A practical approach to nutritional screening and assessment in cirrhosis

Effectiveness of different tools for malnutrition in the assessment of patients with cirrhosis

BACKGROUND

We aimed to evaluate the prevalence of malnutrition using traditional measures of nutritional assessments like body mass index (BMI), mid-arm circumference (MAC), triceps skin fold thickness (TSF), mid-arm muscle circumference (MAMC), hand grip strength (HGS) and subjective global assessments (SGA) among cirrhotic patients referred for liver transplantation (LT).

METHODS

The study was conducted among 215 cirrhotic patients referred for LT at a tertiary care hospital. Patients were enrolled between July 2021 and October 2022 to assess the prevalence of malnutrition. Patient's demographic details, clinical history, BMI using dry weight, MAMC, HGS, SGA score and disease severity were assessed.

RESULTS

Chronic alcoholism was the main causative factor for cirrhosis, followed by viral infection. 58% of cirrhotic patients were moderately to severely malnourished based on SGA, 12% were undernourished based on BMI, 91% had low MAC, and 94% had low HGS/muscle strength indicating malnutrition. Low MAC (p = 0.048) and SGA (p = 0.000) were associated with CTP - B and C class, and low MAC (p = 0.046), low TSF (p = 0.005), and SGA (p = 0.000), were associated with MELD Na score >15. Low MAC (p = 0.011) and SGA (P = 0.000) were associated with mortality, although 78% of patients had MAC within the normal range. A strong association exists between malnutrition and complications, liver disease severity, and death.

CONCLUSION

In patients with chronic liver diseases, SGA performed well as a good predictor of malnutrition, this might be because SGA analyzes various domains which can be affected in chronic liver disease. Assessing malnutrition early may help in initiating appropriate medical nutritional therapy.

Expert consensus on the diagnosis and treatment of end-stage liver disease complicated by infections

End-stage liver disease (ESLD) is a life-threatening clinical syndrome and when complicated with infection the mortality is markedly increased. In patients with ESLD, bacterial or fungal infection can induce or aggravate the occurrence or progression of liver decompensation. Consequently, infections are among the most common complications of disease deterioration. There is an overwhelming need for standardized protocols for early diagnosis and appropriate management for patients with ESLD complicated by infections. Asia Pacific region has the largest number of ESLD patients, due to hepatitis B and the growing population of alcohol and NAFLD. Concomitant infections not only add to organ failure and high mortality but also to financial and healthcare burdens. This consensus document assembled up-to-date knowledge and experience from colleagues across the Asia-Pacific region, providing data on the principles as well as evidence-based current working protocols and practices for the diagnosis and treatment of patients with ESLD complicated by infections.

Myosteatosis is closely associated with sarcopenia and significantly worse outcomes in patients with cirrhosis

BACKGROUND AND AIM

Sarcopenia and myosteatosis are common in patients with cirrhosis. This study aimed to determine the prevalence of these muscle changes, their interrelations and their prognostic impact over a 12-month period.

METHODS

We conducted a prospective multicentre study involving 433 patients. Sarcopenia and myosteatosis were evaluated using computed tomography scans. The 1-year cumulative incidence of relevant events was assessed by competing risk analysis. We used a Fine-Gray model adjusted for known prognostic factors, to evaluate the impact of sarcopenia and myosteatosis on mortality, hospitalization, and liver decompensation.

RESULTS

At enrolment, 166 patients presented with isolated myosteatosis, 36 with isolated sarcopenia, 135 with combined sarcopenia and myosteatosis and 96 patients showed no muscle changes. The 1-year cumulative incidence of death in patients with either sarcopenia and myosteatosis (13.8%) or isolated myosteatosis (13.4%) was over twice that of patients without muscle changes (5.2%) or with isolated sarcopenia (5.6%). The adjusted subhazard ratio for death in patients with muscle changes was 1.36 (95% CI 0.99, 1.86) (P=0.058). The cumulative incidence of hospitalization was significantly higher in patients with combined sarcopenia and myosteatosis than in patients without muscle changes (adjusted subhazard ratio 1.18, 95% CI 1.04 to 1.35). The cumulative incidence of liver decompensation was greater in patients with combined sarcopenia and myosteatosis (p=0.018) and those with isolated sarcopenia (p=0.046) than in patients without muscle changes. Lastly, we found a strong correlation between function tests and frailty scores with the presence of muscle changes.

CONCLUSIONS

Myosteatosis, whether alone or combined with sarcopenia, is highly prevalent in patients with cirrhosis and is associated with significantly worse outcomes. The prognostic role of sarcopenia should always be evaluated in relation to the presence of myosteatosis.

IMPACT AND IMPLICATIONS

This study investigates the prognostic role of muscle changes in patients with liver cirrhosis. The novelty of this study is the multicentre, prospective nature and the distinguishing impact of individual muscle changes and their combination on prognosis in cirrhosis. This study highlights the prognostic role of myosteatosis, especially when combined with sarcopenia. On the other hand, the relevance of sarcopenia could be mitigated when considered together with myosteatosis. The implication from these findings is that sarcopenia should never be evaluated individually and that myosteatosis may have a dominant role in the prognosis of patients with liver cirrhosis.

Are sarcopenia, frailty and malnutrition prognostic markers of liver disease decompensation in the ambulatory setting? - A prospective cohort study

BACKGROUND

sarcopenia, frailty and malnutrition are associated with adverse outcomes in liver cirrhosis. Studies assessing the prognostic value of these conditions in ambulatory patients with cirrhosis are scarce.

METHODS

a prospective cohort study was performed, with consecutive inclusion of all patients with cirrhosis observed in the Hepatology outpatient clinic of a Portuguese tertiary center. At study enrolment, evaluation of muscle mass (ultrasound quadriceps femoris thickness), muscle strength (handgrip dynamometry) and nutritional status (Patient-Generated Subjective Global Assessment Short Form) were performed. Follow-up ended upon the occurrence of a composite endpoint, comprising of liver decompensation events and liver-related death, or last medical appointment/non-liver related death before the end of the study. The prognostic value of anthropometrical parameters and nutritional status in the composite endpoint was assessed using a multivariate Cox regression analysis, adjusted for several confounders.

RESULTS

ninety patients were enrolled (80 % male), with a mean age of 63.5 ± 10.5 years. The median follow-up was 30 (interquartile range 38) weeks, during which, 12 patients reached the composite endpoint. These patients presented a lower mean handgrip strength (23.1 ± 6.41 vs 30.3 ± 10.4 kg, p = 0.04) compared to patients who did not reach the composite endpoint. However, Cox regression multivariate analysis did not find any independent predictors of the composite endpoint, apart from previous decompensation episodes.

CONCLUSION

in this study, muscle strength was lower in the group of patients with cirrhosis who presented a liver-related event. Handgrip strength might be a promising tool in the ambulatory setting to identify patients at risk of liver decompensation and liver-related death in the short term.

Mid-arm muscle circumference cutoff points in patients with cirrhosis: Low muscle mass related to malnutrition predicts mortality

OBJECTIVES

Muscle loss is one of the phenotypic criteria of malnutrition, is highly prevalent in patients with cirrhosis, and is associated with adverse outcomes. Mid-arm muscle circumference (MAMC) estimates the skeletal muscle mass and is especially helpful in cases of fluid overload. This study aimed to propose MAMC cutoff points for patients with cirrhosis and demonstrate its association with 1-year mortality.

METHODS

This is an analysis of cohort databases from five reference centers in Brazil that included inpatients and outpatients with cirrhosis aged ≥18 y. The nutritional variables obtained were the MAMC (n = 1075) and the subjective global assessment (n = 629). We established the MAMC cutoff points stratified by sex based on the subjective global assessment as a reference standard for malnutrition diagnosis, considering the sensitivity, specificity, and Youden index. An adjusted Cox regression model was used to test the association of MAMC cutoff points and 1-year mortality.

RESULTS

We included 1075 patients with cirrhosis, with a mean age of 54.8 ± 11.3 y; 70.4% (n = 757) male. Most patients had alcoholic cirrhosis (47.1%, n = 506) and were classified as Child-Pugh B (44.7%, n = 480). The MAMC cutoff points for moderate and severe depletion were ≤21.5 cm and ≤24.2 cm; ≤20.9 cm and ≤22.9 cm for women and men, respectively. According to these cutoff points, 13.8% (n = 148) and 35.1% (n = 377) of the patients had moderate or severe MAMC depletion, respectively. The 1-year mortality rate was 17.3% (n = 186). In the multivariate analysis adjusted for sex, age, MELD-Na, and Child-Pugh scores, a severe depletion in MAMC was an independent increased risk factor for 1-year mortality (HR: 1.71, 95% CI: 1.24-2.35, P < 0.001). Each increase of 1 cm in MAMC values was associated with an 11% reduction in 1-year mortality risk (HR: 0.89, 95% CI: 0.85-0.94, P < 0.001).

CONCLUSIONS

Low MAMC classified according to the new cutoff points predicts mortality risk in patients with cirrhosis and could be used in clinical practice.

Nutritional aspects of prehabilitation in adults with cirrhosis awaiting liver transplant

Malnutrition, sarcopenia (low muscle mass), and physical frailty have gained increasing recognition in candidates for liver transplant (LT) as these conditions can impact postoperative functional capacity. Multidimensional prehabilitation programs have been proposed as a safe intervention in adults awaiting LT but the nutritional pillar of prehabilitation has been understudied. This review summarizes the nutritional recommendations for prehabilitation for individuals with cirrhosis awaiting LT. Three major aspects of nutritional prehabilitation are discussed: (1) Assess: Evaluate nutritional status and assess for malnutrition, sarcopenia, and frailty to guide the nutritional prehabilitation intervention intensity, increasing across universal, targeted, and specialist levels; (2) Intervene: Prescribe a nutritional prehabilitation intervention to meet established nutrition guidelines in cirrhosis with a targeted focus on improving nutritional status and muscle health; (3) Reassess: Follow-up based on the required intensity of nutritional care with as needed intervention adjustment. Topics covered in the review include nutritional care levels for prehabilitation, energy prescriptions across body mass index strata, detailed considerations around protein intake (amount, distribution, and quality), carbohydrate and fat intake, other nutritional considerations, and the potential role of dietary supplements and nutraceuticals. Future research is warranted to more accurately evaluate energy needs, evaluate emerging dietary supplementation strategies, and establish the role of nutraceuticals alongside food-based interventions. While the general principles of nutritional prehabilitation are ready for immediate application, future large-scale randomized controlled trials in this space will help to quantify the benefit that can be gained by transitioning the LT approach from passive "transplant waitlist time" to active "transplant preparation time."

Enhancing ACLF prediction by integrating sarcopenia assessment and frailty in liver transplant candidates on the waiting list

Background & Aims

Malnutrition, sarcopenia, and frailty are prevalent in cirrhosis. We aimed to assess the correlation between assessment tools for malnutrition, sarcopenia, and frailty in patients on the liver transplant (LT) waiting list (WL), and to identify a predictive model for acute-on-chronic liver failure (ACLF) development.

Methods

This prospective single-center study enrolled consecutive patients with cirrhosis on the WL for LT (May 2019-November 2021). Assessments included subjective global assessment, CT body composition, skeletal muscle index (SMI), ultrasound thigh muscle thickness, sarcopenia HIBA score, liver frailty index (LFI), hand grip strength, and 6-minute walk test at enrollment. Correlations were analyzed using Pearson's correlation. Competing risk regression analysis was used to assess the predictive ability of the liver- and functional physiological reserve-related variables for ACLF.

Results

A total of 132 patients, predominantly with decompensated cirrhosis (87%), were included. Our study revealed a high prevalence of malnutrition (61%), sarcopenia (61%), visceral obesity (20%), sarcopenic visceral obesity (17%), and frailty (10%) among participants. Correlations between the assessment tools for sarcopenia and frailty were poor. Sarcopenia by SMI remained prevalent when frailty assessments were not usable. After a median follow-up of 10 months, 39% of the patients developed ACLF on WL, while 28% experienced dropouts without ACLF. Multivariate analysis identified MELD-Na, SMI, and LFI as independent predictors of ACLF on the WL. The predictive model MELD-Na-sarcopenia-LFI had a C-statistic of 0.85.

Conclusions

The poor correlation between sarcopenia assessment tools and frailty underscores the importance of a comprehensive evaluation. The SMI, LFI, and MELD-Na independently predicted ACLF development in WL. These findings enhance our understanding of the relationship between sarcopenia, frailty, and ACLF in patients awaiting LT, emphasizing the need for early detection and intervention to improve WL outcomes.

Impact and implications

The relationship between sarcopenia and frailty assessment tools, as well as their ability to predict acute-on-chronic liver failure (ACLF) in patients on the liver transplant (LT) waiting list (WL), remains poorly understood. Existing objective frailty screening tests have limitations when applied to critically ill patients. The correlation between sarcopenia and frailty assessment tools was weak, suggesting that they may capture different phenotypes. Sarcopenia assessed by skeletal muscle index, frailty evaluated using the liver frailty index, and the model for end-stage liver disease-Na score independently predicted the development of ACLF in patients on the WL. Our findings support the integration of liver frailty index and skeletal muscle index assessments at the time of inclusion on the WL for LT. This combined approach allows for the identification of a specific patient subgroup with an increased susceptibility to ACLF, underscoring the importance of early implementation of targeted treatment strategies to improve outcomes for patients awaiting LT.

Brief PROMIS Assessment Screens for Frailty and Predicts Hospitalizations in Liver Transplant Candidates

BACKGROUND

Frailty is prevalent in patients with end-stage liver disease and predicts waitlist mortality, posttransplant mortality, and frequency of hospitalizations. The Liver Frailty Index (LFI) is a validated measure of frailty in liver transplant (LT) candidates but requires an in-person assessment.

METHODS

We studied the association between patient-reported physical function and LFI in a single-center prospective study of adult patients with cirrhosis undergoing LT evaluation from October 2020 to December 2021. Frailty was assessed with the LFI and 4-m gait speed. Patient-reported physical function was evaluated using a brief Patient-Reported Outcomes Measurement Information System (PROMIS) survey.

RESULTS

Eighty-one LT candidates were enrolled, with a mean model of end-stage liver disease-sodium of 17.6 (±6.3). The mean LFI was 3.7 (±0.77; 15% frail and 59% prefrail) and the mean PROMIS Physical Function score was 45 (±8.6). PROMIS Physical Function correlated with LFI ( r  = -0.54, P  < 0.001) and 4-m gait speed ( r  = 0.48, P  < 0.001). The mean hospitalization rate was 1.1 d admitted per month. After adjusting for age, sex, and model of end-stage liver disease-sodium, patient-reported physical function-predicted hospitalization rate ( P  = 0.001).

CONCLUSIONS

This study suggests that a brief patient-reported outcome measure can be used to screen for frailty and predict hospitalizations in patients with cirrhosis.

Keeping an eye on the nutrition: The importance of nutrition management on cardiometabolic risk factors in cirrhotic patients

Chronic liver diseases, especially cirrhosis, are associated with significant morbidity and mortality. Besides predisposing to chronic liver disease per se, diabetes, hypertension, and dyslipidemia worsen the prognosis of patients with cirrhosis induced by other causes. There is no standard of care in the management of these factors in patients with cirrhosis. Also, in particular, it is not known whether nutritional interventions in the modification of cardiometabolic factors can improve the course of cirrhosis or not. This narrative review aimed to investigate the clinical significance of diabetes, hypertension, and dyslipidemia and appropriate nutritional interventions in cirrhotic patients. A comprehensive literature search of the published data was performed in regard to the association of cirrhosis with cardiometabolic factors and the management of cirrhosis and its complications. There is limited evidence on the association of cirrhosis with cardiometabolic risk factors. Cirrhotic cardiometabolic abnormalities are associated with an increased risk of complications, such that the coexistence of diabetes, hypertension, and dyslipidemia increases the risk of clinical decompensation in cirrhosis. Dietary management of cirrhotic patients with risk factors such as diabetes, hypertension, or dyslipidemia does not seem to be considerably different from non-cirrhotic patients.

[Sarcopenia in Chronic Liver Disease]

Sarcopenia is a crucial factor in assessing the nutritional status of chronic liver disease patients and predicting their prognosis and survival. The serum ammonia level is closely associated with sarcopenia regarding ammonia, a key regulator in the liver-muscle axis. In addition, various changes in energy metabolism and hormones are also involved in sarcopenia. The psoas muscle area can represent the overall skeletal muscle mass in liver disease patients. Therefore, measuring the psoas muscle area with computed tomography or magnetic resonance imaging is considered an objective and reliable method for assessing muscle mass. Providing sufficient calorie and protein intake is crucial for preventing and treating sarcopenia. In addition, engaging in appropriate exercise and addressing concurrent hormonal and metabolic changes can be helpful.

Exercise training as an intervention for frailty in cirrhotic patients on the liver transplant waiting list: A systematic review

BACKGROUND

The existing literature suggests that exercise for cirrhotic patients is safe and favours significant improvement to their physical capacity. However, exercise training for this population and how to deliver activities, especially in severe stages of the disease and while waiting for a liver transplant (LT), remain undefined.

AIM

To review the existing exercise prescriptions for cirrhotic patients on the waiting list for LT, their results for frailty evolution and their effect on clinical outcomes.

METHODS

A systematic review was performed following the Preferred Reporting Review and Meta-Analysis guidelines and searching the PubMed, MEDLINE, and Scopus databases. The keyword "liver transplant" was used in combination with the free terms "frailty" and "exercise" for the literature review. Clinical studies that evaluated the effect of a regular training program, independent of supervision or the duration or intensity of physical exercise, in cirrhotic patients on the waiting list for LT were reviewed. The data on safe physical activity prescriptions following Frequency, Intensity, Time, and Type recommendations were extracted and summarised.

RESULTS

Nine articles met the inclusion criteria for this review. Various instruments for frailty assessment were used, frequently in combination. Five studies prescribed physical activity for patients, one in-person and four to be performed remotely and unsupervised. The remaining four studies only used a self-report instrument to assess the level of physical activity. None reported adverse events related to exercise training. The exercise frequency mainly varied from daily to a minimum of twice per week. The intensity depended on frailty and included increasing levels of activity. The type of exercise was predominantly a combination of aerobic and resistance training. The duration of exercise varied from 4 to 12 wk. Three articles evaluated the effect of the exercise program on clinical outcomes, reporting a reduction in 90-d readmission rates post-transplant and improved frailty scores, as well as improved survival of cirrhotic patients waiting for LT.

CONCLUSION

Routine frailty assessment is essential for this population. Although more robust evidence is required, the prescription of exercise is safe and can improve patients' functional capacity, improving pre- and post-LT outcomes.

Sarcopenia as an important determinant for adverse outcomes in patients with pyogenic liver abscess

Background

Low muscle mass/sarcopenia has been associated with poor prognosis in many diseases, but its clinical significance in pyogenic liver abscess (PLA) remains unclear. The purpose of this study is to investigate the relationship between muscle mass and prognosis of patients with PLA.

Methods

A total of 154 adult patients with PLA hospitalized at Tongji Hospital (Wuhan, Hubei, China) between October 2011 and June 2021 were included in this retrospective analysis. Muscle-fat related indicators were measured by computed tomography (CT) images at the third lumbar vertebra (L3) level. The data of patients between the sarcopenia group and non-sarcopenia group were compared. Multivariate logistic regression and receiver operating characteristic (ROC) curve analyses were performed.

Results

The skeletal muscle index (SMI) was independently associated with adverse outcomes (95% CI [0.649-0.954], P = 0.015) of PLA in multivariate logistic regression analysis. This conclusion held true in sex-specific subgroup analysis. ROC analysis indicated that SMI may predict adverse outcomes in both male (area under the ROC curve [AUC], 0.718; cut-off, 52.59; P < 0.001) and female (AUC, 0.714; cut-off, 38.39; P = 0.017) patient populations.

Conclusions

Sarcopenia serves as an independent risk factor for poor prognosis in PLA and patients with sarcopenia may be more prone to adverse outcomes.

Hepatic encephalophaty: management and diagnostic therapeutic assistance path of Ligurian Local Health Company 3 (ASL3)

Hepatic encephalophaty (HE) is a neuropsychiatric syndrome with a prevalence in the cirrhotic population ranging from 20 to 80%. HE is a cause of inappropriate hospitalization, caregiver burdening and increased social costs. There is need to create dedicated care pathways to better manage patients and support family caregivers. The data used for the preparation of this diagnostic therapeutic assistance path (DTAP) are based on a detailed analysis of the scientific literature published before June 30, 2022 (PubMed, Web of Science, Scopus, Google Scholar). Furthermore, in the process of developing this work, we consulted in particular the guidelines/ position papers of International Society for Hepatic Encephalopathy and Nitrogen Metabolism (ISHEN), Italian Association for the Study of the Liver (AISF), European Association for the Study of the Liver (EASL), American Association for the Study of Liver Diseases (AASLD), Italian Society on Alcohol (Società Italiana di Alcologia [SIA]) and other relevant papers. DTAP was created based on the most recent recommendations of the international scientific literature. The present DTAP highlight the need for a multidisciplinary activity integrated with territorial medicine in close connection with caregivers. This guarantees improved therapeutic adherence, hospital readmission reduction, improved quality of life for patients and caregivers and a significant reduction in costs.

DIMINISHED HAND GRIP STRENGTH AND CIRRHOSIS: PREVALENCE AND ASSOCIATED FACTORS

BACKGROUND

Sarcopenia is a syndrome characterized by progressive and generalized loss of muscle mass and strength, observed to varying degrees in patients with various chronic conditions. In cirrhotic patients, it reflects protein-energy malnutrition due to metabolic protein imbalance and is associated with worsened prognosis and reduced post-liver transplantation survival.

OBJECTIVE

To evaluate the epidemiological distribution of diminished hand grip (HG) strength in cirrhotic patients at an outpatient clinic of Santa Casa de Misericórdia in Vitória-ES, Brazil, seeking its association with liver function and cirrhosis complications.

METHODS

Cross-sectional, epidemiological, and single-center study. A questionnaire was administered to patients and HG strength was measured using a dynamometer, with three interval measures taken for 3 seconds each.

RESULTS

The study's total population was 64 cirrhotic patients, with a mean age of 58 years and alcohol as the most prevalent etiology. Reduced HG strength was defined based on two reference values: using cutoff point 1, reduced HG strength was identified in 33 patients (51.6%); according to cutoff point 2, 23 (35.9%) had reduced HG strength. The study showed that, among the parameters observed, there was an association between the female gender and diminished HG strength in both cutoff points. Additionally, it was noted that patients with a score of 15 or more on the Model for End-Stage Liver Disease (MELD) had decreased HG strength at cutoff point 2. The study showed no association between decreased HG strength and the occurrence of cirrhosis complications in the population studied.

CONCLUSION

In our study, we obtained a diminished HG strength variation of 35-52%, which was related to higher MELD scores, suggesting an association with worse clinical outcomes. Therefore, the presence of reduced muscle strength in cirrhotic patients may be linked to prognostic factors and should be valued as clinical data in the management of these patients.

Low geriatric nutritional risk index predicts poor prognosis in patients with cirrhosis: a retrospective study

Aim

Malnutrition, which increases the risk of liver disease-related events and mortality, is a serious complication in cirrhosis. This study aimed to investigate whether the geriatric nutritional risk index (GNRI) could predict the long-term prognosis in patients with cirrhosis.

Methods

We retrospectively evaluated 266 patients with cirrhosis and classified them into two groups based on baseline GNRI scores: risk (≤98, n = 104) and no-risk groups (>98, n = 162). The cumulative survival rates were compared between the two groups in patients with compensated and decompensated cirrhosis, respectively. Cox proportional hazards regression analysis was used to identify significant and independent factors associated with mortality.

Results

The median observation period was 54.9 (33.6-61.7) months and 65 (24.4%) liver disease-related deaths occurred during the follow-up period. The GNRI scores significantly and inversely correlated with Child-Pugh score (r = -0.579), model for end-stage liver disease score (r = -0.286), and Mac-2 binding protein glycosylation isomer (r = -0.494). Multivariate analysis identified low GNRI as a significant and independent factor associated with mortality [overall cohort: hazard ratio (HR), 0.926; p < 0.001; compensated cirrhosis: HR, 0.947; p = 0.003; decompensated cirrhosis: HR, 0.923; p < 0.001]. The risk group demonstrated significantly lower cumulative survival rates than the no-risk group in overall cohort, and patients with compensated and decompensated cirrhosis (p < 0.001, <0.001, and = 0.013, respectively).

Conclusion

Low GNRI was associated with poor long-term prognosis in both patients with compensated and decompensated cirrhosis. Therefore, the GNRI is a simple and useful tool for predicting prognosis and modifying the nutritional status in patients with cirrhosis.

Nutritional Management of a Liver Transplant Candidate

Nearly two-thirds of patients with cirrhosis suffer from malnutrition resulting from multiple contributory factors such as poor intake, accelerated starvation, catabolic milieu, and anabolic resistance. Nutritional assessment and optimization are integral to adequate management of a liver transplant (LT) candidate. A detailed nutritional assessment should be done at baseline in all potential transplant candidates with periodic reassessments. Sarcopenia is defined as a reduction in muscle mass, function, and/or performance. Skeletal muscle index at 3rd lumbar vertebra determined by computed tomography is the most objective tool to assess muscle mass. Hand-grip strength and gait speed are simple tools to gauge muscle strength and performance, respectively. Sarcopenia, sarcopenic obesity, and myosteatosis portend poor outcomes. Sarcopenia contributes greatly to frailty, which is a syndrome of reduced physiological reserve and impaired response to stressors. Dietary interventions must ensure adequate calorie (35-40 kcal/kg/day) and protein (1.2-1.5 gm/kg/day) intake via multiple frequent meals and late-evening calorie-dense snack. Micronutrient supplementation is essential, keeping in mind the etiology of cirrhosis. Individualized, gradually up-titrated exercise prescription consisting of both aerobic and resistance training of 150 min/week is advisable after appropriate risk assessment. Early initiation of enteral nutrition within 12-24 h of LT is recommended. Data with respect to immune-nutrition, monomeric formulas, and hormone replacement remain conflicting at present. A multidisciplinary team comprising of hepatologists, transplant surgeons, intensivists, dieticians, and physiotherapists is vital to improve overall nutrition and outcomes in this vulnerable group.

Association between serum trace elements and sleep disturbance in patients with decompensated cirrhosis

Background

Sleep disturbance and trace elements imbalance are common features in patients with decompensated cirrhosis, partially sharing similar mechanistic contributors and linking to adverse outcomes. However, there is a paucity of data concerning their relationship.

Objectives

To investigate the association between serum trace elements levels and sleep quality in the context of cirrhosis.

Design

Cross-sectional study.

Methods

We consecutively enrolled 160 patients with decompensated cirrhosis. The sleep disturbance was determined by the Pittsburgh Sleep Quality Index (PSQI > 5). Serum trace elements [magnesium, calcium, iron, copper (Cu), zinc (Zn), lead, and manganese] was measured by inductively coupled plasma mass spectrometry. Association of examined trace elements levels and sleep disturbance was analyzed by multiple linear (global PSQI scores) and multivariate logistic (dichotomized PSQI categories) regression models, respectively.

Results

In total, 91 patients (56.88%) represented PSQI-defined sleep disturbance, characterized by female preponderance, lower body mass index levels, and higher serum Cu levels (all p < 0.05). Looking into its clinical relevance with debilitating conditions, we showed that Cu/Zn ratio (CZr) is significantly higher in cirrhosis with poor sleep quality (1.77 versus 1.48, p = 0.003). Diagnostic performance analysis indicated CZr > 1.62 to exhibit better discrimination relative to respective Cu. Both multiple linear (β = 0.355, p < 0.001) and multivariate logistic regression (odds ratio = 2.364, p = 0.019) identified higher CZr as an independent risk factor associated with sleep disturbance.

Conclusion

Our findings implied an association between higher CZr and the presence of sleep disturbance in patients with decompensated cirrhosis.

British Society of Gastroenterology Best Practice Guidance: outpatient management of cirrhosis - part 1: compensated cirrhosis

The prevalence of cirrhosis has risen significantly over recent decades and is predicted to rise further. Widespread use of non-invasive testing means cirrhosis is increasingly diagnosed at an earlier stage. Despite this, there are significant variations in outcomes in patients with cirrhosis across the UK, and patients in areas with higher levels of deprivation are more likely to die from their liver disease. This three-part best practice guidance aims to address outpatient management of cirrhosis, in order to standardise care and to reduce the risk of progression, decompensation and mortality from liver disease. Here, in part one, we focus on outpatient management of compensated cirrhosis, encompassing hepatocellular cancer surveillance, screening for varices and osteoporosis, vaccination and lifestyle measures. We also introduce a compensated cirrhosis care bundle for use in the outpatient setting. Part two concentrates on outpatient management of decompensated disease including management of ascites, encephalopathy, varices, nutrition as well as liver transplantation and palliative care. The third part of the guidance covers special circumstances encountered in managing people with cirrhosis: surgery, pregnancy, travel, managing bleeding risk for invasive procedures and portal vein thrombosis.

From Listing to Recovery: A Review of Nutritional Status Assessment and Management in Liver Transplant Patients

Liver transplantation (LT) is a complex surgical procedure requiring thorough pre- and post-operative planning and care. The nutritional status of the patient before, during, and after LT is crucial to surgical success and long-term prognosis. This review aims to assess nutritional status assessment and management before, during, and after LT, with a focus on patients who have undergone bariatric surgery. We performed a comprehensive topic search on MEDLINE, Ovid, In-Process, Cochrane Library, EMBASE, and PubMed up to March 2023. It identifies key factors influencing the nutritional status of liver transplant patients, such as pre-existing malnutrition, the type and severity of liver disease, comorbidities, and immunosuppressive medications. The review highlights the importance of pre-operative nutritional assessment and intervention, close nutritional status monitoring, individualised nutrition care plans, and ongoing nutritional support and monitoring after LT. The review concludes by examining the effect of bariatric surgery on the nutritional status of liver transplant recipients. The review offers valuable insights into the challenges and opportunities for optimising nutritional status before, during, and after LT.

Implications of anaemia and response to anaemia treatment on outcomes in patients with cirrhosis

Background & Aims

Anaemia is frequently observed in patients with cirrhosis and was identified as a predictor of adverse outcomes, such as increased mortality and occurrence of acute-on-chronic liver failure. To date, the possible effects of iron supplementation on these adverse outcomes are not well described. We therefore aimed to assess the role of iron supplementation in patients with cirrhosis and its capability to improve prognosis.

Methods

Laboratory diagnostics were performed in consecutive outpatients with cirrhosis admitted between July 2018 and December 2019 to the University Hospital Essen. Associations with transplant-free survival were assessed in regression models.

Results

A total of 317 outpatients with cirrhosis were included, of whom 61 received a liver transplant (n = 19) or died (n = 42). In multivariate Cox regression analysis, male sex (hazard ratio [HR] = 3.33, 95% CI [1.59, 6.99], p = 0.001), model for end-stage liver disease score (HR = 1.19, 95% CI [1.11, 1.27], p <0.001) and the increase of haemoglobin levels within 6 months (ΔHb6) (HR = 0.72, 95% CI [0.63, 0.83], p <0.001) were associated with transplant-free survival. Regarding the prediction of haemoglobin increase, intake of rifaximin (beta = 0.50, SD beta = 0.19, p = 0.007) and iron supplementation (beta = 0.79, SD beta = 0.26, p = 0.003) were significant predictors in multivariate analysis.

Conclusions

An increase of haemoglobin levels is associated with improvement of transplant-free survival in patients with cirrhosis. Because the prediction of haemoglobin increase significantly depends on rifaximin and iron supplementation, application of these two medications can have an important impact on the outcome of these patients.

Impact and implications

Anaemia is very common in patients with cirrhosis and is known to be a predictor of negative outcomes, but little is known about the effect of iron substitution in these individuals. In our cohort, increase of haemoglobin levels improved transplant-free survival of patients with cirrhosis. The increase of haemoglobin levels was mainly induced by iron supplementation and was even stronger in the case of concomitant use of iron and rifaximin.

Clinical trial registration

UME-ID-10042.

Predicting dry weight in patients with cirrhotic ascites undergoing large-volume paracentesis

BACKGROUND & AIMS

Ascites impairs the correct diagnosis and nutritional management in patients with cirrhosis, because the body weight, which is needed for nutritional assessment and calculation of nutritional needs, is overestimated. To adjust the weight in patients with ascites, dietetic guidances indicate substracting 2.2-14 kg or 5-15% of the measured body weight according to the degree of ascites, however, there is a lack of evidence to substantiate these values. The aim of this study was to develop new prediction equations to estimate the dry weight, comparing them with the currently used weight adjustments in patients with refractory cirrhotic ascites.

METHODS

Cross-sectional study, that included patients with decompensated cirrhosis undergoing large-volume paracentesis. Patients were submitted to nutritional risk screening, nutritional assessment, and anthropometric measurements that included body weight, abdominal circumference (both measured before and after paracentesis) height, and upper mid-arm circumference. The volume of ascitic fluid drained was also registered. For the predictions of dry weight, linear regression models were performed using as predictor variables: height, pre-paracentesis weight, pre-paracentesis abdominal circumference, or mid-upper arm circumference, and as response variable: post-paracentesis weight. The capacity of these models to predict the post-paracentesis weight was evaluated by comparing it with the currently used predictions through the intraclass correlation coefficient (ICC) and the mean squared error (MSE).

RESULTS

Nineteen patients were included, 15 male, and 18 with high nutritional risk and malnutrition. The difference between post-paracentesis weight and pre-paracentesis weight was -5.0 (-3.6 to -9.9) kg, similar to ascitic fluid volume drained. Two equations were developed to predict post-paracentesis weight. ICC values showed that both prediction equations were strongly correlated (r > 0.94) with post-paracentesis weight. Our models also showed lower MSEs (<17.97), compared with the current predictions (MSEs <64.19, when the pre-paracentesis weight is adjusted from absolute values and MSEs <33.24 when adjusted from percentage values), indicating a more accurate prediction.

CONCLUSION

The predictive equations from this study may be better options for dry weight estimation in patients with refractory cirrhotic ascites since they showed higher reliability compared to the currently used weight adjustment. External validation in a larger sample is still needed to confirm the clinical applicability of these equations.

Nutritional Support for Alcoholic Liver Disease

Malnutrition is a common finding in alcohol use disorders and is associated with the prognosis of patients with alcoholic liver disease (ALD). These patients also frequently show deficiencies in vitamins and trace elements, increasing the likelihood of anemia and altered cognitive status. The etiology of malnutrition in ALD patients is multifactorial and complex and includes inadequate dietary intake, abnormal absorption and digestion, increased skeletal and visceral protein catabolism, and abnormal interactions between ethanol and lipid metabolism. Most nutritional measures derive from general chronic liver disease recommendations. Recently, many patients with ALD have been diagnosed with metabolic syndrome, which requires individualized treatment via nutritional therapy to avoid overnutrition. As ALD progresses to cirrhosis, it is frequently complicated by protein–energy malnutrition and sarcopenia. Nutritional therapy is also important in the management of ascites and hepatic encephalopathy as liver failure progresses. The purpose of the review is to summarize important nutritional therapies for the treatment of ALD.

Circadian rhythms and the liver

This narrative review briefly describes the mammalian circadian timing system, the specific features of the liver clock, also by comparison with other peripheral clocks, the role of the liver clock in the preparation of food intake, and its relationship with energy metabolism. It then goes on to provide a chronobiological perspective of the pathophysiology and management of several types of liver disease, with a particular focus on metabolic-associated fatty liver disease (MAFLD), decompensated cirrhosis and liver transplantation. Finally, it provides some insight into the potential contribution of circadian principles and circadian hygiene practices in preventing MAFLD, improving the prognosis of advanced liver disease and modulating liver transplantation outcomes.

Nutritional Strategies to Manage Malnutrition and Sarcopenia following Liver Transplantation: A Narrative Review

Persisting or newly developed malnutrition and sarcopenia after liver transplant (LT) are correlated with adverse health outcomes. This narrative review aims to examine the literature regarding nutrition strategies to manage malnutrition and sarcopenia after LT. The secondary aims are to provide an overview of the effect of nutrition strategies on the incidence of infections, hospital length of stay (LOS), acute cellular rejection (ACR), and mortality after LT. Four databases were searched. A total of 25 studies, mostly of mid-high quality, were included. Six studies found a beneficial effect on nutritional parameters using branched-chain amino acids (BCAA), immunomodulating diet (IMD), or enteral nutrition (EN) whereas two studies using beta-hydroxy-beta-methylbutyrate (HMB) found a beneficial effect on muscle mass and function. Fourteen studies using pre- or pro-biotics, IMD, and EN were effective in lowering infection and six studies using IMD, BCAA or HMB reported reduced hospital LOS. Finally, four studies using HMB and vitamin D were effective in reducing ACR and one study reported reduced mortality using vitamin D after LT. In conclusion, nutritional intervention after LT has different beneficial effects on malnutrition, sarcopenia, and other advert outcomes. Additional large and well-constructed RCTs using validated tools to assess nutritional status and sarcopenia are warranted to ensure more robust conclusions.

Power of mortality prediction in patients awaiting liver transplantation according to the Global Leadership Initiative on Malnutrition criteria and Subjective Global Assessment and Royal Free Hospital Global Assessment scores

OBJECTIVES

This study aimed to analyze the performance of the Global Leadership Initiative on Malnutrition (GLIM) criteria and Subjective Global Assessment (SGA) and Royal Free Hospital Global Assessment (RFH-GA) scores in predicting 12-mo mortality in patients awaiting liver transplantation.

METHODS

This is a longitudinal observational study, carried out between March 2019 and November 2021. Clinical data were collected and nutritional assessment was performed through anthropometry and application of validated instruments, such as the SGA, GLIM criteria, and RFH-GA. A Cox regression model was carried out, in which the dependent variable was mortality in 1 y, and the independent variables were the classifications of nutritional status by the different methods.

RESULTS

The sample consisted of 126 patients, most of them male (56.35%). Malnutrition was diagnosed in 85.71% of the patients according to the RFH-GA, 62.70% according to the SGA, and 56.31% according to the GLIM criteria. Malnutrition assessed by GLIM was related to a 3.79-fold increase in the chance of mortality over time in patients awaiting liver transplantation. Moreover, the GLIM criteria had good discriminatory power in identifying mortality in patients awaiting liver transplantation, compared with the initial and final SGA and RFH-GA scores and the Model for End-stage Liver Disease-Sodium (MELD-Na) index.

CONCLUSIONS

The GLIM criteria were a good predictor of increased risk of mortality in malnourished patients with chronic liver disease awaiting liver transplantation, compared with the SGA and RFH-GA scores and the MELD-Na index.

Food Intake Visual Scale-A practical tool for assessing the dietary intake of hospitalized patients with decompensated cirrhosis

BACKGROUND

The aim of this study was whether the Food Intake Visual Scale (FIVS) can be used in clinical practice to measure food intake in patients with decompensated cirrhosis.

METHODS

A cross-sectional study was performed with patients with cirrhosis between April 2017 and July 2019. The food intake was assessed through the 1-day diet record (DR) and according to FIVS, which consists of pictures of four plates of food at different levels of consumption: "about all," "half," "a quarter," or "nothing." The analysis of variance test with Bonferroni multiple comparison analysis was used to compare the mean energy intake through the DR according to the FIVS categories.

RESULTS

This study included 94 patients with a mean age of 60.29 ± 9.33 years. Patients with lower food intake according to the FIVS categories also had lower mean energy and macronutrient intake according to the DR: patients eating "about all" (n = 49, 52.1%) consumed a mean of 1526.58 ± 428.27 kcal/day, patients eating "half" (n = 16, 17%) consumed a mean of 1282.08 ± 302.83 kcal/day, patients eating "a quarter" (n = 25, 26.6%) consumed a mean of 978.96 ± 468.81 kcal/day, and patients eating "nothing" (n = 4, 4.3%) consumed a mean of 353.59 ± 113.16 kcal/day (P < .001).

CONCLUSION

The results of this study demonstrate that FIVS can be implemented in clinical practice to measure food intake in patients with decompensated cirrhosis as a substitute for the DR because it is a noninvasive, low-cost, quick, reliable, and easy bedside method for obtaining data.

Measurement of mid-arm circumference as a starting point for nutritional assessment of patients with decompensated cirrhosis: A prospective cohort study

BACKGROUND

The mid-arm circumference (MAC) is an accessible, quick, and inexpensive measurement, which can be performed at the bedside only with a measuring tape. In this sense, the present study aims to suggest MAC cut-off values to assess the nutritional status and its association with mortality of hospitalised patients with decompensated cirrhosis.

METHODS

A prospective cohort study was performed with decompensated cirrhotic patients. Nutritional status was assessed by MAC and Subjective Global Assessment (SGA). Considering the SGA as the reference standard and based on receiver operating characteristic curve analysis, the MAC cut-off values with the best sensitivity and specificity were selected. Predictors of mortality were identified using multivariate analysis.

RESULTS

The study included 100 patients with a mean ± SD age of 60.1 ± 10.3 years. The median follow-up time was 11.2 months and overall mortality was 60%. Considering malnutrition assessed by SGA as the reference standard, the area under the curve of MAC for women and men was 0.947 (95% confidence interval [CI] = 0.878-1.000) and 0.813 (95% CI = 0.694-0.932). The MAC cut-off values of ≤ 28 cm for women and ≤ 30 cm for men reached a sensitivity and specificity of 85.5% and 71%, respectively. According to multivariate analysis, a low MAC was significantly associated with mortality (hazard ratio = 2.41; 95% CI = 1.20-4.84).

CONCLUSIONS

The MAC cut-off values had satisfactory accuracy for men and women in predicting malnutrition. Additionally, a low MAC was an independent predictor of mortality. Thus, these MAC cut-off values can be used as the first step of nutritional assessment to prioritise patients who require more detailed assessment.

Lymphopenia at the time of transplant is associated with short-term mortality after deceased donor liver transplantation

Absolute lymphocyte count (ALC) is considered a surrogate marker for nutritional status and immunocompetence. We investigated the association between ALC and post-liver transplant outcomes in patients who received a deceased donor liver transplant (DDLT). Patients were categorized by ALC at liver transplant: low (<500/μL), mid (500-1000/μL), and high ALC (>1000/μL). Our main analysis used retrospective data (2013-2018) for DDLT recipients from Henry Ford Hospital (United States); the results were further validated using data from the Toronto General Hospital (Canada). Among 449 DDLT recipients, the low ALC group demonstrated higher 180-day mortality than mid and high ALC groups (83.1% vs 95.8% and 97.4%, respectively; low vs mid: P = .001; low vs high: P < .001). A larger proportion of patients with low ALC died of sepsis compared with the combined mid/high groups (9.1% vs 0.8%; P < .001). In multivariable analysis, pretransplant ALC was associated with 180-day mortality (hazard ratio, 0.20; P = .004). Patients with low ALC had higher rates of bacteremia (22.7% vs 8.1%; P < .001) and cytomegaloviremia (15.2% vs 6.8%; P = .03) than patients with mid/high ALC. Low ALC pretransplant through postoperative day 30 was associated with 180-day mortality among patients who received rabbit antithymocyte globulin induction (P = .001). Pretransplant lymphopenia is associated with short-term mortality and a higher incidence of posttransplant infections in DDLT patients.

Sarcopenia and Frailty in Cirrhosis

Sarcopenia and frailty are frequent in cirrhosis, and both contribute to increased morbidity and mortality. The complex pathogenesis of sarcopenia in cirrhosis is mainly determined by hyperammonemia and malnutrition. Sarcopenia/frailty screening and reevaluation should be undertaken in all cirrhotic patients. Frailty tests are useful in the ambulatory setting, whereas the computed tomography scan is the diagnostic gold standard for sarcopenia. To manage sarcopenia/frailty, a multidisciplinary team should develop a personalized comprehensive care plan that includes patient education, protein/calorie intake goals, late evening meals, exercise programs, and micronutrient replenishment. In selected patients, branched-chain amino acid and testosterone supplements may also be beneficial.

Cirrhosis Management in the Intensive Care Unit

Patients with cirrhosis frequently require admission to the intensive care unit as complications arise in the course of their disease. These admissions are associated with high short- and long-term morbidity and mortality. Thus, understanding and characterizing complications and unique needs of patients with cirrhosis and acute-on-chronic liver failure helps providers identify appropriate level of care and evidence-based treatments. While there is no widely accepted critical care admission criteria for patients with cirrhosis, the presence of organ failure and primary or nosocomial infections are associated with particularly high in-hospital mortality. Optimal management of patients with cirrhosis in the critical care setting requires a system-based approach that acknowledges deviations from canonical pathophysiology. In this review, we discuss appropriate considerations and evidence-based practices for the general care of patients with cirrhosis and critical illness.

Improvement of sarcopenia is beneficial for prognosis in cirrhotic patients after TIPS placement

BACKGROUND

The relationship between the improvement of sarcopenia and post-TIPS prognosis has not been fully investigated.

AIMS

To assess what level of sarcopenia improvement is required for potential benefits to post-TIPS prognosis.

METHODS

In this retrospective study, 109 cirrhotic patients with sarcopenia who underwent TIPS between February 2016 and January 2021 were included. The change in skeletal muscle index (SMI) at 6 months post-TIPS was assessed and the correlations of SMI improvement with clinical outcomes were analyzed.

RESULTS

During follow up, 59 (65.6%) patients reversed from sarcopenic to non-sarcopenic, and the cumulative mortality (8.5 % vs. 26.0%, log rank P = 0.013) and incidence of overt hepatic encephalopathy (OHE) (18.6% vs. 44.0%, log rank P = 0.004) in patients who reversed were significantly lower than who did not. SMI improvement rate was identified as an independent risk factor for mortality and OHE. In addition, the cumulative survival rate of patients with sarcopenia reversal or SMI improvement rate > 10.4% was significantly higher than that of patients with an SMI improvement rate ≤ 10.4% (92.5% vs. 58.6%, log rank P < 0.001).

CONCLUSION

Reversal of sarcopenia or significant SMI improvement by TIPS could reduce the risk of death and OHE.

TRANSLATION AND CROSS-CULTURAL ADAPTATION OF THE ROYAL FREE HOSPITAL-NUTRITIONAL PRIORITIZING TOOL (RFH-NPT)

BACKGROUND

Nutritional screening is defined by American Society for Parenteral and Enteral Nutrition (ASPEN) as a process to identify individuals at risk of malnutrition. Malnutrition is a prevalent condition in cirrhotic patients, and it results in important prognostic implications. Most of the commonly used instruments fail in considering the particularities of cirrhotic patients. The Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT) is a nutritional screening tool developed and validated to identify malnutrition risk in patients with liver disease.

OBJECTIVE

The study's aim was to conduct the transcultural adaptation (translation and adaptation) of RFH-NPT tool to Portuguese (Brazil).

METHODS

The process of cultural translation and adaptation followed the Beaton et al. methodology. The process involved the steps of initial translation, synthesis translation, back translation pretest of the final version with 40 nutritionists and a specialists committee. The internal consistency was calculated with the Cronbach coefficient and the content validation was verified with the content validation index.

RESULTS

Forty clinical nutritionists with experience in treatment of adult patients participated in the step of cross-cultural adaptation. The alpha Cronbach coefficient was 0.84, which means high reliability. In the specialists analyzes all the tool's questions achieved a validation content index higher than 0.8, showing high agreement.

CONCLUSION

The NFH-NPT tool was translated and adapted to Portuguese (Brazil) and showed high reliability.

[Malnutrition management of hospitalized patients with diabetes/hyperglycemia and liver cirrhosis]

Introduction

Liver cirrhosis is a progressive and chronic disease of the liver, of diverse etiology, which is frequently associated with glucose intolerance and in some cases concurs with type 2 diabetes (DM2). DM2 is associated with adverse outcomes in patients with cirrhosis, including a higher rate of hospitalizations, a higher prevalence of hepatocellular carcinoma, and an increased risk of mortality. Malnutrition is another frequent complication of cirrhosis, the prevalence of which increases with the degree of liver dysfunction, worsening the prognosis. This article describes the results of the expert consensus and the responses of the panelists on the nutritional management in routine clinical practice of patients with diabetes/hyperglycemia hospitalized (non-critically ill) with liver cirrhosis.

Effect of Preoperative Sarcopenia, Malnutrition and Functional status on Postoperative Morbidity Following Liver Transplantation

INTRODUCTION

The effect of sarcopenia, malnutrition, and functional status on immediate post liver transplantation outcome is not well established. Most studies on sarcopenia are related to 1 and 3-year mortality. Studies evaluating the effect of malnutrition are at least a decade old.

PROJECT AIMS

We evaluated the effect of preoperative sarcopenia, malnutrition, and functional status on postoperative length of hospital and ICU stay, incidence of complications, and mortality.

DESIGN

In this prospective study conducted on living donor liver transplant recipients, sarcopenia and malnutrition were identified using the psoas muscle thickness to height and the Royal Free Hospital- Nutritional Prioritizing Tool respectively. The Eastern Cooperative Oncology Group performance status score was noted. Postoperatively, length-of-hospital stay, ICU stay, duration of mechanical ventilation and incidence of postoperative complications were noted.

RESULTS

Hospital and ICU length of stay, and duration of mechanical ventilation were greater in sarcopenic versus non-sarcopenic patients (35.9 (14.6) versus 26.7 (10.7) days, P  =  0.02; 12.9 (4.8) versus 9.6 (3.8) days, P  =  0.02 and 8 [5,23] versus 5 [4,7] days, P  =  0.01 respectively). The incidence of acute kidney injury was higher in patients with sarcopenia (53.3% vs 19.4%, P  =  0.02). Patients with malnutrition and repeated hospitalizations had higher ICU stays but hospital length of stay duration of mechanical ventilation or the incidence of postoperative complications were not affected. The Eastern Cooperative Oncology Group score did not affect postoperative outcome.

CONCLUSION

In living donor liver transplant recipients, sarcopenia increased hospital and ICU stays, and duration of mechanical ventilation postoperatively. Malnutrition increased ICU stays.

Comorbid Chronic Diseases and Survival in Compensated and Decompensated Cirrhosis: A Population-Based Study

INTRODUCTION

The burden of liver disease is substantial and increasing; the impact of comorbid chronic diseases on the clinical course of patients with compensated and decompensated cirrhosis is not well-defined. The aim of this study was to examine the individual and additive impact of comorbid chronic diseases on mortality in patients with cirrhosis.

METHODS

In this population-based study, we used Cox proportional hazards modeling with time-dependent covariates to assess the impact of comorbid chronic diseases (diabetes mellitus, chronic kidney disease, and cardiovascular disease [CVD]) on mortality in patients with cirrhosis in a large, diverse Metroplex.

RESULTS

There were 35,361 patients with cirrhosis (mean age 59.5 years, 41.8% females, 29.7% non-White, and 17.5% Hispanic ethnicity). Overall, the presence of chronic comorbidities was 1 disease (28.9%), 2 diseases (17.5%), and 3 diseases (12.6%) with a majority having CVD (45%). Adjusted risk of mortality progressively increased with an increase in chronic diseases from 1 (hazard ratio [HR] 2.5, 95% confidence interval [CI] 2.23-2.8) to 2 (HR 3.27.95% CI 2.9-3.69) to 3 (HR 4.52, 95% CI 3.99-5.12) diseases. Survival of patients with compensated cirrhosis and 3 chronic diseases was similar to subsets of decompensated cirrhosis (67.7% as compared with decompensated cirrhosis with 1-3 conditions, 61.9%-63.9%).

DISCUSSION

In patients with cirrhosis, a focus on comorbid chronic disease(s) as potential management targets may help avoid premature mortality, regardless of etiology. Multidisciplinary care early in the clinical course of cirrhosis is needed in addition to the current focus on management of complications of portal hypertension.

Sarcopenia-related gut microbial changes are associated with the risk of complications in people with cirrhosis

Background & Aims

Sarcopenia and gut dysbiosis are common in individuals with cirrhosis. However, the association between sarcopenia and microbial alterations, and the subsequent impact on cirrhotic outcomes are poorly understood. This study aimed to identify muscle-dependent microbial changes and related risks of cirrhotic complications.

Methods

From September 2018 to December 2020, 89 individuals with cirrhosis and 16 healthy volunteers were prospectively enrolled. Muscle and nutritional status, serum amino acids, and fecal microbiota were analyzed. The association between microbial signatures of sarcopenia and cirrhotic complications was investigated.

Results

A decline in muscle mass and strength were associated with gut microbial alterations in individuals with cirrhosis. The greatest microbial dissimilarity was observed between those with sarcopenia (both decline in muscle mass and strength) and those with normal-muscle status (p = 0.035). Individuals with sarcopenia had lower serum levels of alanine, valine, leucine, isoleucine, proline, tryptophan and ornithine. Besides, gut microbial functions associated with amino acid biosynthesis were significantly reduced in individuals with sarcopenia and cirrhosis. Depletion of Dialister, Ruminococcus 2, and Anaerostipes were associated with cirrhotic sarcopenia, and significantly correlated with the serum levels of amino acids. Individuals with coexistent depletion of Ruminococcus 2 and Anaerostipes developed more infectious (44.4% vs. 3.0%) and non-infectious (74.1% vs. 3.0%) complications, and more hospitalizations (54 vs. 3) than those with cirrhosis with good microbial signatures (all p <0.001). In contrast, fecal enrichment of Ruminococcus 2 and Anaerostipes independently decreased the risk of 1-year complications.

Conclusions

Sarcopenia-related fecal microbial alterations are associated with cirrhotic complications. These findings may facilitate measures to improve the outcomes of individuals with cirrhosis and sarcopenia by modifying gut microbiota.

Impact and implications

The composition and biosynthetic functions of gut microbiota are significantly changed in individuals with sarcopenic cirrhosis. Those with a sarcopenia-related poor microbial signature, in which Ruminococcus 2 and Anaerostipes were both depleted, had significantly more infectious and non-infectious complications, as well as more hospitalizations. These findings highlight the therapeutic potential of modifying the gut microbiota of individuals with sarcopenic cirrhosis to improve their clinical outcomes.

Nutritional assessment in patients with liver cirrhosis

Malnutrition is a liver cirrhosis complication affecting more than 20%-50% of patients. Although the term can refer to either nutrient deficiency or excess, it usually relates to undernutrition in cirrhosis settings. Frailty is defined as limited physical function due to muscle weakness, whereas sarcopenia is defined as muscle mass loss and an advanced malnutrition stage. The pathogenesis of malnutrition in liver cirrhosis is multifactorial, including decreased oral intake, maldigestion/malabsorption, physical inactivity, hyperammonemia, hypermetabolism, altered macronutrient metabolism and gut microbiome dysbiosis. Patients with chronic liver disease with a Body Mass Index of < 18.5 kg/m² and/or decompensated cirrhosis or Child-Pugh class C are at the highest risk of malnutrition. For patients at risk of malnutrition, a detailed nutritional assessment is required, typically including a history and physical examination, laboratory testing, global assessment tools and body composition testing. The latter can be done using anthropometry, cross-sectional imaging including computed tomography or magnetic resonance, bioelectrical impedance analysis and dual-energy X-ray absorptiometry. A multidisciplinary team should screen for and treat malnutrition in patients with cirrhosis. Malnutrition and sarcopenia are associated with an increased risk of complications and a poor prognosis in patients with liver cirrhosis; thus, it is critical to diagnose these conditions early and initiate the appropriate nutritional therapy. In this review, we describe the prevalence and pathogenesis of malnutrition in liver cirrhosis patients and discuss the best diagnostic approach to nutritional assessment for them.

A nomogram as an indirect method to identify sarcopenia in patients with liver cirrhosis

INTRODUCTION AND OBJECTIVES

Sarcopenia is one of the most common complications of cirrhosis, associated with an increased risk of morbidity and mortality. It is therefore necessary to perform a proper nutritional evaluation in these patients. Although CT scans are the gold standard for diagnosing sarcopenia, they are not widely used in clinical practice. There is thus a need to find indirect methods for identifying sarcopenia in patients with cirrhosis.

MATERIAL AND METHODS

This is a cross-sectional study consecutively including all cirrhotic outpatients who underwent CT scans.

RESULTS

A total of 174 patients met all the inclusion criteria and none of exclusion criteria. Fifty-five patients (31.6%) showed sarcopenia on CT scans. Multivariate analysis revealed that the factors that were independently associated with the presence of sarcopenia on CT scans were: male sex (OR 11.27, 95% CI 3.53-35.95; p<0.001), lower body mass index (BMI) (OR 1.22, 95% CI 1.11-1.34; p<0.001) and lower phase angle by bioelectrical impedance analysis (OR 2.83, 95% CI 1.74-4.6; p<0.001). With the variables identified from the multivariate study we developed a nomogram that allows ruling out the presence of sarcopenia. Our model rules out sarcopenia with an area under the receiver operating characteristic curve value of 0.8. The cutoff point of the probability to rule out sarcopenia was 0.6 (sensitivity 85%, specificity 73%, Youden index 0.58, PPV 82.5% and NPV 91.3%).

CONCLUSION

Since CT scans involve exposure to radiation and their availability is limited, we propose using this nomogram as an indirect method to rule out sarcopenia in cirrhotic patients.

Current Medical Treatment for Alcohol-Associated Liver Disease

Alcohol-associated liver disease is one of the main causes of chronic liver disease. It comprises a clinical-histologic spectrum of presentations, from steatosis, steatohepatitis, to different degrees of fibrosis, including cirrhosis and severe necroinflammatory disease, called alcohol-associated hepatitis. In this focused update, we aim to present specific therapeutic interventions and strategies for the management of alcohol-associated liver disease. Current evidence for management in all spectra of manifestations is derived from general chronic liver disease recommendations, but with a higher emphasis on abstinence and nutritional support. Abstinence should comprise the treatment of alcohol use disorder as well as withdrawal syndrome. Nutritional assessment should also consider the presence of sarcopenia and its clinical manifestation, frailty. The degree of compensation of the disease should be evaluated, and complications, actively sought. The most severe acute form of this disease is alcohol-associated hepatitis, which has high mortality and morbidity. Current treatment is based on corticosteroids that act by reducing immune activation and blocking cytotoxicity and inflammation pathways. Other aspects of treatment include preventing and treating hepatorenal syndrome as well as preventing infections although there is no clear evidence as to the benefit of probiotics and antibiotics in prophylaxis. Novel therapies for alcohol-associated hepatitis include metadoxine, interleukin-22 analogs, and interleukin-1-beta antagonists. Finally, granulocyte colony-stimulating factor, microbiota transplantation, and gut-liver axis modulation have shown promising results. We also discuss palliative care in advanced alcohol-associated liver disease.

Management of Decompensated Cirrhosis in the Surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document

Management of decompensated cirrhosis (DC) can be challenging for the surgical intensivist. Management of DC is often complicated by ascites, coagulopathy, hepatic encephalopathy, gastrointestinal bleeding, hepatorenal syndrome, and difficulty assessing volume status. This Clinical Consensus Document created by the American Association for the Surgery of Trauma Critical Care Committee reviews practical clinical questions about the critical care management of patients with DC to facilitate best practices by the bedside provider.

Inadequate practices for hepatic encephalopathy management in the inpatient setting

Hepatic encephalopathy (HE) is an important complication of decompensated liver disease. Hospital admission for episodes of HE are very common, with these patients being managed by the hospitalists. These admissions are costly and burdensome to the health-care system. Diagnosis of HE at times is not straightforward, particularly in patients who are altered and unable to provide any history. Precipitants leading to episodes of HE, should be actively sought and effectively tackled along with the overall management. This mandates timely diagnostics, appropriate initiation of pharmacological treatment, and supportive care. Infections are the most important precipitants leading to HE and should be aggressively managed. Lactulose is the front-line medication for primary treatment of HE episodes and for prevention of subsequent recurrence. However, careful titration in the hospital setting along with the appropriate route of administration should be established and supervised by the hospitalist. Rifaximin has established its role as an add-on medication, in those cases where lactulose alone is not working. Overall effective management of HE calls for attention to guideline-directed nutritional requirements, functional assessment, medication reconciliation, patient education/counseling, and proper discharge planning. This will potentially help to reduce readmissions, which are all too common for HE patients. Early specialty consultation may be warranted in certain conditions. Numerous challenges exist to optimal care of hospitalized OHE patients. However, hospitalists if equipped with knowledge about a systematic approach to taking care of these frail patients are in an ideal position to ensure good inpatient and transition of care outcomes.

Sarcopenia in chronic advanced liver diseases: A sex-oriented analysis of the literature

Sarcopenia, defined as progressive and generalized loss of muscle mass and strength, is common in chronic liver disease. It significantly impacts the quality of life and increases the risk of liver-related complications and mortality in cirrhotic patients. Moreover, recent studies showed a negative impact of sarcopenia on patients awaiting liver transplantation (LT), on post-LT outcomes, and on response to hepatocellular carcinoma therapies. Data about the influence of sex on the incidence, prevalence, diagnosis and treatment of sarcopenia in chronic liver diseases are poor and conflicting. The aims of this review of the literature are to define sex differences in sarcopenic cirrhotic patients and to highlight the necessity of a sex stratified analysis in future studies. This analysis of the literature showed that most of the studies are retrospective, with a higher prevalence of sarcopenia in males, probably due to anatomical differences between the sexes. Moreover, diagnostic criteria for sarcopenia are different between studies, as there is not a defined cut-off and, as a consequence, no comparable results. In conclusion, sex seems to have an impact on sarcopenia, and future studies must accurately investigate its role in identifying and treating high-risk patients, reducing the negative impact of sarcopenia on the survival and quality of life of cirrhotic patients.

Evaluation of liver transplant candidates with non-alcoholic steatohepatitis

Non-alcoholic steatohepatitis (NASH) is anticipated to become the leading indication for liver transplantation (LT) in the United States in the near future. LT is indicated in patients with NASH-related cirrhosis who have medically refractory hepatic decompensation, synthetic dysfunction, and hepatocellular carcinoma (HCC) meeting certain criteria. The objective of LT evaluation is to determine which patient will derive the most benefit from LT with the least risk, thus maximizing the societal benefits of a limited resource. LT evaluation is a multidisciplinary undertaking involving several specialists, assessment tools, and diagnostic testing. Although the steps involved in LT evaluation are relatively similar across different liver diseases, patients with NASH-related cirrhosis have unique demographic and clinical features that affect transplant outcomes and influence their LT evaluation. LT candidates with NASH should be assessed for metabolic syndrome and obesity, malnutrition and sarcopenia, frailty, and cardiovascular disease. Interventions that treat cardiometabolic co-morbidities and improve patients' nutrition and functionality should be considered in order to improve patient outcomes in the waitlist and after LT.

HDL-C levels added to the MELD score improves 30-day mortality prediction in Asian patients with cirrhosis

Objectives

Lower high-density lipoprotein cholesterol (HDL-C) levels have been observed in chronic liver disease patients. The aim of this study was to develop a model that incorporates HDL-C levels and the Model for End-stage Liver Disease (MELD) score to predict 30-day mortality in Asian cirrhosis patients.

Methods

Cirrhosis patients were recruited from two hospitals in this retrospective observational study. Propensity score matching was used. The model’s performance was evaluated, including its ability to predict 30-day mortality, accuracy, and clinical utility. Net reclassification improvement (NRI) and integrated discrimination improvement (IDI) were calculated.

Results

The HDL-C + MELD model showed good ability to predict 30-day mortality (area under the curve, 0.784; sensitivity, 0.797; specificity, 0.632), which was better than that of the MELD score alone. It also showed good calibration and a net benefit for all patients, which was better than that of the MELD score, except at the threshold probability. NRI and IDI results confirmed that adding HDL-C levels to the MELD score improved the model’s performance in predicting 30-day mortality.

Conclusion

We added HDL-C levels to the MELD score to predict 30-day mortality in Asian patients with cirrhosis. The HDLC + MELD model shows good ability to predict 30-day mortality and clinical utility.

Hepatocellular Carcinoma in Patients Without Cirrhosis: The Fibrosis Stage Distribution, Characteristics and Survival

BACKGROUND

The data on hepatocellular carcinoma (HCC) patients without liver cirrhosis is scarce.

AIMS

To study the epidemiology, underlying etiology and fibrosis distribution in noncirrhotic HCC and compare the survival outcomes to cirrhotic HCC.

METHODS

We conducted a retrospective study including all adult patients diagnosed with HCC at two US tertiary academic centers from 2000 to 2015. Univariable and multivariable Cox regression analyses were performed to evaluate the variables associated with patient survival.

RESULTS

Two thousand two hundred and thirty-seven HCC patients were included in the final analysis, of which, 13% had no liver cirrhosis. The most common underlying liver disease in non-cirrhotic patients was cryptogenic cause (40%), followed by nonalcoholic fatty liver disease (NAFLD) (25.2%) and hepatitis C (19%). The percentage of F0-F1, F2, and F3 was 72%, 17%, and 11% (cryptogenic cause); 69%, 12%, and 19% (NAFLD); 50%, 17%, and 33% (alcohol); 33%, 39%, and 28% (hepatitis B); 20%, 40%, and 40% (hemochromatosis); and 12%, 40%, and 48% (hepatitis C), respectively. In non-cirrhotic compared to cirrhotic patients, the tumor was more likely to be larger and fell outside Milan criteria (all p < 0.001). Cirrhotic patients had significant shorter survival than non-cirrhotic patients (p < 0.001). On the multivariable analysis, having liver cirrhosis (HR 1.48; 1.21-1.82, p < 0.001), combined viral hepatitis and alcohol use (HR 1.51; 1.23-1.88, p < 0.001), morbid obesity (HR 1.31; 1.01-1.69, p = 0.040) and underweight (HR 2.06; 1.27-3.34, p = 0.004) were associated with worse patient survival.

CONCLUSIONS

The fibrosis distribution in non-cirrhotic HCC differed among each etiology of liver diseases. Despite more advanced HCC, patients without cirrhosis had significantly longer survival than those with cirrhosis.

Nutritional Assessment of Greek Liver Cirrhosis Patients: Mini Nutritional Assessment Predicts Mortality

Malnutrition is highly prevalent in liver cirrhosis (LC). It increases as the severity of the disease progresses and it is related to poor survival. The objectives of the study were the nutritional assessment of Greek LC patients, using various nutritional assessment and screening tools, and the comparison of their predictive value for mortality. In total, 137 (77 male) consecutive LC patients (median age: 67 years) were assessed with subjective global assessment (SGA) and mini nutritional assessment (MNA) questionnaires, anthropometrics, handgrip strength (HGS) tests, and bioelectric impedance analysis (BIA), in comparison to a control group of 148 healthy people. Disease severity was assessed using the model for end-stage liver disease (MELD) scores. Patients were followed up for a median of 19 months. Survival curves were calculated using the Kaplan–Meier method. In total, 60% and 43% of patients were of adequate nutritional status by SGA and MNA, respectively, which was confirmed by most anthropometric measurements. MNA and SGA scores correlated significantly with anthropometrics and BIA-derived parameters. Besides the MELD score, mid-arm circumference (MAC), triceps skinfold (TSF), BIA’s phase angle (Pha), and MNA predicted mortality in cirrhotic patients. The nutritional assessment demonstrated an unexpectedly high prevalence of well-nourished LC patients. MNA was a strong predictor of mortality.

Specific nutrition evaluation of patients with advanced chronic liver disease: Development and validation

BACKGROUND

Malnutrition is frequently identified in patients with advanced chronic liver disease (ACLD), and its early identification is necessary for effective nutrition treatment. The aim of this study was to develop and validate a tool for specific nutrition evaluation of patients with ACLD (SNE-ACLD).

METHODS

SNE-ACLD was developed by consensus among experts using Delphi technique. The initial proposal for the SNE-ACLD had six domains (history of weight loss, changes in food intake, gastrointestinal symptoms, changes in functional capacity, presence of complications of liver disease, and a nutrition-focused physical examination) and 11 items. Fifteen experts participated in content validation. In a cross-sectional study design, the new tool was applied to 129 inpatients and outpatients from a gastrohepatology unit. Nutrition status was evaluated with SNE-ACLD and subjective global assessment by one researcher. Content validation and semantic analysis were obtained by content validity index. To verify accuracy of SNE-ACLD, the sensitivity, specificity, Youden index, and area under the receiver operating characteristic curve (AUC) were calculated.

RESULTS

After five evaluative sequences conducted by experts, experts excluded the domain for history of weight loss and its respective item. The final version of SNE-ACLD consists of five domains and 10 items. The new instrument showed good accuracy in identifying any level of malnutrition (AUC = 0.83; 95% CI, 0.76-0.91) and severe malnutrition (AUC = 0.90; 95% CI, 0.79-1.00).

CONCLUSION

SNE-ACLD can be used in nutrition assessment of patients with liver disease. Future works should investigate its agreement with other methods and its predictive value.