Norms and correlates of bioimpedance phase angle in healthy human subjects, hospitalized patients, and patients with liver cirrhosis

Fat-free mass at admission predicts 28-day mortality in intensive care unit patients: the international prospective observational study Phase Angle Project

PURPOSE

Phase angle as measured by bioelectrical impedance analysis reflects fat-free mass. Fat-free mass loss relates to worse prognosis in chronic diseases. Primary aim of this study was: to determine the association between fat-free mass at intensive care unit admission and 28-day mortality.

METHODS

Ten centres in nine countries participated in this multicentre prospective observational study. The inclusion criteria were age >18 years; expected length of stay >48 h; absence of pacemaker, heart defibrillator implant, pregnancy and lactation. Fat-free mass was assessed by measurement of the 50-kHz phase angle at admission. The primary endpoint was 28-day mortality. The area under the receiver operating characteristic curve (AUC) was used to assess prediction of 28-day mortality by fat-free mass at ICU admission. The variables associated with 28-day mortality were analysed by means of multivariable logistic regression.

RESULTS

Of the 3605 patients screened, 931 were analysed: age 61 ± 16 years, male 60 %, APACHE II 19 ± 9, body mass index 26 ± 6, day 1 phase angle 4.5° ± 1.9°. Day 1 phase angle was lower in patients who eventually died than in survivors (4.1° ± 2.0° vs. 4.6° ± 1.8°, P = 0.001). The day 1 phase angle AUC for 28-day mortality was 0.63 [0.58-0.67]. In multivariable analysis, the following were independently associated with 28-day mortality: age (adjusted odds ratio (aOR) 1.014 [95 % confidence interval 1.002-1.027], P = 0.03), day 1 phase angle (aOR 0.86 [0.78-0.96], P = 0.008), APACHE II (aOR 1.08 [1.06-1.11], P < 0.001), surgical patient (aOR 0.51 [0.33-0.79], P = 0.002), and admission for other diagnosis (aOR 0.39 [0.21-0.72], P = 0.003). A multivariable combined score improved the predictability of 28-day mortality: AUC = 0.79 [0.75-0.82].

CONCLUSION

Low fat-free mass at ICU admission is associated with 28-day mortality. A combined score improves mortality predictability.

TRIAL REGISTRATION

NCT01907347 ( http://www.clinicaltrials.gov ).

Nutrition assessment and its effect on various clinical variables among patients undergoing liver transplant

BACKGROUND

Malnutrition is highly prevalent in patients undergoing liver transplantation and has been associated to various clinical variables and outcome of the surgery.

METHODS

We recruited 54 adult patients undergoing living donor liver transplant (LT) as study sample. Nutrition assessment was performed by body mass index (BMI), BMI for ascites, albumin, subjective global assessment (SGA) and anthropometry [mid upper arm circumference (MUAC), mid arm muscle circumference (MAMC), and triceps skin-fold (TSF)], Hand Grip strength, and phase angle of the body. Prevalence and comparison of malnutrition was performed with various clinical variables: aetiology, Child Turcotte Pugh scores and model for end stage liver disease (ESLD) grades, degree of ascites, blood product usage, blood loss during the surgery, mortality, days [intensive care unit (ICU), Ventilator and Hospital], and Bio-impedance analysis [weight, fat mass, fat free mass (FFM), muscle mass and body fat%].

RESULTS

Assessment of nutrition status represents a major challenge because of complications like fluid retention, hypoalbuminemia and hypoproteinemia. Different nutrition assessment tools show great disparity in the level of malnutrition among ESLD patients. In the present study recipient nutrition status evaluation by different nutrition assessment tools used showed malnutrition ranging from 3.7% to 100%. BMI and anthropometric measurements showed lower prevalence of malnutrition than phase angle and SGA whereas hand grip strength showed 100% malnutrition. Agreement among nutrition assessment methods showed moderate agreement (κ=0.444) of SGA with phase angle of the body. Malnutrition by different assessment tools was significantly associated to various clinical variables except MELD and days (ICU, Ventilator and Hospital). SGA was significantly (P<0.05) associated to majority of the clinical variables like aetiology, child Turcotte Pugh grades, degree of ascites, blood product usage, blood loss during the surgery, BIA (fat mass, FFM, muscle mass and body fat%).

CONCLUSIONS

The different nutrition assessment tools showed great variability of results. SGA showed moderate agreement with phase angle of the body and was associated with various clinical and prognostic variables of liver transplantation.

Body composition of Slovak midlife women with cardiovascular complications

The aim of this study was to analyse differences in body composition of women with and without cardiovascular complications. Bioelectrical parameters were measured with bioimpedance monofrequency analyser (BIA 101) and tissue electric properties were analysed by bioelectric impedance vector analysis (BIVA). The clinical sample (with CVD) consisted of 254 women ranging in age between 39 and 65 years. The sample of women without CVD consisted of 318 women in the same age range and was created from database of our previous studies. Statistical analysis adjusted for age showed significant differences in body composition characteristics of the studied samples. The results of vector analysis showed significantly different tissue electric properties of women in studied groups, what was confirmed by the Hotelling T2- test (p=0.0000). More women with CVD attained risky mean values of obesity indices of BMI and WHR than their “healthy” counterparts. Among women with CVD 80.2% had higher value of the BMI index than optimal one (>24.9 kg/m2) and 74.4% of women had higher value of the WHR index than optimal (>0.80). From the BIA parameters strong correlation coefficient was found between BMI and FM in both groups (r=0.962 for women with CVD; r=0.968 for relatively healthy women). Our data confirmed that cardiovascular disease complications are strongly linked in body composition changes. The cross-sectional nature of our study makes it difficult to draw conclusions regarding causal pathways, though variables of obesity are in line with unhealthy conditions.

Bioimpedance Vector Analysis in Diagnosing Severe and Non-Severe Dengue Patients

Real-time monitoring and precise diagnosis of the severity of Dengue infection is needed for better decisions in disease management. The aim of this study is to use the Bioimpedance Vector Analysis (BIVA) method to differentiate between healthy subjects and severe and non-severe Dengue-infected patients. Bioimpedance was measured using a 50 KHz single-frequency bioimpedance analyzer. Data from 299 healthy subjects (124 males and 175 females) and 205 serologically confirmed Dengue patients (123 males and 82 females) were analyzed in this study. The obtained results show that the BIVA method was able to assess and classify the body fluid and cell mass condition between the healthy subjects and the Dengue-infected patients. The bioimpedance mean vectors (95% confidence ellipse) for healthy subjects, severe and non-severe Dengue-infected patients were illustrated. The vector is significantly shortened from healthy subjects to Dengue patients; for both genders the p-value is less than 0.0001. The mean vector of severe Dengue patients is significantly shortened compare to non-severe patients with a p-value of 0.0037 and 0.0023 for males and females, respectively. This study confirms that the BIVA method is a valid method in differentiating the healthy, severe and non-severe Dengue-infected subjects. All tests performed had a significance level with a p-value less than 0.05.

Body Composition Tools for Assessment of Adult Malnutrition at the Bedside: A Tutorial on Research Considerations and Clinical Applications

Because of the key role played by the body's lean tissue reserves (of which skeletal muscle is a major component) in the response to injury and illness, its maintenance is of central importance to nutrition status. With the recent development of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition diagnostic framework for malnutrition, the loss of muscle mass has been recognized as one of the defining criteria. Objective methods to evaluate muscle loss in individuals with acute and chronic illness are needed. Bioimpedance and ultrasound techniques are currently the best options for the clinical setting; however, additional research is needed to investigate how best to optimize measurements and minimize error and to establish if these techniques (and which specific approaches) can uniquely contribute to the assessment of malnutrition, beyond more subjective evaluation methods. In this tutorial, key concepts and statistical methods used in the validation of bedside methods to assess lean tissue compartments are discussed. Body composition assessment methods that are most widely available for practice and research in the clinical setting are presented, and clinical cases are used to illustrate how the clinician might use bioimpedance and/or ultrasound as a tool to assess nutrition status at the bedside. Future research needs regarding malnutrition assessment are identified.

Anthropometric Predictors of Bio-Impedance Analysis (BIA) Phase Angle in Healthy Adults

INTRODUCTION

Phase Angle (PhA) is a ratio of whole body reactance and resistance obtained from Bioelectrical Impedance Analysis (BIA). It indicates cellular health and integrity and is considered as prognostic tool in medical disorders. In spite of prognostic potentials of PhA, it has limited usefulness in clinical practice and in population studies because of non-availability of normal population reference limits for comparison. Moreover, it is influenced by various factors like age, sex, race and body composition (i.e. body fat, muscle mass, visceral fat, body cell mass, total body water, etc).

AIM

The aim of this study was to evaluate predictors of phase angle which will be useful in formulation of reference values for Indian population.

MATERIALS AND METHODS

BIA was performed by Tanita Body Composition Analyser on healthy adults aged 17-24 years. The inbuilt software measured the phase angle by the formula: Phase angle (PhA) = Reactance (xc)/Resistance (R)* (180/π). Phase angle values were compared across categories of age, sex, weight, height, Body Mass Index (BMI), total fat, visceral fat and muscle mass.

RESULTS

Mean value of phase angle was found to be 5.65. Phase angle was significantly (p< 0.001) higher in male than in female. Phase angle was significantly predicted from height (p< 0.001), weight (p< 0.002), muscle mass (p< 0.002) and visceral fat (p< 0.02) in multiple regression models.

CONCLUSION

Phase angle differs across anthropometric and body composition categories. Thus height, weight and muscle mass should also be taken into consideration while deriving population specific reference limits of phase angle.

Bioelectrical phase angle and psoriasis: a novel association with psoriasis severity, quality of life and metabolic syndrome

BACKGROUND

Obesity, metabolic syndrome (MetS), and psoriasis, largely driven by environmental factors, show multiple bidirectional associations, with important metabolic implications in psoriatic patients. Besides body mass index (BMI) as a measure of obesity, data on phase angle (PhA), a direct measure by bioelectrical impedance analysis (BIA), used as a marker of cellular health and a predictor of morbidity and mortality in various diseases, are still lacking in psoriasis. In this case-control, cross-sectional study, we investigated the PhA in 180 pairs of adult psoriatic patients and healthy controls, evaluating also the potential use of the PhA as marker of the clinical severity, the quality of life, and the presence of the MetS in psoriatic patients.

METHODS

Anthropometric measures, metabolic profile and bioelectrical variables were evaluated. The clinical severity was assessed by standardized psoriasis area and severity index (PASI) score and c-reactive protein (CRP) levels, and the quality of life was evaluated by dermatology life quality index (DLQI). MetS was diagnosed according to Adult Treatment Panel III.

RESULTS

Psoriatic patients presented smaller PhA (p < 0.001) and higher prevalence MetS compared with controls. The PhA was significantly associated with number of parameters of MetS in both groups (p < 0.001). After adjusting for BMI, this association remained significant in psoriatic patients only (p < 0.001). Among psoriatic patients, the PhA was the major index value for the diagnosis of MetS (OR 5.87, 95 % CI 5.07-6.79) and was inversely associated with both PASI score and DLQI, independently of BMI (p < 0.001). At multiple regression analysis, the PhA well predicted the PASI score and DLQI. Based on ROC curves, the most sensitive and specific cutoffs of PhA to predict the highest PASI score and the lowest DQLI were ≤4.8° and ≤4.9°, respectively.

CONCLUSIONS

We reported that psoriatic patients presented small PhAs, with a novel association between PhA, clinical severity, quality of life in psoriatic patients, and MetS. Further studies are required to validate the PhA's prognostic ability in assessing the clinical severity and MetS in psoriatic patients.

Role of Nutrition and Muscle in Cirrhosis

OPINION STATEMENT

Most widely recognized complications in cirrhotic patients include ascites, hepatic encephalopathy, variceal bleeding, kidney dysfunction, and hepatocellular carcinoma; however, malnutrition and muscle wasting (sarcopenia) constitute common complications which negatively impact survival, quality of life, and response to stressors, such as infection and surgery in patients with cirrhosis. Despite the important role that malnutrition and sarcopenia play in the prognosis of patients with cirrhosis, they are frequently overlooked, in part because nutritional assessment can be a difficult task in patients with cirrhosis due to fluid retention and/or overweight. Moreover, patients with cirrhosis may develop simultaneous loss of skeletal muscle and gain of adipose tissue, culminating in the condition of "sarcopenic obesity." In addition, muscle depletion is characterized by both a reduction in muscle size and increased proportion of intermuscular and intramuscular fat-denominated "myosteatosis." Sarcopenia in cirrhotic patients has been associated with increased mortality, sepsis complications, hyperammonemia, overt hepatic encephalopathy, and increased length of stay after liver transplantation. Muscularity assessment with cross-sectional imaging studies has become an attractive index of nutritional status evaluation in cirrhosis, as sarcopenia reflects a chronic detriment in general physical condition, rather than acute severity of the liver disease. In this review, we discuss the current diagnostic methods to evaluate malnutrition and muscle abnormalities in cirrhosis and also analyze the current knowledge regarding incidence and clinical impact of malnutrition and muscle abnormalities in cirrhosis and their impact after liver transplantation. We also discuss existing and potential novel therapeutic strategies for malnutrition in cirrhosis, emphasizing the recognition of sarcopenia in cirrhosis in an effort to improve survival and reduce morbidity related to cirrhosis. Finally, we analyze new studies including sarcopenia with the MELD score that seems to allow better prediction of mortality among cirrhotic patients waiting for liver transplantation.

Impact of a ketogenic diet intervention during radiotherapy on body composition: I. Initial clinical experience with six prospectively studied patients

Background

Based on promising preclinical data, ketogenic diets (KDs) have been proposed as supplementary measures for cancer patients undergoing standard-of-care therapy. However, data is still scarce on the tolerability and effects of KDs on cancer patients undergoing radiotherapy (RT). Here we present six cases of patients who underwent RT and concurrently consumed a self-administered KD in our clinic within a busy community hospital setting.

Methods

All patients were followed prospectively with measurements of blood parameters, quality of life and body weight and composition using bioelectrical impedance analysis.

Results

No adverse diet-related side effects occurred. Two patients had no elevated ketone body levels in serum despite self-reporting compliance to the diet. There was consensus that the KD was satiating and weight loss occurred in all patients, although this was only significant in two patients. Our data indicate that weight loss was mainly due to fat mass loss with concurrent preservation of muscle mass. Overall quality of life remained fairly stable, and all subjects reported feeling good on the diet. Tumor regression occurred as expected in five patients with early stage disease; however one subject with metastatic small cell lung cancer experienced slight progression during three cycles of combined chemotherapy + KD and progressed rapidly after ending the KD.

Conclusions

Our data lend support to the hypothesis that KDs administered as supportive measures during standard therapy are safe and might be helpful in preservation of muscle mass. Further studies with control groups are needed to confirm these findings and address questions regarding any putative anti-tumor effects. Based on the experience with these six cases we implemented further steps to improve issues with KD compliance and initiated a clinical study that is described in a companion paper.

Evaluation of C-terminal Agrin Fragment as a marker of muscle wasting in patients after acute stroke during early rehabilitation

BACKGROUND

C-terminal Agrin Fragment (CAF) has been proposed as a novel biomarker for sarcopenia originating from the degeneration of the neuromuscular junctions. In patients with stroke muscle wasting is a common observation that predicts functional outcome. We aimed to evaluate agrin sub-fragment CAF22 as a marker of decreased muscle mass and physical performance in the early phase after acute stroke.

METHODS

Patients with acute ischaemic or haemorrhagic stroke (n = 123, mean age 70 ± 11 y, body mass index BMI 27.0 ± 4.9 kg/m(2)) admitted to inpatient rehabilitation were studied in comparison to 26 healthy controls of similar age and BMI. Functional assessments were performed at begin (23 ± 17 days post stroke) and at the end of the structured rehabilitation programme (49 ± 18 days post stroke) that included physical assessment, maximum hand grip strength, Rivermead motor assessment, and Barthel index. Body composition was assessed by bioelectrical impedance analysis (BIA). Serum levels of CAF22 were measured by ELISA.

RESULTS

CAF22 levels were elevated in stroke patients at admission (134.3 ± 52.3 pM) and showed incomplete recovery until discharge (118.2 ± 42.7 pM) compared to healthy controls (95.7 ± 31.8 pM, p < 0.001). Simple regression analyses revealed an association between CAF22 levels and parameters of physical performance, hand grip strength, and phase angle, a BIA derived measure of the muscle cellular integrity. Improvement of the handgrip strength of the paretic arm during rehabilitation was independently related to the recovery of CAF22 serum levels only in those patients who showed increased lean mass during the rehabilitation.

CONCLUSIONS

CAF22 serum profiles showed a dynamic elevation and recovery in the subacute phase after acute stroke. Further studies are needed to explore the potential of CAF22 as a serum marker to monitor the muscle status in patients after stroke.

Phase angle is associated with advanced fibrosis in patients chronically infected with hepatitis C virus

AIMS

The objective of this study was to evaluate the association of phase angle (PhA) with advanced liver fibrosis in patients chronically infected with hepatitis C virus (HCV).

MAIN METHODS

One hundred sixty consecutive patients chronically infected with HCV were treated at the Hepatitis C outpatient care setting of our hospital from April 2010 to May 2011 and prospectively evaluated. Bioelectrical impedance analysis measurements were performed during the first hospital visit. Biochemical measurements and liver biopsy data were collected from the patients' medical records and included in the analysis only if they were performed within three months of the inclusion of the patient in the study.

KEY FINDINGS

One hundred sixty consecutive patients were evaluated and 25 patients were excluded. A total of 135 patients with 49.8±11.4years old were studied. Among these patients, 60% were male and the PhA was 6.5±0.8°. Regarding the stage of fibrosis, patients with advanced fibrosis were older and had more insulin resistance and more inflammation compared with patients that had mild fibrosis. Logistic regression analysis revealed that PhA was a predictor of advanced fibrosis even when adjusted for gender, age, HOMA-IR, HDL-cholesterol and AST (OR: 0.227; CI 95%: 0.090-0.569; p: 0.013). The best PhA cut-off points associated with advanced fibrosis for the combined data, for females and for males were 6.43°, 5.94° and 6.72°, respectively.

SIGNIFICANCE

PhA was predictor of advanced liver fibrosis in patients chronically infected with HCV. In the sample evaluated, for each one-degree decrease in PhA, the risk of advanced fibrosis increased more than four-fold.

Impact of a ketogenic diet intervention during radiotherapy on body composition: II. Protocol of a randomised phase I study (KETOCOMP)

BACKGROUND

We have found that a ketogenic diet (KD) during the course of radiotherapy (RT) was feasible and led to a preservation or favorable changes of body composition. Based on these observations and theoretical considerations, we initiated a study to investigate the impact of a KD or a ketogenic breakfast intervention in patients undergoing RT.

METHODS

All patients presenting for curative RT with age between 18 and 75, body mass index between 18 and 34 kg/m² and a histologically confirmed cancer of the breast, colorectum or head and neck region are considered for inclusion. Exclusion criteria are Karnofsky index <70, pregnancy, metallic body parts that interfere with bioimpedance analysis (BIA), type I diabetes, known enzyme defects that contradict a KD and renal insufficiency. Randomization is achieved by all consecutive patients first entering the control group and then an intervention group 1 until both groups contain 15 breast, 15 colorectal and 5 head and neck cancer patients. Intervention group 1 will receive each radiotherapy fraction after an overnight fast and subsequently ingest a ketogenic breakfast consisting of (i) 50-250 ml of a medium-chain triglyceride drink (betaquick^®, vitaflo, Bad Homburg, Germany) plus (ii) 5-15 g amino acids (MAP, dr. reinwald healthcare gmbh+co kg, Schwarzenbruck, Germany). If willing to undertake a complete KD for the duration of RT, patients are entered into intervention group 2. Intervention group 2 does not have to fast prior to RT fractions but will be supplemented with MAP analogous to intervention group 1. The control group will not receive dietary advice to follow a KD or reduce carbohydrate intake. The objective is twofold: (i) to test whether the ketogenic interventions are feasibly, as measured by the number of dropouts; (ii) to see whether intervention groups 1 and 2 attain a better preservation of BIA phase angle than the control group.

ENDPOINTS

Primary endpoints are the feasibility of the interventions (measured through dropout rates), and changes in body weight and composition (measured through BIA). Secondary endpoints are changes in quality of life (EORTC questionnaires) and blood parameters as well as the occurrence and grade of toxicities and grade of regression after surgery in case of colorectal carcinomas.

Nutritional assessment in cirrhotic patients with hepatic encephalopathy

Hepatic encephalopathy (HE) is one of the worst complications of liver disease and can be greatly influenced by nutritional status. Ammonia metabolism, inflammation and muscle wasting are relevant processes in HE pathophysiology. Malnutrition worsens the prognosis in HE, requiring early assessment of nutritional status of these patients. Body composition changes induced by liver disease and limitations superimposed by HE hamper the proper accomplishment of exams in this population, but evidence is growing that assessment of muscle mass and muscle function is mandatory due to the role of skeletal muscles in ammonia metabolism. In this review, we present the pathophysiological aspects involved in HE to support further discussion about advantages and drawbacks of some methods for evaluating the nutritional status of cirrhotic patients with HE, focusing on body composition.

Application of standards and models in body composition analysis

The aim of this review is to extend present concepts of body composition and to integrate it into physiology. In vivo body composition analysis (BCA) has a sound theoretical and methodological basis. Present methods used for BCA are reliable and valid. Individual data on body components, organs and tissues are included into different models, e.g. a 2-, 3-, 4- or multi-component model. Today the so-called 4-compartment model as well as whole body MRI (or computed tomography) scans are considered as gold standards of BCA. In practice the use of the appropriate method depends on the question of interest and the accuracy needed to address it. Body composition data are descriptive and used for normative analyses (e.g. generating normal values, centiles and cut offs). Advanced models of BCA go beyond description and normative approaches. The concept of functional body composition (FBC) takes into account the relationships between individual body components, organs and tissues and related metabolic and physical functions. FBC can be further extended to the model of healthy body composition (HBC) based on horizontal (i.e. structural) and vertical (e.g. metabolism and its neuroendocrine control) relationships between individual components as well as between component and body functions using mathematical modelling with a hierarchical multi-level multi-scale approach at the software level. HBC integrates into whole body systems of cardiovascular, respiratory, hepatic and renal functions. To conclude BCA is a prerequisite for detailed phenotyping of individuals providing a sound basis for in depth biomedical research and clinical decision making.

Nutrition in Chronic Liver Disease

Protein-calorie malnutrition is a transversal condition to all stages of chronic liver disease. Early recognition of micro or macronutrient deficiencies is essential, because the use of nutritional supplements reduces the risk of complications. The diet of patients with chronic liver disease is based on a standard diet with supplements addition as necessary. Restrictions may be harmful and should be individualized. Treatment management should aim to maintain an adequate protein and caloric intake and to correct nutrient deficiencies. The large majority of patients with grade I/II hepatic encephalopathy can tolerate a regular diet. Protein restriction can aggravate malnutrition and is not recommended, except in cases of hepatic encephalopathy unresponsive to optimized therapy.

Nutritional assessment methods for zinc supplementation in prepubertal non-zinc-deficient children

BACKGROUND

Zinc is an essential nutrient that is required for numerous metabolic functions, and zinc deficiency results in growth retardation, cell-mediated immune dysfunction, and cognitive impairment.

OBJECTIVE

This study evaluated nutritional assessment methods for zinc supplementation in prepubertal non-zinc-deficient children.

DESIGN

We performed a randomised, controlled, triple-blind study. The children were divided into a control group (10% sorbitol, n=31) and an experimental group (10 mg Zn/day, n=31) for 3 months. Anthropometric and dietary assessments as well as bioelectrical measurements were performed in all children.

RESULTS

Our study showed (1) an increased body mass index for age and an increased phase angle in the experimental group; (2) a positive correlation between nutritional assessment parameters in both groups; (3) increased soft tissue, and mainly fat-free mass, in the body composition of the experimental group, as determined using bioelectrical impedance vector analysis; (4) increased consumption of all nutrients, including zinc, in the experimental group; and (5) an increased serum zinc concentration in both groups (p<0.0001).

CONCLUSIONS

Given that a reference for body composition analysis does not exist for intervention studies, longitudinal studies are needed to investigate vector migration during zinc supplementation. These results reinforce the importance of employing multiple techniques to assess the nutritional status of populations.

Sarcopenia and liver transplant: The relevance of too little muscle mass

Loss of muscle mass and function is a common occurrence in both patients with decompensated cirrhosis and those undergoing liver transplantation. Sarcopenia is associated with morbidity and mortality before and after liver transplantation. The ability of skeletal muscle mass to recover after transplant is questionable, and long term adverse events associated with persistent sarcopenia have not been well studied. Limited data is available examining mechanisms by which decreased muscle mass might develop. It is not clear which interventions might reduce the prevalence of sarcopenia and associated health burdens. However, measures to either decrease portal hypertension or improve nutrition appear to have benefit. Research on sarcopenia in the liver transplant setting is hampered by differing methodology to quantify muscle mass and varied thresholds determining the presence of sarcopenia. One area highlighted in this review is the heterogeneity used when defining sarcopenia. The health consequences, clinical course and potential pathophysiologic mechanisms of sarcopenia in the setting of cirrhosis and liver transplantation are further discussed.

Malnutrition in cirrhosis increases morbidity and mortality

BACKGROUND AND AIMS

Malnutrition is frequent in patients with cirrhosis and is associated with complications like ascites, hepatic encephalopathy, infections, and death. We determined the prevalence of malnutrition by various methods and its clinical importance in patients with cirrhosis.

METHODS

Consecutive patients of cirrhosis from August 2013 to February 2015 were assessed. Nutritional status was assessed by traditional model (mid-arm circumference, triceps skinfold thickness, serum albumin, creatinine height index, total lymphocyte count), handgrip, and body composition analysis measuring skeletal muscle mass and body fat mass. All patients were followed up for 12 months to assess the outcome.

RESULTS

247 patients (age 42.10 ± 10.14 years, 81% male) were included in the study. Etiology of cirrhosis was alcohol in 53% patients. Prevalence of malnutrition was 59.5% according to traditional model, 66.8% by body composition analysis and 71.4% by handgrip. Nutritional status was poor in alcoholic cirrhotics versus nonalcoholics as assessed by triceps skinfold thickness (9.33 ± 2.9 vs 11.64 ± 3.5 mm; P = 0.001), serum albumin (25.1 ± 4 vs 28.1 ± 4 g/L; P = 0.001), and body fat mass (7.6 ± 3.1 vs 8.7 ± 3.3 kg; P = 0.008). Prevalence of malnutrition was 12/27 (44.5%), 96/131 (73.3%) and 84/89 (94.4%) in Child's class A, B, and C respectively. Complications requiring hospitalization (71.3% vs 38.2%; 0.002) and mortality (41.1% vs 18.2%; P = 0.001) were more in malnourished patients compared to well nourished. Nutritional assessment parameters significantly correlated with the liver disease severity (P < 0.05).

CONCLUSIONS

Prevalence of malnutrition is high in patients with cirrhosis. It is associated with increased complications and mortality.

Bioimpedance phase angle indicates catabolism in Type 2 diabetes

AIMS

Body cell mass is directly proportional to the bioimpedance phase-angle which is an indicator of the amount of electrical charge that cell membranes can hold and is an index of cellular health and function. To evaluate whether the bioimpedance phase angle is relevant for indicating catabolism in people with diabetes and whether it discriminates between people with diabetes receiving different types of therapy.

METHODS

A cross-sectional study was performed in 182 people with Type 2 diabetes and 107 age- and BMI-matched control subjects. The phase angle was measured at 5, 50 and 100 kHz using multifrequency bioimpedance analysis. The phase angles were compared among different diabetes therapy groups (untreated patients with diabetes, patients receiving oral antidiabetic drugs and patients receiving insulin therapy).

RESULTS

The phase angle at 100 kHz strongly correlated with total body potassium (r = 0.70, P = 0.001), and was therefore a good indicator of body cell mass. The phase angle at 100 kHz discriminated more strongly between patients with Type 2 diabetes and control subjects than did the phase angle at 50 kHz. Compared with control subjects, patients with Type 2 diabetes had a smaller phase angle at 100 kHz (men: 5.2° vs. 4.5°, P < 0.0001; women: 4.8° vs. 4.2°, P < 0.0001) and a smaller phase angle at 50 kHz (men: 5.9° vs. 5.3°, P < 0.0001; women: 5.4° vs. 4.8°, P = 0.0001), but a larger phase angle at 5 kHz (men: 2.0° vs. 2.6°, P = 0.0001; women: 2.3° vs. 3.0°, P = 0.00001). Phase angle ratios better discriminated between patients and control subjects than phase angles alone (phase angle at 5 kHz/ phase angle at 50 kHz ratio, P = 1.51 × 10(-16) ; phase angle at 5kHz/phase angle at 100 kHz ratio, P = 2.13 × 10(-15) ). No differences were found among phase angles in the different therapy groups. In patients with diabetes, the phase angle at 50 kHz and the phase angle at 100 kHz correlated inversely with duration of disease (men: P = 0.026, P = 0.016; women: only phase angle at 100 kHz, P = 0.003) and with HbA1c concentration (men: P = 0.010, P = 0.001; women: P = 0.007, P = 0.043).

CONCLUSIONS

The phase angle at 100 kHz is a promising measurement for assessing catabolic state in people with diabetes.

Effect of chemotherapy on dietary glycemic index and load in patients with breast cancer and their relationships to body fat and phase angle

Dietary glycemic index (GI) and glycemic load (GL) are indicators of carbohydrate consumption and widely used in studies evaluating the risk for breast cancer. However, the effect of chemotherapy on these indices has been scarcely studied. The aim of this study was to evaluate dietary levels of GI and GL in women with breast cancer during chemotherapy treatment and their relationships to body fat and phase angle. Twenty-five patients were assessed according to demographic, clinical, anthropometric, and food consumption data. Dietary intake was assessed by 24-h dietary recalls applied on nonconsecutive days. Anthropometric measures and body composition were determined at all study timepoints: prior to the first chemotherapy cycle (T0), immediately after the last chemotherapy cycle (T1), and 2 months after T1 (T2). There was no difference in mean GI and GL among study timepoints. However, a high prevalence of inadequate GI and GL values was noted, independent of study timepoint. GI and GL were associated with phase angle at T1. GI was associated with percentage fat at T0 only. Dietary GI and GL were unchanged during chemotherapy, but were associated with indicators of clinical outcome, such as percentage fat and phase angle.

Bioelectrical impedance phase angle in septic patients admitted to intensive care units

Objective

To calculate the values of the phase angle of septic patients using bioelectrical impedance analysis, correlate the values with clinical and biochemical variables, and compare them to reference values.

Methods

Cohort study conducted with 50 septic patients aged ≥18 years old, admitted to intensive care units, and assessed according to prognostic indexes (APACHE II and SOFA), clinical progression (mortality, severity of sepsis, length of stay in intensive care unit), biochemical parameters (albumin and C-reactive protein), and the phase angle.

Results

The average age of the sample was 65.6±16.5 years. Most patients were male (58%) and suffering from septic shock (60%). The average APACHE II and SOFA scores were 22.98±7.1 and 7.5±3.4, respectively. The patients who survived stayed nine days on average (five to 13) in the intensive care unit, and the mortality rate was 30%. The average value of the phase angle was 5.4±2.6º in the total sample and was smaller among the females compared with the males (p=0.01). The phase angle measures did not exhibit an association with the severity of the sepsis, mortality, gender, and age or correlate with the length of hospitalization or the biochemical parameters. The participants' phase angle values adjusted per gender and age were 1.1 to 1.9 times lower compared with the values for a normal population.

Conclusion

The average value of the phase angle of septic patients was lower compared with the reference values for a healthy population. The phase angle measures did not exhibit association with the clinical and biochemical variables, which might be explained by the sample homogeneity.

Malnutrition assessed through phase angle and its relation to prognosis in patients with compensated liver cirrhosis: a prospective cohort study

BACKGROUND

Malnutrition is a frequent complication of cirrhosis and it has been associated to more severe disease and development of complications. Phase angle is a bedside reliable tool for nutritional assessment based on conductivity properties of body tissues.

AIM

To evaluate the association between malnutrition assessed through phase angle and mortality in patients with liver cirrhosis.

METHODS

We performed a prospective cohort study in a tertiary care centre; 249 patients were enrolled with 48 months of follow-up. Clinical, nutritional (malnutrition = phase angle ≤ 4.9°) and biochemical evaluations were performed. Student's t-test and χ(2) method were used as appropriate. Kaplan-Meier curves and multivariate Cox regression were used to evaluate mortality.

RESULTS

Mean follow-up was 33.5 months. Survival analysis showed higher mortality in the malnourished group compared to the well-nourished group (p = 0.076), Kaplan-Meier curves were further stratified according to compensated and decompensated status showing higher mortality in compensated patients according to Child-Pugh (p = 0.002) and Model for End-Stage Liver Disease score (p = 0.008) when malnutrition was present. Multivariate analysis showed that malnutrition was independently associated with mortality (HR = 2.15, 1.18-3.92).

CONCLUSIONS

In our cohort, malnutrition was independently associated with mortality. This is the first study showing higher mortality in malnourished compensated cirrhotic patients.

Phase angle and handgrip strength are sensitive early markers of energy intake in hypophagic, non-surgical patients at nutritional risk, with contraindications to enteral nutrition

The assessment of nutritional intakes during hospitalization is crucial, as it is known that nutritional status tends to worsen during the hospital stay, and this can lead to the negative consequences of malnutrition. International guidelines recommend the use of parenteral nutrition (PN) in hypophagic, non-surgical patients at nutritional risk, with contraindications to enteral nutrition. However, to date, there are no published data regarding either energy intake or objective measurements associated with it in this patient population. The aim of the present exploratory methodological study was to evaluate whether phase angle (PhA) and handgrip strength normalized for skeletal muscle mass (HG/SMM) are sensitive early markers of energy intake in hypophagic, non-surgical patients at nutritional risk, with contraindications to enteral nutrition. We evaluated 30 eligible patients, who were treated with personalized dietary modifications and supplemental PN for at least one week during hospitalization. In a liner regression model adjusted for age, gender, basal protein intake and the basal value of each variable, a trend toward improvement of PhA and preservation of HG/SMM was observed in patients satisfying the estimated calorie requirements (N = 20), while a significant deterioration of these parameters occurred in those who were not able to reach the target (N = 10). The mean adjusted difference and 95% CI were +1.4° (0.5-2.3) (p = 0.005) for PhA and +0.23 (0.20-0.43) (p = 0.033) for HG/SMM. A significant correlation between PhA and HG/SMM variations was also observed (r = 0.56 (95% CI, 0.23-0.77); p = 0.0023). PhA and HG/SMM were able to distinguish between hypophagic, non-surgical patients at nutritional risk who satisfied their estimated caloric requirements and those who did not after a one-week personalized nutritional support. Clinical studies are warranted, in order to verify these preliminary observations and to validate the role of PhA variations as early markers of anabolic/catabolic fluctuations.

Creatina e treinamento resistido: efeito na hidratação e massa corporal magra

INTRODUÇÃO: a creatina é um recurso ergogênico cuja suplementação tem sido associada ao aumento da hidratação corporal total e ao aumento da massa muscular dos consumidores. Entretanto, estudiosos questionam se o aumento da massa muscular é um ganho real.OBJETIVO: avaliar o efeito da suplementação de creatina sobre a hidratação e o aumento de massa magra em indivíduos previamente treinados e não treinados, submetidos a um programa de treinamento resistido.MÉTODOS: ensaio clínico não randomizado, constituído por três momentos, M1 - Início da suplementação com 20g/dia de creatina; M2 - 7 dias após iniciada a suplementação e redução da suplementação para 5g/dia; M3 - 28 dias de suplementação. Nos momentos propostos, foram realizadas aferições de peso, estatura e avaliação da composição corporal (massa magra, água corporal total) com a utilização do BYODINAMICS(r) Modelo 310. Para todos os testes estatísticos, foi adotado o nível de significância de 95% (p<0,05).RESULTADOS: participaram desse estudo 14 voluntários adultos do sexo masculino, com idade média de 22,57(±1,45) anos, dos quais sete eram treinados e sete não treinados. Após 28 dias de suplementação, no grupo treinado observou-se um aumento significativo no peso, água corporal total, massa magra e hidratação da massa magra, mas nenhum aumento significativo foi observado no grupo não treinado. Em relação ao ângulo de fase, este aumentou no grupo não treinado e reduziu no grupo treinado.CONCLUSÃO: a suplementação de creatina associada ao treinamento resistido é mais efetiva na hidratação de indivíduos treinados, como também é suficiente para reduzir a diferença significativa do ângulo de fase intergrupos, sugerindo assim, maior hidratação celular em ambos os grupos. Contudo, esse aumento na hidratação não revelou aumento significativo no tecido muscular.

Use of bioelectrical impedance analysis for the assessment of nutritional status in critically ill patients

Malnutrition is common in the critically ill patients and known to cause a variety of negative clinical outcomes. However, various conventional methods for nutrition assessment have several limitations. We hypothesized that body composition data, as measured using bioelectrical impedance analysis (BIA), may have a significant role in evaluating nutritional status and predicting clinical outcomes in critically ill patients. We gathered clinical, biochemical, and BIA data from 66 critically ill patients admitted to an intensive care unit. Patients were divided into three nutritional status groups according to their serum albumin level and total lymphocyte counts. The BIA results, conventional indicators of nutrition status, and clinical outcomes were compared and analyzed retrospectively. Results showed that the BIA indices including phase angle (PhA), extracellular water (ECW), and ECW/total body water (TBW) were significantly associated with the severity of nutritional status. Particularly, PhA, an indicator of the health of the cell membrane, was higher in the well-nourished patient group, whereas the edema index (ECW/TBW) was higher in the severely malnourished patient group. PhA was positively associated with albumin and ECW/TBW was negatively associated with serum albumin, hemoglobin, and duration of mechanical ventilation. In non-survivors, PhA was significantly lower and both ECW/TBW and %TBW/fat free mass were higher than in survivors. In conclusion, several BIA indexes including PhA and ECW/TBW may be useful for nutritional assessment and represent significant prognostic factors in the care of critically ill patients.

Bioelectrical impedance phase angle relates to function, disease severity and prognosis in stable chronic obstructive pulmonary disease

BACKGROUND & AIMS

Bioelectrical impedance analysis (BIA) provides a simple method to assess changes in body composition. Raw BIA variables such as phase angle provide direct information on cellular mass and integrity, without the assumptions inherent in estimating body compartments, e.g. fat-free mass (FFM). Phase angle is a strong functional and prognostic marker in many disease states, but data in COPD are lacking. Our aims were to describe the measurement of phase angle in patients with stable COPD and determine the construct and discriminate validity of phase angle by assessing its relationship with established markers of function, disease severity and prognosis.

METHODS

502 outpatients with stable COPD were studied. Phase angle and FFM by BIA, quadriceps strength (QMVC), 4-m gait speed (4MGS), 5 sit-to-stand time (5STS), incremental shuttle walk (ISW), and composite prognostic indices (ADO, iBODE) were measured. Patients were stratified into normal and low phase angle and FFM index.

RESULTS

Phase angle correlated positively with FFM and functional outcomes (r = 0.35-0.66, p < 0.001) and negatively with prognostic indices (r = -0.35 to -0.48, p < 0.001). In regression models, phase angle was independently associated with ISW, ADO and iBODE whereas FFM was removed. One hundred and seventy patients (33.9% [95% CI, 29.9-38.1]) had a low phase angle. Phenotypic characteristics included lower QMVC, ISW, and 4MGS, higher 5STS, ADO and iBODE scores, and more exacerbations and hospital days in past year. The proportion of patients to have died was significantly higher in patients with low phase angle compared to those with normal phase angle (8.2% versus 3.6%, p = 0.02).

CONCLUSION

Phase angle relates to markers of function, disease severity and prognosis in patients with COPD. As a directly measured variable, phase angle offers more useful information than fat-free mass indices.

Restricting carbohydrates to fight head and neck cancer-is this realistic?

Head and neck cancers (HNCs) are aggressive tumors that typically demonstrate a high glycolytic rate, which results in resistance to cytotoxic therapy and poor prognosis. Due to their location these tumors specifically impair food intake and quality of life, so that prevention of weight loss through nutrition support becomes an important treatment goal. Dietary restriction of carbohydrates (CHOs) and their replacement with fat, mostly in form of a ketogenic diet (KD), have been suggested to accommodate for both the altered tumor cell metabolism and cancer-associated weight loss. In this review, I present three specific rationales for CHO restriction and nutritional ketosis as supportive treatment options for the HNC patient. These are (1) targeting the origin and specific aspects of tumor glycolysis; (2) protecting normal tissue from but sensitizing tumor tissue to radiation- and chemotherapy induced cell kill; (3) supporting body and muscle mass maintenance. While most of these benefits of CHO restriction apply to cancer in general, specific aspects of implementation are discussed in relation to HNC patients. While CHO restriction seems feasible in HNC patients the available evidence indicates that its role may extend beyond fighting malnutrition to fighting HNC itself.

Evaluation of nutritional indicators and body composition in patients with advanced liver disease enrolled for liver transplantation

PURPOSE

Malnutrition is prevalent in patients with advanced liver disease (LD) related to multifactorial causes. Fluid retention can underestimate the nutritional status based on anthropometric measures. We evaluated nutritional indicators and body composition (BC) in patients with liver cirrhosis and correlated them with LD severity.

METHODS

Forty three patients with LD enrolled for liver transplantation were evaluated by Anthropometric measures, subjective evaluation (Global Assessment of Nutritional Status - SGA) and biochemical indicators. Single-frequency electrical bioimpedance (SFE-BIA) was used to evaluate body composition (BC). It measured resistance (R), reactance (Xc) and the phase angle (PA). LD severity was estimated by Child-Pugh and Meld criteria (Model for End-Stage Liver Disease).

RESULTS

Child-Pugh index between patients was 7.11 ± 1.70 and Meld was 12.23 ± 4.22. Arm Circumference, Arm Muscle Circumference and Arm Muscle Area, SGA, hemoglobin, hematocrit and albumin showed better correlation with disease severity. Xc and PA showed correlation both with Meld and Child-Pugh score when BC were evaluated. PA was depleted in 55.8% of the patients.

CONCLUSIONS

Diagnosis of malnutrition varied according to the method. Global assessment of nutritional status showed better correlation with disease severity than with objective methods. Single-frequency electrical bioimpedance for body composition analysis in cirrhotic patients must be cautiously used; however, primary vectors seems to be valid and promising in clinical practice.

The Association between Phase Angle of Bioelectrical Impedance Analysis and Survival Time in Advanced Cancer Patients: Preliminary Study

Background

A frequent manifestation of advanced cancer patients is malnutrition, which is correlated with poor prognosis and high mortality. Bioelectrical impedance analysis (BIA) is an easy-to-use and non-invasive technique to evaluate changes in body composition and nutritional status. We investigated BIA-derived phase angle as a prognostic indicator for survival in advanced cancer patients.

Methods

Twenty-eight patients treated at the hospice center of Seoul St. Mary's Hospital underwent BIA measurements from January, 2013 to May, 2013. We also evaluated palliative prognostic index (PPI) and palliative performance scale to compare with the prognostic value of phase angle. Cox's proportional hazard models were constructed to evaluate the prognostic effect of phase angle. The Kaplan Meier method was used to calculate survival.

Results

Using univariate Cox analysis, phase angle (hazard ratio [HR], 0.61/per degree increase; 95% confidence interval [CI], 0.42 to 0.89; P = 0.010), PPI (HR, 1.21; 95% CI, 1.00 to 1.47; P = 0.048) were found to be significantly associated with survival. Adjusting age, PPI, body mass index, phase angle significantly showed association with survival in multivariate analysis (HR, 0.64/per degree increase; 95% CI, 0.42 to 0.95; P = 0.028). Survival time of patients with phase angle ≥ 4.4° was longer than patients with phase angle < 4.4° (log rank, 6.208; P-value = 0.013).

Conclusion

Our data suggest BIA-derived phase angle may serve as an independent prognostic indicator in advanced cancer patients.

Nutrition and exercise in the management of liver cirrhosis

Liver cirrhosis (LC) patients often have protein-energy malnutrition (PEM) and decreased physical activity. These conditions often lead to sarcopenia, which is the loss of skeletal muscle volume and increased muscle weakness. Recent studies have demonstrated that PEM and sarcopenia are predictors for poor survival in LC patients. Nutrition and exercise management can improve PEM and sarcopenia in those patients. Nutrition management includes sufficient dietary intake and improved nutrient metabolism. With the current high prevalence of obesity, the number of obese LC patients has increased, and restriction of excessive caloric intake without the exacerbation of impaired nutrient metabolism is required for such patients. Branched chain amino acids are good candidates for supplemental nutrients for both obese and non-obese LC patients. Exercise management can increase skeletal muscle volume and strength and improve insulin resistance; however, nutritional status and LC complications should be assessed before an exercise management regimen is implemented in LC patients. The establishment of optimal exercise regimens for LC patients is currently required. In this review, we describe nutritional status and its clinical impact on the outcomes of LC patients and discuss general nutrition and exercise management in LC patients.

Anabolic Effect of Exercise Training in People with End-Stage Renal Disease on Hemodialysis: A Systematic Review with Meta-analysis

PURPOSE

The primary purpose of this systematic review was to evaluate the anabolic effect of exercise intervention in adults with end-stage renal disease on hemodialysis (HD). The secondary objectives were to evaluate the influences of participant characteristics and exercise parameters on changes in muscle size.

METHODS

Electronic databases (Cochrane, CINAHL, EMBASE, PEDro, PubMed and SCOPUS) were searched from inception to November 2012. Randomized clinical trials published in English that included adults on HD undergoing an exercise intervention where muscle mass was measured as an outcome were included in this review. Two reviewers independently selected the studies, extracted data, and assessed risk of bias within the included studies. RESULTS were then combined by meta-analysis. The effect of exercises was determined using a standardized mean difference (SMD), expressed as Hedges' g, computed using a random effects model.

RESULTS

Seven SMDs extracted from five studies were included for final analysis. Strength training was used in all studies; one study used aerobic and mixed strength and aerobic training with two subgroups of participants. The overall effect of exercise on muscle mass was statistically significant (SMD: 0.272; 95% CI, 0.020-0.525).

CONCLUSIONS

Our results confirm a small but significant effect of strengthening exercise as an anabolic intervention to increase muscle mass. Exercise training should be included in routine management of people on maintenance HD. Although current results indicate that one in nine people on HD is likely to benefit from exercise intervention, parameters influencing these results require further research.

Phase angle, frailty and mortality in older adults

BACKGROUND

Frailty is a multidimensional phenotype that describes declining physical function and a vulnerability to adverse outcomes in the setting of physical stress such as illness or hospitalization. Phase angle is a composite measure of tissue resistance and reactance measured via bioelectrical impedance analysis (BIA). Whether phase angle is associated with frailty and mortality in the general population is unknown.

OBJECTIVE

To evaluate associations among phase angle, frailty and mortality.

DESIGN

Population-based survey.

SETTING

Third National Health and Nutritional Examination Survey (1988-1994).

PARTICIPANTS

In all, 4,667 persons aged 60 and older.

MEASUREMENTS

Frailty was defined according to a set of criteria derived from a definition previously described and validated.

RESULTS

Narrow phase angle (the lowest quintile) was associated with a four-fold higher odds of frailty among women and a three-fold higher odds of frailty among men, adjusted for age, sex, race-ethnicity and comorbidity. Over a 12-year follow-up period, the adjusted relative hazard for mortality associated with narrow phase angle was 2.4 (95 % confidence interval [95 % CI] 1.8 to 3.1) in women and 2.2 (95 % CI 1.7 to 2.9) in men. Narrow phase angle was significantly associated with mortality even among participants with little or no comorbidity.

LIMITATIONS

Analyses of BIA and frailty were cross-sectional; BIA was not measured serially and incident frailty during follow-up was not assessed. Participants examined at home were excluded from analysis because they did not undergo BIA.

CONCLUSIONS

Narrow phase angle is associated with frailty and mortality independent of age and comorbidity.

Association between phase angle, anthropometric measurements, and lipid profile in HCV-infected patients

OBJECTIVE

The objective of this study was to investigate the associations between phase angle, anthropometric measurements, and lipid profile in patients chronically infected with the hepatitis C virus.

METHODS

A total of 160 consecutive patients chronically infected with the hepatitis C virus and who received treatment at the hepatitis C outpatient unit of our hospital from April 2010 to May 2011 were prospectively evaluated. Bioelectrical impedance analysis, anthropometric measurements, and serum lipid profile analysis were performed.

RESULTS

Twenty-five patients were excluded. A total of 135 patients with a mean age of 49.8±11.4 years were studied. Among these patients, 60% were male. The phase angle and BMI means were 6.5±0.8° and 26.5±4.8 kg/m2, respectively. Regarding anthropometric variables, mid-arm circumference, mid-arm muscle circumference, and arm muscle area had a positive correlation with phase angle. In contrast, when analyzing the lipid profile, only HDL was inversely correlated with phase angle. However, in multiple regression models adjusted for age and gender, only mid-arm circumference (p = 0.005), mid-arm muscle circumference (p = 0.003), and arm muscle circumference (p = 0.001) were associated with phase angle in hepatitis C virus-infected patients.

CONCLUSIONS

In conclusion, phase angle is positively correlated with anthropometric measures in our study. However, there is no association between phase angle and lipid profile in these patients. Our results suggest that phase angle is related to lean body mass in patients chronically infected with hepatitis C virus.

Nutrition status and intestinal permeability in patients eligible for liver transplantation

BACKGROUND

Increased intestinal permeability has been reported in multiple studies of cirrhotic patients, although specific factors associated with this finding have not been fully elucidated. Thus, the aim of this study was to investigate whether there was an association between nutrition status measured by different methods and intestinal permeability in cirrhotic patients who were candidates for liver transplantation.

MATERIALS AND METHODS

The study group comprised 18 cirrhotic patients and 15 healthy controls. Patients' nutrition status was evaluated by Subjective Global Assessment (SGA), anthropometry, dynamometry, and phase angle, which was determined by bioelectrical impedance analysis. Intestinal permeability was assessed by the lactulose/mannitol test.

RESULTS

The prevalence of malnutrition showed wide variance between different assessment methods (5.5%-77.8%). Intestinal permeability was significantly higher in cirrhotic patients than in healthy controls. In relation to nutrition status, intestinal permeability and phase angle did not differ significantly between patients who were considered well nourished (median intestinal permeability, 0.010 [range, 0.001-0.198]; median phase angle, 6.0 [range, 4.2-6.9]) and malnourished patients (intestinal permeability, 0.032 [range, 0.002-0.079]; phase angle, 4.8 [range, 2.2-6.1]) by SGA. In addition, no correlation was found between nutrition diagnosis as assessed by different methods, patient age, liver disease severity scores, and laboratory measurements with intestinal permeability.

CONCLUSION

Although intestinal permeability was increased in cirrhotic patients, this finding was not associated with nutrition status.

TIPS: 25 years later

In the 25 years since the first TIPS intervention has been performed, technical standards, indications, and contraindications have been set up. The previous considerable problem of shunt failure by thrombosis or intimal proliferation in the stent or in the draining hepatic vein has been reduced considerably by the availability of polytetrafluoroethylene (PTFE)-covered stents resulting in reduced rebleeding and improved survival. Unfortunately, most clinical studies have been performed prior to the release of the covered stent and, therefore, do not represent the present state of the art. In spite of this, TIPS has gained increasing acceptance in the treatment of the various complications of portal hypertension and vascular diseases of the liver.