combined ammonia and ethanol incubation of C2C12 myotubes exacerbated myotube atrophy and dysregulation of anabolic and catabolic signalling pathways associated with either component individually. Ubiquitin proteasome‐mediated protein breakdown appears to play an important role in myotube protein loss with ethanol and ammonia.

Preoperative nutrition and postoperative liver function: a correlation study of pediatric living donor liver transplantation

Objective

There is little information focusing on the nutritional issue of pediatric recipients before they receive living donor liver transplantation. This study illustrates the relationship between nutritional status and graft liver function and provides a reference regarding nutritional interventions in future studies.

Methods

We prospectively collected data from 30 pediatric living donor liver transplant recipients from January 1, 2016, to June 30, 2016. The information included demographic data, preoperative nutritional assessment, and postoperative laboratory examinations. The nutritional assessment included the serum concentration of vitamin D, bone density, trace element, and weight Z value. The laboratory examinations included white blood cell count, neutrophil percentage, hemoglobin, blood platelet, total protein, albumin, total bilirubin, direct bilirubin, alanine transaminase, aspartate aminotransferase (AST), alkaline phosphatase, gamma-glutamyl transpeptidase, creatinine, bile acid, blood glucose (Glu), prothrombin time, international normalized ratio, tacrolimus concentration, and graft-to-recipient weight ratio (GRWR). The data were collected on Days 1, 2, 3, 4, 5, 6, 7, 14, 30, and 60 after liver transplantation.

Results

The recipients consisted of 15 (50%) males and 15 (50%) females. The median age was 7 months (4–48 months). The mean height and weight were 69.07±9.98 cm and 8.09±2.63 kg, respectively. According to the univariate analysis, the gender, diagnosis, blood type, and GRWR did not significantly impact the liver function after the operation. The posttransplantation AST levels and Glu showed significant differences in terms of the nutritional status, with P<0.05. The multivariate correlation analysis showed that the serum concentrations of vitamin D and AST were midrange positively correlated, with P<0.05.

Conclusions

The nutritional status of patients with biliary atresia is relatively poor. There is a definite midrange positive correlation between nutrition and graft liver function that might play a relatively important role in the recovery of the graft.

The impact of obesity in cirrhotic patients with septic shock: A retrospective cohort study

BACKGROUND & AIMS

The prevalence of obesity in cirrhosis is rising. The impact of obesity in critically ill cirrhotic patients with sepsis/septic shock has not been evaluated. This study aimed to examine the relationship between obesity and mortality in cirrhotic patients admitted to the intensive care unit with septic shock.

METHODS

A retrospective cohort study of all cirrhotic patients with septic shock (n = 362) and a recorded body mass index (BMI) from an international, multicentre (CATSS) database (1996-2015) was performed. Patients were classified by BMI as per WHO categories. Primary outcome was in-hospital mortality. Multivariate logistic regression analyses were carried out to determine independent associations with outcome.

RESULTS

In this analysis, mean age was 56.4 years, and 62% were male. Median BMI was 26.3%, and 57.7% were overweight/obese. In-hospital mortality was 71%. Obese patients were more likely to have comorbidities of cardiac disease, lung disease and diabetes. Compared to survivors (n = 105), non-survivors (n = 257) had significantly higher MELD and APACHEII scores and higher requirements for renal replacement therapy and mechanical ventilation (P < .03 for all). Using multivariable logistic regression, increase in BMI (OR 1.07, P = .034), time delay to appropriate antimicrobials (OR 1.16 per hour, P = .003), APACHEII (OR 1.12 per unit, P = .008) and peak lactate (OR 1.15, P = .028) were independently associated with in-hospital mortality.

CONCLUSIONS

Septic shock in cirrhosis carries a high mortality. Increased BMI is common in critically ill cirrhotic patients and independently associated with increased in-hospital mortality.

Application of transcutaneous ultrasonography for the diagnosis of muscle mass loss in patients with liver cirrhosis

BACKGROUND

To propose an ultrasound-based parameter for the diagnosis of muscle mass loss (MML) in cirrhosis.

METHODS

This is an IRB-approved cross-sectional study (October 2013 to January 2017) with written informed consent including 357 subjects-234 cirrhosis and 123 controls. MML was diagnosed using the skeletal muscle index at the L3 level (L3-SMI) on computed tomography (CT). Transcutaneous ultrasound was used to demonstrate a cross section of the right iliopsoas muscle, and the iliopsoas muscle index (IP index) was defined by the iliopsoas muscle area/height² (mm²/m²). Receiver operating characteristic (ROC) curve analysis was performed to assess the diagnostic ability of IP index for MML.

RESULTS

The iliopsoas muscle was detected in all subjects. The IP index was lower in cirrhosis than in controls: males (211.2 ± 73.8 vs. 295.5 ± 139.4, P < 0.0001) and females (200.2 ± 72.5 vs. 284.4 ± 112.4, P < 0.0001). L3-SMI and IP index showed correlations in males (r = 0.699, P < 0.0001) and in females (r = 0.707, P < 0.0001). Independent factors for MML by multivariate analysis were body mass index and IP index in both males and females. Sensitivity, specificity, and area under the ROC curve by IP index to detect MML were 79.5%, 73.1%, and 0.835, respectively, with the best cut-off value of 189.2 for males, and 84.6%, 78.8%, and 0.874, respectively, with the best cut-off value of 180.6 for females.

CONCLUSIONS

Using transcutaneous ultrasound, the IP index may be a valuable diagnostic parameter for MML in cirrhosis.

Alpha-syntrophin null mice are protected from non-alcoholic steatohepatitis in the methionine-choline-deficient diet model but not the atherogenic diet model

Adipose tissue dysfunction contributes to the pathogenesis of non-alcoholic steatohepatitis (NASH). The adapter protein alpha-syntrophin (SNTA) is expressed in adipocytes. Knock-down of SNTA increases preadipocyte proliferation and formation of small lipid droplets, which are both characteristics of healthy adipose tissue. To elucidate a potential protective role of SNTA in NASH, SNTA null mice were fed a methionine-choline-deficient (MCD) diet or an atherogenic diet which are widely used as preclinical NASH models. MCD diet mediated loss of fat mass was largely improved in SNTA-/- mice compared to the respective wild type animals. Hepatic lipids were mostly unchanged while the oxidative stress marker malondialdehyde was only induced in the wild type mice. The expression of inflammatory markers and macrophage immigration into the liver were reduced in SNTA-/- animals. This protective function of SNTA loss was absent in atherogenic diet induced NASH. Here, hepatic expression of inflammatory and fibrotic genes was similar in both genotypes though mutant mice gained less body fat during feeding. Hepatic cholesterol and ceramide were strongly induced in both strains upon feeding the atherogenic diet, while hepatic sphingomyelin, phosphatidylserine and phosphatidylethanolamine levels were suppressed. SNTA deficient mice are protected from fat loss and NASH in the experimental MCD model. NASH induced by an atherogenic diet is not influenced by loss of SNTA. The present study suggests the use of different experimental NASH models to study the pathophysiological role of proteins like SNTA in NASH.

Branched-chain amino acids in liver diseases

Branched chain amino acids (BCAAs) are involved in various bioprocess such as protein metabolism, gene expression, insulin resistance and proliferation of hepatocytes. BCAAs have also been reported to suppress the growth of hepatocellular carcinoma (HCC) cells in vitro and to be required for immune cells to perform the function. In advanced cirrhotic patients, it has been clarified that serum concentrations of BCAA are decreased, whereas those of aromatic amino acids (AAAs) are increased. These alterations are thought to be the causes of hepatic encephalopathy (HE), sarcopenia and hepatocarcinogenesis and may be associated with the poor prognosis of patients with these conditions. Administration of BCAA-rich medicines has shown positive results in patients with cirrhosis.

Sarcopenia in Liver Disease: Current Evidence and Issues to Be sResolved

Sarcopenia is a common clinical symptom in aging and patients with wasting diseases, characterized by a decreased skeletal muscle mass. As a consequence of lifestyle change, the nonalcoholic fatty liver disease (NAFLD) presents a rising trend. In the past three decades, increasing evidence has proved that sarcopenia is related to NAFLD. In this chapter, we will summarize the emerging evidence of the predictive role of sarcopenia in NAFLD and review the diagnosis value, feasible mechanism, and therapy strategies of sarcopenia in NAFLD. Sarcopenia is a potential risk factor for NAFLD, and targeting sarcopenia can benefit NAFLD to some extent.

Sarcopenia predicts minimal hepatic encephalopathy in patients with liver cirrhosis

AIM

Minimal hepatic encephalopathy (MHE) and sarcopenia impair the health-related quality of life and prognosis of patients with liver cirrhosis; however, the relationship between MHE and sarcopenia remains unclear. The aim of this study was to investigate their relationship and to identify the predictors of MHE in cirrhotic patients.

METHODS

This retrospective study evaluated 120 cirrhotic patients who were tested for MHE and sarcopenia. Minimal hepatic encephalopathy was diagnosed by using the computer-aided neuropsychiatric test. Sarcopenia was diagnosed based on the assessment criteria recommended by the Japan Society of Hepatology. Muscle mass and muscle strength were measured by using bio-impedance analysis and digital grip strength dynamometer. Univariate and multivariate logistic regression analyses were carried out to identify the predictors of MHE.

RESULTS

Of the 120 cirrhotic patients, 28 (23%) and 32 (27%) were diagnosed with MHE and sarcopenia, respectively. The prevalence of MHE was higher in patients with sarcopenia than in those without sarcopenia (P = 0.01). By the univariate analysis, MHE was significantly complicated with sarcopenia (P < 0.01). In the multivariate analysis, sarcopenia (odds ratio = 3.31, 95% confidence interval = 1.19-9.42; P = 0.02) and serum branched-chain amino acids levels <327 nmol/mL (odds ratio = 2.98, 95% confidence interval = 1.08-8.34; P = 0.03) were found to be associated with MHE.

CONCLUSIONS

Sarcopenia and serum branched-chain amino acids levels were predictors of MHE. The amelioration of sarcopenia and/or amino acids imbalance may improve MHE in patients with liver cirrhosis.

Nutrition and Muscle in Cirrhosis

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.

Elevated serum myostatin level is associated with worse survival in patients with liver cirrhosis

BACKGROUND

We aimed to elucidate the relationship between serum myostatin levels and other markers including skeletal muscle mass and to investigate the influence of serum myostatin levels on survival for patients with liver cirrhosis (LC).

METHODS

A total of 198 LC subjects were analysed in this study. Myostatin levels were measured using stored sera. We retrospectively investigated the relationship between myostatin level and other markers, and the influence of myostatin level on overall survival (OS). Assessment of skeletal muscle mass was performed using the psoas muscle index (PMI) on computed tomography images at baseline. PMI indicates the sum of bilateral psoas muscle mass calculated by hand tracing at the lumber three level on computed tomography images divided by height squared (cm² /m² ). The study cohort was divided into two groups based on the median myostatin value in each gender.

RESULTS

Our study cohort included 108 male and 90 female patients with a median age of 67.5 years. The median (range) myostatin level for male patients was 3419.6 pg/mL (578.4-12897.7 pg/mL), whereas that for female patients was 2662.4 pg/mL (710.4-8782.0 pg/mL) (P = 0.0024). Median (range) serum myostatin level for Child-Pugh A patients (n = 123) was 2726.0 pg/mL (578.4-12667.2 pg/mL), whereas that for Child-Pugh B or C patients (n = 75) was 3615.2 pg/mL (663.3-12897.7 pg/mL) (P = 0.0011). For the entire cohort, the 1-, 3-, 5-, and 7-year cumulative OS rates were 93.94%, 72.71%, 50.37%, and 38.47%, respectively, in the high-myostatin group and 96.97%, 83.27%, 73.60%, and 69.95%, respectively, in the low-myostatin group (P = 0.0001). After excluding hepatocellular carcinoma patients (at baseline) from our analysis (n = 158), the 1-, 3-, 5-, and 7-year cumulative OS rates were 96.0%, 77.93%, 52.97%, and 39.08%, respectively, in the high-myostatin group and 96.39%, 87.58%, 77.63%, and 73.24%, respectively, in the low-myostatin group (P = 0.0005). Higher age (P = 0.0111) and lower PMI (P < 0.0001) were identified as significant predictors of poorer OS in our multivariate analysis, while higher serum myostatin (P = 0.0855) tended to be a significant adverse predictor. In both genders, PMI, serum albumin, prothrombin time, and branched-chain amino acid to tyrosine ratio showed a significantly inverse correlation with myostatin levels, and serum ammonia levels showed a significantly positive correlation with myostatin levels.

CONCLUSIONS

Higher serum myostatin levels correlated with muscle mass loss, hyperammonemia, and impaired protein synthesis, as reflected by lower serum albumin levels and lower branched-chain amino acid to tyrosine ratio levels. High serum myostatin levels were also associated with a reduced OS rate in LC patients.

Hepatopulmonary Syndrome: Oxidative Stress and Physical Exercise

Hepatopulmonary syndrome (HPS) may be defined by hepatic disease, gas exchange abnormalities that may lead to hypoxaemia, and the presence of pulmonary vascular dilations. The balance between the many substances involved in vasodilation and vasoconstriction is regulated by the liver; thus, liver damage may generate systemic changes throughout the body. The pulmonary tissue may be damaged by reactive oxygen species or nitric oxide. Dyspnoea is the most frequent pulmonary symptom, caused by tissue damage, and may become worse when an individual exercises. In experimental research the surgical model of bile duct ligation is the optimal model to simulate the typical lung alterations present in HPS, which results in an increase in oxidative stress in hepatic and pulmonary tissues. In liver injury, the muscular system may also be damaged, for example sarcopenia may seriously aggravate cirrhosis and is associated with cirrhotic patient mortality. Muscular changes can be explained by the actions of myostatin and insulin-like growth factor and the increase in body levels of ammonia. As a result of impaired cardiopulmonary and muscular conditions, HPS patients may exhibit a low exercise tolerance, low muscle strength, and low functionality. Liver disease can contribute to HPS oxidative stress and is one of the main factors responsible for the reduction of gas exchange. Physical exercise can be performed as a way of modifying this pathophysiological state. Studies that have investigated physical exercise as a therapy for cirrhosis suggest that this approach may be beneficial for cirrhotic patients, primarily with regard to muscular and cardiorespiratory injuries.

Characterization of body composition and definition of sarcopenia in patients with alcoholic cirrhosis: A computed tomography based study

BACKGROUND

Alterations in body composition (BC) as loss of fat and muscle mass (sarcopenia) are associated with poor outcome in alcoholic cirrhosis (ALC). Prevalence of sarcopenia depends upon the method of assessment. Computed Tomography (CT) is a gold standard tool for assessing BC.

AIM

To characterize BC and define sarcopenia in ALC patients using CT.

METHODS

Single slice CT images at L3 vertebrae of healthy controls (HC) - organ transplant donors and ALC patients were analysed to give cross-sectional area of five skeletal muscles normalized for height -skeletal muscle index (SMI; cm² /m² ), area of subcutaneous (SAT;cm² ) and visceral adipose tissue (VAT;cm² ). Cut-offs for defining sarcopenia was established at 2SD below the mean of HC. HC were compared with Child A-compensated (C) and Child B+C-decompensated (DC) patients.

RESULTS

Cut-offs of SMI derived from HC (n = 275; M: 50%; age 32.2 ± 9.8 years; BMI 24.2 ± 3.2 Kg/m² ) were 36.54 in males and 30.21 in females. Sarcopenia was found in 12.8% of ALC patients [n = 148; C (31.8%): DC (68.2%); M: 100%; age 46.6 ± 9.7 years; BMI 24.5 ± 4.4]. Compared to HC, compensated patients had higher adiposity and comparable muscularity; decompensated patients had significantly lower muscle and also fat mass compared to both HC and compensated patients. HC vs C vs DC: SAT (140 ± 82 vs 177.3 ± 11 vs 112 ± 8.2); VAT (96.5 ± 6.5 vs 154.9 ± 8.7 vs 87.5 ± 6.5) and SMI (52.1 ± 0.9 vs 49.6 ± 1.2 vs 46 ± 0.9).

CONCLUSIONS

Compensated ALC have increased adiposity and relatively preserved muscularity but decompensation leads to loss of both muscle and fat mass. Prevalence of sarcopenia, based on derived ethnic cut-offs was 12.8%.

Aggressive nutrition intervention reduces ascites and frequency of paracentesis in malnourished patients with cirrhosis and ascites

Background and Aim

Alterations in nutrient metabolism, nutritional requirements, and reduced dietary intakes are common in chronic liver disease (CLD). These result in malnutrition, sarcopenia, and exacerbate progression to decompensation and ascites. We aimed to investigate the effects of continuous tube feeding (TF) on nutritional status and levels of ascites in malnourished individuals with decompensated cirrhosis.

Methods

Fourteen malnourished patients with decompensated cirrhosis and ascites who failed to respond to standard oral nutritional interventions received supplementary continuous nasogastric TF for 7 ± 1 weeks. Liver disease severity was assessed by model for end‐stage liver disease (MELD) and Child–Turcotte–Pugh (CTP) scores.

Results

Continuous TF occurred at home for 7 weeks (1.5–12 weeks). Prior to feeding, 12 patients had severe ascites, 10 required paracentesis, and 13 were severely malnourished. At completion of TF, five patients did not have ascites, four had mild ascites, four had moderate ascites, and only one had severe ascites and 10 no longer required paracentesis (P < 0.001). Median patient survival was 26 ± 7 months. Five survived to transplantation and three remained transplant‐free at 8, 1.9, and 1.7 years. Seven patients were moderately malnourished at completion of TF with an overall improvement in hand grip strength from 51% to 65% of predicted (P = 0.02).

Conclusion

Supplementary continuous TF may help to reduce ascites and paracentesis requirements and improve nutritional status. Supplementary continuous TF should be considered as a treatment for malnourished patients with decompensated cirrhosis and refractory ascites.

The Long Winding Road to Transplant: How Sarcopenia and Debility Impact Morbidity and Mortality on the Waitlist

Frailty and sarcopenia are common complications of cirrhosis. Frailty has been described as an increased susceptibility to stressors secondary to a cumulative decline in physiologic reserve; this decline occurs with aging or is a result of the disease process, across multiple organ systems. Sarcopenia, a key component of frailty, is defined as progressive and generalized loss of skeletal muscle mass and strength. The presence of either of these complications is associated with increased morbidity and mortality, as these are tightly linked to decompensation and increased complication rates. Recognition of these entities is critical. Studies have shown improvement in muscle strength and function lead to reduced mortality, suggesting both frailty and sarcopenia are modifiable risk factors. In this review we outline the prevalence of frailty and sarcopenia in cirrhosis and the impact on clinical outcomes such as decompensation, hospitalization, and mortality. Existing and potential novel therapeutic approaches for frailty and sarcopenia are also reviewed.

Prognostic significance of low skeletal muscle mass compared with protein-energy malnutrition in liver cirrhosis

AIMS

To investigate the impact of low skeletal muscle mass (LSMM) on survival as compared with protein-energy malnutrition (PEM) in patients with liver cirrhosis (LC).

METHODS

A total of 206 individuals with LC were analyzed. We retrospectively examined the impact of LSMM, as defined by psoas muscle mass at the third lumber on computed tomography, on survival as compared with PEM. In terms of comparison of the effects of LSMM and PEM on survival, we used time-dependent receiver operating characteristics (ROC) analysis.

RESULTS

Our study cohort included 115 men and 91 women with a median age of 67 years. There were 140 patients with Child-Pugh A, 62 with Child-Pugh B, and 4 with Child-Pugh C. A total of 117 patients (56.8%) had LSMM and 52 patients (25.2%) had PEM. The proportion of PEM in patients with LSMM (31.62%, 37/117) was significantly higher than in patients without LSMM (16.85%, 15/89) (P = 0.0229). In the multivariate analysis for the entire cohort, the presence of hepatocellular carcinoma, lower body mass index, presence of LSMM, lower triglyceride value, poorer renal function, and higher des-γ-carboxy prothrombin value were found to be significant adverse predictors linked to overall survival, while presence of PEM tended to be significant. In the time-dependent ROC analysis, all area under the ROCs for survival in LSMM at each time point were higher than those in PEM except for Child-Pugh B patients.

CONCLUSION

In this comparison of LSMM and PEM on clinical outcomes in LC patients, it was shown that LSMM may have stronger prognostic impact than PEM.

ALTERAÇÕES DO SISTEMA CARDIOPULMONAR DE PACIENTES CIRRÓTICOS

RESUMO Introdução: A cirrose gera alterações nas trocas gasosas e a desnutrição proteico-calórica em pacientes hepatopatas. Objetivo: Avaliar e comparar as variáveis cardiopulmonares, a força do aperto de mão (FAM) e a composição corporal entre pacientes cirróticos pelo vírus da hepatite C e indivíduos saudáveis, e correlacionar o consumo máximo de oxigênio (VO2MAX) com a FAM. Métodos: Esta pesquisa caracteriza-se como estudo de caso-controle composto por 36 participantes (18 pacientes cirróticos com HCV e 18 indivíduos hígidos) de ambos os sexos, maiores de 18 anos. A força de preensão palmar foi mensurada por dinamometria com dinamômetro mecânico de empunhadura com alça ajustável. As variáveis ventilatórias foram avaliadas por ergoespirometria com teste de carga progressiva em cicloergômetro. A composição corporal foi mensurada por um técnico em cineantropometria nível II. Foram utilizados os testes t independente e Mann-Whitney para comparação entre os grupos e a correlação de Spearman para associação entre as variáveis. Resultados: Foram encontradas diferenças no consumo máximo de oxigênio 16,20 (11,60-18,55), mediana e intervalo interquartil x 19,90 (16,27-26,85), ventilação 45,40 (36,45-54,20) x 63,40 (50,40-78,00), produção de dióxido de carbono 785,88 (655,81-963,14) x 988,04 (826,93-1546,21), frequência cardíaca máxima (127,66 ± 23,26 média e ± DP) x (146,29 ± 23,31), primeiro limiar ventilatório (10,700 ± 3,19) x (14,912 ± 4,45) e segundo limiar ventilatório (14,16 ± 4,48) x (18,25 ± 5,54) entre cirróticos e controles, respectivamente. Encontramos correlação positiva moderada entre o consumo máximo de oxigênio e a força do aperto de mão (r = 0,474, p = 0,047). Conclusão: Existem alterações nas variáveis cardiopulmonares e há associação entre o VO2MAX e a FAM em pacientes cirróticos pelo vírus da hepatite C.

Significance of psoas muscle thickness as an indicator of muscle atrophy in patients with hepatocellular carcinoma treated with sorafenib

Sarcopenia has been reported to be associated with the prognosis of patients with liver cirrhosis and hepatocellular carcinoma (HCC). The aim of the present study was to determine whether sarcopenia was associated with the prognosis of patients with HCC treated with sorafenib. A total of 40 patients with HCC who were treated with sorafenib were evaluated. As an indicator of skeletal muscle mass, transverse psoas muscle thickness (TPMT) was measured on computed tomography images at the level of the umbilicus prior to treatment initiation and after 1-3 months of treatment. Pre-TPMT/height was not associated with progression-free survival (PFS) or overall survival (OS). The change in TPMT/height prior to and following treatment was also not associated with PFS; however, the change of TPMT/height was an independent factor affecting OS (P=0.020). A total of 40 patients were divided into two groups depending on the degree of TPMT/height loss (mild and severe muscle atrophy groups). Patients with mild muscle atrophy exhibited a significantly longer OS compared with patients with severe muscle atrophy (P=0.045). Thus, the change in skeletal muscle thickness calculated as TPMT/height may be a simple predictor of survival for patients with HCC treated with sorafenib.

Sarcopenia in Alcoholic Liver Disease: Clinical and Molecular Advances

Despite advances in treatment of alcohol use disorders that focus on increasing abstinence and reducing recidivism, alcoholic liver disease (ALD) is projected to be the major cause of cirrhosis and its complications. Malnutrition is recognized as the most frequent complication in ALD, and despite the high clinical significance, there are no effective therapies to reverse malnutrition in ALD. Malnutrition is a relatively imprecise term, and sarcopenia or skeletal muscle loss, the major component of malnutrition, is primarily responsible for the adverse clinical consequences in patients with liver disease. It is, therefore, critical to define the specific abnormality (sarcopenia) rather than malnutrition in ALD, so that therapies targeting sarcopenia can be developed. Skeletal muscle mass is maintained by a balance between protein synthesis and proteolysis. Both direct effects of ethanol (EtOH) and its metabolites on the skeletal muscle and the consequences of liver disease result in disturbed proteostasis (protein homeostasis) and consequent sarcopenia. Once cirrhosis develops in patients with ALD, abstinence is unlikely to be effective in completely reversing sarcopenia, as other contributors including hyperammonemia, hormonal, and cytokine abnormalities aggravate sarcopenia and maintain a state of anabolic resistance initiated by EtOH. Cirrhosis is also a state of accelerated starvation, with increased gluconeogenesis that requires amino acid diversion from signaling and substrate functions. Novel therapeutic options are being recognized that are likely to supplant the current "deficiency replacement" approach and instead focus on specific molecular perturbations, given the increasing availability of small molecules that can target specific signaling components. Myostatin antagonists, leucine supplementation, and mitochondrial protective agents are currently in various stages of evaluation in preclinical studies to prevent and reverse sarcopenia, in cirrhosis in general, and ALD, specifically. Translation of these data to human studies and clinical application requires priority for allocation of resources.

Review article: maximising quality of life while aspiring for quantity of life in end-stage liver disease

BACKGROUND

With recent advances in the management of chronic liver disease and its complications, the long-term survival in cirrhosis has improved. Therefore, the number of individuals who will spend a significant proportion of their life with end-stage liver disease (ESLD) may continue to rise. Thus, more attention to quality of life (QOL) and its integration with traditional clinical endpoints is needed.

AIMS

Recently, there have been many studies looking at treatment outcomes and their impact on the QOL in patients with ESLD. The aim of this review was to summarise and compare the insights gained from these intervention studies and to make concise recommendations to further promote and improve QOL in this patient population.

METHODS

A literature search was conducted using PubMed and Web of Science. Search terms "Quality of life" "Cirrhosis" and "end-stage liver disease" were used as MeSH terms or searched in the title of the article.

RESULTS

These studies uniformly show significant improvement in health-related QOL (HRQOL) with management of malnutrition, hepatic encephalopathy and ascites. Thus, early recognition and management of these complications are keys to better serve our patients. Early involvement of palliative care also leads to improved quality of end-of-life care.

CONCLUSIONS

Complications of cirrhosis including malnutrition, encephalopathy, ascites and variceal bleeding lead to a decrease in HRQOL. Assessment of HRQOL has an important implication for the patient. The findings of this review illuminate the importance of using consistent tools to accurately assess QOL in patients with ESLD.

Comparison of Prognostic Impact between the Child-Pugh Score and Skeletal Muscle Mass for Patients with Liver Cirrhosis

AIMS

To investigate the influence of skeletal muscle mass index (SMI) as determined by bioimpedance analysis (BIA) (appendicular skeletal muscle mass/(height)²) on survival by comparing the Child-Pugh score in patients with liver cirrhosis (LC, n = 383, average age = 65.2 years).

PATIENTS AND METHODS

In terms of comparison of the effects of SMI and other markers on survival, we used time-dependent receiver operating characteristics (ROC) analysis.

RESULTS

The average SMI for male was 7.4 cm²/m² whereas that for female was 6.0 cm²/m² (p < 0.0001). As for the Child-Pugh score, five points were in the majority, both in males (51.7%, (106/205)) and females (44.9%, (80/178)). For both genders, the survival curve was well stratified according to SMI (p < 0.0001 for males and p = 0.0056 for females). In the multivariate analysis for survival, SMI and Child-Pugh scores were found to be significant both in males and females. In time-dependent ROC analyses, all area under the ROCs (AUROCs) for SMI in each time point were higher than those for Child-Pugh scores in males, while in females AUROCs for Child-Pugh scores at each time point were higher than those for SMI.

CONCLUSION

SMI using BIA can be helpful for predicting outcomes, at least in male LC patients.

Ammonia lowering reverses sarcopenia of cirrhosis by restoring skeletal muscle proteostasis

Sarcopenia or skeletal muscle loss is a frequent, potentially reversible complication in cirrhosis that adversely affects clinical outcomes. Hyperammonemia is a consistent abnormality in cirrhosis that results in impaired skeletal muscle protein synthesis and breakdown (proteostasis). Despite the availability of effective ammonia-lowering therapies, whether lowering ammonia restores proteostasis and increases muscle mass is unknown. Myotube diameter, protein synthesis, and molecular responses in C2C12 murine myotubes to withdrawal of ammonium acetate following 24-hour exposure to 10 mM ammonium acetate were complemented by in vivo studies in the hyperammonemic portacaval anastomosis rat and sham-operated, pair-fed Sprague-Dawley rats treated with ammonia-lowering therapy by l-ornithine l-aspartate and rifaximin orally for 4 weeks. We observed reduced myotube diameter, impaired protein synthesis, and increased autophagy flux in response to hyperammonemia, which were partially reversed following 24-hour and 48-hour withdrawal of ammonium acetate. Consistently, 4 weeks of ammonia-lowering therapy resulted in significant lowering of blood and skeletal muscle ammonia, increase in lean body mass, improved grip strength, higher skeletal muscle mass and diameter, and an increase in type 2 fibers in treated compared to untreated portacaval anastomosis rats. The increased skeletal muscle myostatin expression, reduced mammalian target of rapamycin complex 1 function, and hyperammonemic stress response including autophagy markers normally found in portacaval anastomosis rats were reversed by treatment with ammonia-lowering therapy. Despite significant improvement, molecular and functional readouts were not completely reversed by ammonia-lowering measures.

CONCLUSION

Ammonia-lowering therapy results in improvement in skeletal muscle phenotype and function and molecular perturbations of hyperammonemia; these preclinical studies complement previous studies on ammonia-induced skeletal muscle loss and lay the foundation for prolonged ammonia-lowering therapy to reverse sarcopenia of cirrhosis. (Hepatology 2017;65:2045-2058).

Implication of Psoas Muscle Index on Survival for Hepatocellular Carcinoma Undergoing Radiofrequency Ablation Therapy

Aims We aimed to retrospectively examine the impact of pretreatment psoas muscle index (PMI) as determined by computed tomography on survival for treatment naïve hepatocellular carcinoma (HCC) patients who underwent percutaneous radiofrequency ablation (RFA) therapy (n=182; 111 males and 71 females with median age of 70 years).

Patients and methods Optimal cut-off points of PMI in male and female were calculated by receiver operating characteristic analysis for survival. We investigated parameters associated with overall survival (OS) in the univariate and multivariate analyses.

Results The median follow-up period in this study was 4.28 years. For all cases, the 5-year cumulative OS rate after initial RFA was 69.2%. The median (range) value in PMI for male was 6.03 (1.63-9.90) cm²/m² whereas that for female was 4.06 (1.21-7.32) cm²/m². Maximum tumor size ranged from 0.7 cm to 3.5 cm (median, 1.5cm). There were 145 patients with single nodule and 37 with multiple nodules. The optimal cut-off point for PMI was 6.31 cm²/m² in male and 3.91 cm²/m² in female. The 5-year cumulative OS rates were 51.5% in the decreased PMI group (n=90) and 86.5% in the non-decreased PMI group (n=92) (P<0.0001). In patients with Child-Pugh A (n=137) and Child-Pugh B or C (n=45), similar results were obtained. In the multivariate analysis, presence of decreased PMI (P<0.0001), total bilirubin ≥1.2 mg/dl (P=0.0015) and des-γ-carboxy prothrombin ≥34 mAU/ml (P=0.0089) were found to be significant adverse predictors related to OS.

Conclusion PMI can be useful for predicting outcomes in HCC patients undergoing percutaneous RFA therapy.

Prognostic significance of sarcopenia in patients with hepatocellular carcinoma undergoing sorafenib therapy

The present study aimed to examine the impact of sarcopenia, defined as low muscle mass on computed tomography (CT), prior to sorafenib therapy on the clinical outcomes of patients with hepatocellular carcinoma (HCC) receiving sorafenib therapy. In total, 232 patients with unresectable HCC (median age, 72 years) were analyzed, and the extent of sarcopenia was assessed using CT. Cross-sectional areas (cm²) of the skeletal muscles at the third lumbar vertebra level were determined by manual outlining on the CT images. The cross-sectional areas were normalized for height [skeletal muscle index (SMI), cm²/m²]. Based on the findings of previous studies, male patients with SMI ≤36.2 cm²/m² and female patients with SMI ≤29.6 cm²/m² were defined as having sarcopenia. The baseline characteristics, overall survival (OS) rates, progression-free survival (PFS) rates and best treatment response of the sarcopenia group were retrospectively compared with those of the non-sarcopenia group, and the factors associated with OS and PFS were examined. Sarcopenia was observed in 151 patients (65.1%). There were 165 patients with Child-Pugh A and 67 with Child-Pugh B cirrhosis. In the sarcopenia group, the median treatment duration was 66 days, whereas in the non-sarcopenia group it was 103 days (P=0.001). The median OS time was 174 days in the sarcopenia group and 454 days in the non-sarcopenia group (P<0.0001). The median PFS was 77 days in the sarcopenia group and 106 days in the non-sarcopenia group (P=0.0131). Multivariate analysis identified sarcopenia to be an independent predictor of OS (hazard ratio, 0.365; P<0.0001). The objective response rate and disease control rate in the sarcopenia group were significantly lower, compared with those in the non-sarcopenia group (P=0.0146 and P=0.0151, respectively). In conclusion, sarcopenia may be an indicator of poor clinical course in patients with HCC receiving sorafenib.

[Research advances in nutritional assessment methods in children with chronic liver diseases]

Malnutrition is commonly seen in children with chronic liver diseases, and there are interactions between them. Chronic liver diseases can cause malnutrition and this can affect the prognosis of children with chronic liver diseases. Due to the complexity of nutritional assessment in children with chronic liver diseases, there are still no unified standards for the diagnosis of malnutrition. Early identification of malnutrition and related intervention helps to improve the prognosis of children with chronic liver diseases. This article reviews the features of nutrition in children with chronic liver diseases and related nutritional assessment methods.

Effect of psoas muscle mass after endoscopic therapy for patients with esophageal varices

We aimed to investigate the impact of decrease of muscle mass on survival after eradication of esophageal varices (EVs) treated by endoscopic therapies as a primary prophylaxis in patients with liver cirrhosis (LC). In all, 177 LC individuals with EVs undergoing endoscopic therapies were analyzed. We retrospectively examined the impact of muscle mass decrease as determined by psoas muscle mass (PMM) at the third lumber on computed tomography (depletion of PMM [DPMM]) on survival as compared with serum sodium combined Model for End-stage Liver Disease (MELD-Na). In comparison of the effects of these parameters, we used time-dependent receiver-operating characteristics (ROC) analysis. We also investigated parameters related to overall survival in the univariate and multivariate analyses. This study included 116 males and 61 females with a median age of 66 years. The median follow-up periods were 2.7 years (range 0.1-9.6 years). In all, 110 patients (62.1%) had DPMM. The median MELD-Na score was 7.200 (range -3.451 to 30.558). The MELD-Na score in patients with DPMM (median 7.685) was significantly higher than that in patients without DPMM (median 6.235) (P = .0212). In the multivariate analysis, presence of hepatocellular carcinoma (P < .0001), presence of DPMM (P < .0001), and MELD-Na ≥7.2 (P = .0438) were revealed to be significant predictors related to overall survival. In time-dependent ROC analyses, all area under the ROCs for DPMM in each time point were higher than those for MELD-Na in the entire cohort and in patients without hepatocellular carcinoma at baseline (n = 133). In conclusion, for LC patients treated by endoscopic therapies for EVs, DPMM had stronger prognostic impact than MELD-Na.

The value of grip test, lysophosphatidlycholines, glycerophosphocholine, ornithine, glucuronic acid decrement in assessment of nutritional and metabolic characteristics in hepatitis B cirrhosis

The liver is essential for the regulation of energy, protein and amino acids, as well as in other aspects of metabolism. To identify efficient indexes for evaluation of nutritional status and metabolic characteristics during different Child-Pugh stages of hepatitis B cirrhosis, 83 patients and 35 healthy individuals were enrolled in our study. We found that grip strength, triceps skinfold thickness (TSF), body fat and skeletal muscle of the patients were reduced compared to the control group (P<0.05). Ultra-high-performance liquid chromatography data combined with mass spectrometry (UPLC-MS) showed that levels of a variety of metabolites, including lysophosphatidylcholines (LysoPCs), glycerophosphocholine, ornithine and glucuronic acid were reduced in the serum of patients with hepatitis B cirrhosis (P<0.001). However, glycerophosphoserine and taurocholic acid levels were higher than in the control group (P<0.001). Moreover, grip strength was correlated with the Child-Pugh score (P<0.05). Serum albumin, total cholesterol, LDL, LysoPCs, glycerophosphocholine, ornithine, glucuronic acid, glycerophosphoserine and taurocholic acid were correlated with the Child-Pugh score (P<0.01). These findings suggested that grip strength and the above small molecular substances might be considered as sensitive and important indexes for evaluating nutritional status and metabolic characteristics of patients with hepatitis B cirrhosis, which may help assess prognosis and adjust nutritional treatment.

A new definition of sarcopenia in patients with cirrhosis undergoing liver transplantation

Although sarcopenia is a common complication of cirrhosis, its diagnosis remains nonconsensual: computed tomography (CT) scan determinations vary and no cutoff values have been established in cirrhotic populations undergoing liver transplantation (LT). Our aim was to compare the accuracy of the most widely used measurement techniques and to establish useful cutoffs in the setting of LT. From the 440 patients transplanted between January 2008 and May 2011 in our tertiary center, we selected 256 patients with cirrhosis for whom a recent CT scan was available during the 4 months prior to LT. We measured different muscle indexes: psoas muscle area (PMA), PMA normalized by height or body surface area (BSA), and the third lumbar vertebra skeletal muscle index (L3SMI). Receiver operating characteristic curves were evaluated and prognostic factors for post-LT 1-year survival were then analyzed. PMA offered better accuracy (area under the curve [AUC] = 0.753) than L3SMI (AUC = 0.707) and PMA/BSA (AUC = 0.732), and the same accuracy as PMA/squared height. So, for its accuracy and simplicity of use, the PMA index was used for the remainder of the analysis and to define sarcopenia. In men, the better cutoff value for PMA was 1561 mm² (Se = 94%, Sp = 57%), whereas in women, it was 1464 mm² (Se = 52%, Sp = 91%). A PMA lower than these values defined sarcopenia in patients with cirrhosis awaiting LT. One- and 5-year overall survival rates were significantly poorer in the sarcopenic group (n = 57) than in the nonsarcopenic group (n = 199), at 59% versus 94% and 54% versus 80%, respectively (P < 0.001). In conclusion, pre-LT PMA is a simple tool to assess sarcopenia. We established sex-specific cutoff values (1561 mm² in men, 1464 mm² in women) in a cirrhotic population and showed that 1-year survival was significantly poorer in sarcopenic patients. Liver Transplantation 23 143-154 2017 AASLD.

Liver volume is a prognostic indicator for clinical outcome of patients with alcoholic hepatitis

PURPOSE

To evaluate the prognostic value of abdominal computed tomography (CT) in patients with alcoholic hepatitis (AH).

METHODS

This ancillary study was based on data collected during a previous randomized controlled trial in patients with AH. Clinical response was defined as the improvement of the baseline MELD score ≥3 points at 3 months. All patients underwent contrast-enhanced CT of the abdomen. The following parameters were measured: (1) liver density, spleen density, and liver-to-spleen density ratio; (2) liver-to-body weight (LBW) ratio; and (3) subcutaneous fat, visceral fat, and muscular content. Improvers and non-improvers were compared with univariate, multivariate, and ROC analyses. Results were compared with a validation cohort of patients.

RESULTS

Fifty-eight patients (mean age, 56 years) were analyzed, including 34 (59 %) improvers. On multivariate analysis, LBW ratio (OR = 3.73; 95 % CI, 1.65-8.46; p = 0.002) and subcutaneous fat (OR = 1.01; 95 % CI, 1.00-1.02; p = 0.022) were associated with clinical response, with AUROC curves of 0.78 ± 0.06 (p < 0.001) and 0.66 ± 0.07 (p = 0.043), respectively. LBW ≥2.4 % predicted response with 88 % sensitivity and 63 % specificity. In the validation cohort (n = 42, 64 % improvers), the same cut-off value predicted response with 93 % sensitivity and 60 % specificity.

CONCLUSIONS

In patients suffering from AH, the liver volume appears to be a major positive prognostic factor.

Cockcroft-Gault revisited: New de-liver-ance on recommendations for use in cirrhosis

The Cockcroft-Gault (CG) equation has become perhaps the most popular practical approach for estimating renal function among health care professionals. Despite its widespread use, clinicians often overlook not only the limitations of the original serum creatinine (SCr) based equation, but also may not appreciate the validity of the many variations used to compensate for these limitations. For cirrhotic patients in particular, the underlying pathophysiology of the disease contributes to a falsely low SCr, thereby overestimating renal function with use of the CG equation in this population. We reviewed the original CG trial from 1976 along with data surrounding clinician specific alterations to the CG equation that followed through time. These alterations included different formulas for body weight in obese patients and the “rounding up” approach in patients with low SCr. Additionally, we described the pathophysiology and hemodynamic changes that occur in cirrhosis; and reviewed several studies that attempted to estimate renal function in this population. The evidence we reviewed regarding the most accurate manipulation of the original CG equation to estimate creatinine clearance (CrCl) was inconclusive. Unfortunately, the homogeneity of the patient population in the original CG trial limited its external validity. Elimination of body weight in the CG equation actually produced the estimate closest to the measure CrCl. Furthermore, “rounding up” of SCr values often underestimated CrCl. This approach could lead to suboptimal dosing of drug therapies in patients with low SCr. In cirrhotic patients, utilization of SCr based methods overestimated true renal function by about 50% in the literature we reviewed.

Low phase angle is associated with the development of hepatic encephalopathy in patients with cirrhosis

AIM

Evaluate the association between phase angle and the development of hepatic encephalopathy in the long-term follow-up of cirrhotic patients.

METHODS

This was a prospective cohort study. Clinical, nutritional and biochemical evaluations were performed. Mann-Whitney’s U and χ² tests were used as appropriate. Kaplan-Meier curves and Cox proportional Hazards analysis were used to evaluate the prediction and incidence of hepatic encephalopathy.

RESULTS

Two hundred and twenty were included; the most frequent etiology of cirrhosis was hepatitis C infection, 52% of the patients developed hepatic encephalopathy (18.6% covert and 33.3% overt); the main precipitating factors were infections and variceal bleeding. Kaplan-Meier curves showed a higher proportion of HE in the group with low phase angle (39%) compared to the normal phase angle group (13%) (P = 0.012). Furthermore, creatinine and phase angle remained independently associated to hepatic encephalopathy in the Cox regression multivariate analysis [hazard ratio = 1.80 (1.07-3.03)].

CONCLUSION

In our cohort of patients low phase angle was associated with an increased incidence of hepatic encephalopathy. Phase angle is a useful nutritional marker that evaluates cachexia and could be used as a part of the integral assessment in patients with cirrhosis.

Sarcopenia from mechanism to diagnosis and treatment in liver disease

Sarcopenia or loss of skeletal muscle mass is the major component of malnutrition and is a frequent complication in cirrhosis that adversely affects clinical outcomes. These include survival, quality of life, development of other complications and post liver transplantation survival. Radiological image analysis is currently utilized to diagnose sarcopenia in cirrhosis. Nutrient supplementation and physical activity are used to counter sarcopenia but have not been consistently effective because the underlying molecular and metabolic abnormalities persist or are not influenced by these treatments. Even though alterations in food intake, hypermetabolism, alterations in amino acid profiles, endotoxemia, accelerated starvation and decreased mobility may all contribute to sarcopenia in cirrhosis, hyperammonemia has recently gained attention as a possible mediator of the liver-muscle axis. Increased muscle ammonia causes: cataplerosis of α-ketoglutarate, increased transport of leucine in exchange for glutamine, impaired signaling by leucine, increased expression of myostatin (a transforming growth factor beta superfamily member) and an increased phosphorylation of eukaryotic initiation factor 2α. In addition, mitochondrial dysfunction, increased reactive oxygen species that decrease protein synthesis and increased autophagy mediated proteolysis, also play a role. These molecular and metabolic alterations may contribute to the anabolic resistance and inadequate response to nutrient supplementation in cirrhosis. Central and skeletal muscle fatigue contributes to impaired exercise capacity and responses. Use of proteins with low ammoniagenic potential, leucine enriched amino acid supplementation, long-term ammonia lowering strategies and a combination of resistance and endurance exercise to increase muscle mass and function may target the molecular abnormalities in the muscle. Strategies targeting endotoxemia and the gut microbiome need further evaluation.

Metabolic adaptation of skeletal muscle to hyperammonemia drives the beneficial effects of l-leucine in cirrhosis

BACKGROUND & AIMS

Increased skeletal muscle ammonia uptake with loss of muscle mass adversely affects clinical outcomes in cirrhosis. Hyperammonemia causes reduced protein synthesis and sarcopenia but the cellular responses to impaired proteostasis and molecular mechanism of l-leucine induced adaptation to ammonia induced stress were determined.

METHODS

Response to activation of amino acid deficiency sensor, GCN2, in the skeletal muscle from cirrhotic patients and the portacaval anastomosis (PCA) rat were quantified. During hyperammonemia and l-leucine supplementation, protein synthesis, phosphorylation of eIF2α, mTORC1 signaling, l-leucine transport and response to l-leucine supplementation were quantified. Adaptation to cellular stress via ATF4 and its target GADD34 were also determined.

RESULTS

Activation of the eIF2α kinase GCN2 and impaired mTORC1 signaling were observed in skeletal muscle from cirrhotic patients and PCA rats. Ammonia activated GCN2 mediated eIF2α phosphorylation (eIF2α-P) and impaired mTORC1 signaling that inhibit protein synthesis in myotubes and MEFs. Adaptation to ammonia induced stress did not involve translational reprogramming by activation transcription factor 4 (ATF4) dependent induction of the eIF2α-P phosphatase subunit GADD34. Instead, ammonia increased expression of the leucine/glutamine exchanger SLC7A5, l-leucine uptake and intracellular l-leucine levels, the latter not being sufficient to rescue the inhibition of protein synthesis, due to potentially enhanced mitochondrial sequestration of l-leucine. l-leucine supplementation rescued protein synthesis inhibition caused by hyperammonemia.

CONCLUSIONS

Response to hyperammonemia is reminiscent of the cellular response to amino acid starvation, but lacks the adaptive ATF4 dependent integrated stress response (ISR). Instead, hyperammonemia-induced l-leucine uptake was an adaptive response to the GCN2-mediated decreased protein synthesis.

LAY SUMMARY

Sarcopenia or skeletal muscle loss is the most frequent complication in cirrhosis but there are no treatments because the cause(s) of muscle loss in liver disease are not known. Results from laboratory experiments in animals and muscle cells were validated in human patients with cirrhosis to show that ammonia plays a key role in causing muscle loss in patients with cirrhosis. We identified a novel stress response to ammonia in the muscle that decreases muscle protein content that can be reversed by supplementation with the amino acid l-leucine.

Nutritional evaluation in cirrhosis: Emphasis on the phase angle

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.

Effect of diet based on the principles of Iranian traditional medicine on cirrhosis (a clinical trial)

OBJECTIVES

Cirrhosis is associated with morbidity and mortality worldwide. Iranian traditional medicine (ITM) focused on nutritional intervention in order to improve liver function. The aim of this study was to assess the effectiveness of a diet designed based on ITM and current dietary recommendations.

DESIGN

This controlled trial study was performed on 57 subjects with cirrhosis in 5 tertiary hospitals in Teharn, Iran.

SETTING

Subjects were included if they were diagnosed with class A or B cirrhosis between October 2013 and December 2014.

INTERVENTIONS

Subjects were randomly allocated into intervention (28 subjects) who received dietary and lifestyle recommendations based on ITM and controls (29 subjects) who received routine dietary and lifestyle recommendations for 3 months. Subjects were assessed at baseline and at the end of the intervention for anthropometric measures, liver function tests and cirrhosis severity scoring.

MAIN OUTCOME MEASURES

Model for End-Stage Liver Disease (MELD), anthropometric measures, serum albumin, liver function tests, International Normalized Ratio and alkaline phosphatase as well as subjective findings.

RESULTS

Mean age of the subjects was 51.19±11.88years. Weight reduction was observed in 41 subjects (22 subjects in intervention and 19 in control group). Dietary intervention resulted in a significant decrease in alanine aminotransferase (AST) (p=0.04) and significant resolution of icterus in sclera (p=0.02) in weight loss group and increase serum albumin in weight gain group (p=0.02).

CONCLUSIONS

ITM recommendations could be beneficial for cirrhotic patients both for the purpose of weight reduction and weight gain.

Nutrition and Alcoholic Liver Disease: Effects of Alcoholism on Nutrition, Effects of Nutrition on Alcoholic Liver Disease, and Nutritional Therapies for Alcoholic Liver Disease

Malnutrition is the most frequent and nearly universal consequence in alcoholic liver disease (ALD) that adversely affects clinical outcomes. Sarcopenia or skeletal muscle loss is the major component of malnutrition in liver disease. There are no effective therapies to prevent or reverse sarcopenia in ALD because the mechanisms are not well understood. Consequences of liver disease including hyperammonemia, hormonal perturbations, endotoxemia and cytokine abnormalities as well as the direct effects of alcohol and its metabolites contribute to sarcopenia in ALD. This article focuses on the prevalence, methods to quantify malnutrition, specifically sarcopenia and potential therapies including novel molecular targeted treatments.

Lower values of handgrip strength and adductor pollicis muscle thickness are associated with hepatic encephalopathy manifestations in cirrhotic patients

Hepatic encephalopathy (HE) is a late complication of liver cirrhosis and is clearly associated with poor outcomes. Chronic liver insufficiency leads to progressive muscle wasting, impairing ammonia metabolism and thus increasing the risk for HE. Given the association between lean mass and adductor pollicis muscle thickness (APMT), it has been used to predict outcome and complications in many conditions, but not yet in cirrhotic patients. Therefore, this article aimed to study the association between HE manifestations and measures related to muscle mass and strength. This cross-sectional study included 54 cirrhotic outpatients with HE varying from subclinical to grade II according to the West-Haven criteria, who were submitted to neuropsychometric tests, electroencephalogram, brain Single Photon Emission Computed Tomography (SPECT), anthropometric measurements, handgrip strength (HGS) and dual energy X-ray absorptiometry exam (DXA). Multiple logistic regression analysis was performed to investigate the association between body composition measures and HE grade. Analysis of the area under the receiver operator characteristic (AUROC) curve revealed the values related to neurological manifestations (HE grades I and II). Reductions in APMT and HGS were associated with higher HE grades, suggesting a big impact caused by the loss of muscle mass and function on HE severity. The link between HE manifestations and anthropometric measures, namely APMT and HGS, point to a significant relation concerning skeletal muscles and the neurological impairment in this population.

Rapid skeletal muscle wasting predicts worse survival in patients with liver cirrhosis

AIM

Sarcopenia impairs the outcome of patients with liver cirrhosis independently of liver function reserves. The aim of this study was to investigate whether the rate of skeletal muscle wasting predicts mortality in cirrhotic patients.

METHODS

This retrospective study evaluated 149 cirrhotic patients who visited our hospital between March 2004 and September 2012. The skeletal muscle cross-sectional area at the level of the third lumbar vertebra was measured by computed tomography, from which the skeletal muscle index was obtained for diagnosis of sarcopenia. The relative change in skeletal muscle area per year (ΔSMA/y) was calculated in each patient. Cox proportional hazards regression analysis was performed to evaluate risk factors for mortality.

RESULTS

Of the 149 cirrhotic patients, 94 (63%) were diagnosed with sarcopenia. The median of ΔSMA/y in all patients was -2.2%. For patients in Child-Pugh class A, B and C, ΔSMA/y was -1.3%, -3.5% and -6.1%, respectively. During a median follow-up period of 39 months (range, 1-110), 45 patients (30%) died. The optimal cut-off value of ΔSMA/y for predicting mortality was -3.1%; the survival rate in patients with ΔSMA/y of -3.1% or less was significantly lower than in patients with ΔSMA/y of more than -3.1% (P < 0.0001). The multivariate Cox proportional hazards model found ΔSMA/y of -3.1% or less to be significantly associated with mortality in cirrhotic patients (hazard ratio = 2.73, 95% confidence interval = 1.43-5.44, P < 0.01).

CONCLUSION

ΔSMA/y is useful for predicting mortality in patients with liver cirrhosis. Management of skeletal muscle may contribute toward improving the outcome of cirrhotic patients.

Serum hyaluronic acid predicts protein-energy malnutrition in chronic hepatitis C

Serum hyaluronic acid (HA) is a well-established marker of fibrosis in patients with chronic liver disease (CLD). However, the relationship between serum HA level and protein-energy malnutrition (PEM) in patients with CLD is an unknown. We aimed to examine the relationship between serum HA level and PEM in patients with chronic hepatitis C (CHC) compared with the relationships of other serum markers of fibrosis. A total of 298 CHC subjects were analyzed. We defined patients with serum albumin level of ≤3.5 g/dL and nonprotein respiratory quotient <0.85 using indirect calorimetry as having PEM. We investigated the effect of serum HA level on the presence of PEM. Receiver operating characteristic curve (ROC) analysis was performed for calculating the area under the ROC (AUROC) for serum HA level, platelet count, aspartate aminotransferase (AST) to platelet ratio index, FIB-4 index, AST to alanine aminotransferase ratio, and Forns index for the presence of PEM. The median serum HA level in this study was 148.0 ng/mL (range: 9.0-6340.0 ng/mL). In terms of the degree of liver function (chronic hepatitis, Child-Pugh A, B, and C), the analyzed patients were well stratified according to serum HA level (overall significance, P < 0.0001). The median value (range) of serum HA level in patients with PEM (n = 61) was 389.0 ng/mL (43.6-6340.0 ng/mL) and that in patients without PEM (n = 237) was 103.0 ng/mL (9.0-783.0 ng/mL) (P < 0.0001). Among 6 fibrosis markers, serum HA level yielded the highest AUROC with a level of 0.849 at an optimal cut-off value of 151.0 ng/mL (sensitivity 93.4%; specificity 62.0%; P < 0.0001). In the multivariate analysis, serum HA level was found to be a significant prognostic factor related to the presence of PEM (P = 0.0001).In conclusion, serum HA level can be a useful predictor of PEM in patients with CHC.