Malnutrition, Frailty, and Sarcopenia in Patients With Cirrhosis: 2021 Practice Guidance by the American Association for the Study of Liver Diseases

Nutritional risk assessment using the Nutritional Prognostic Index predicts mortality in Advanced Chronic Liver Disease patients

OBJECTIVES

Early clinical prognosis and mortality reduction remains a challenge in chronic liver disease (CLD). The full potential of the Nutritional Prognostic Index (NPI) for nutritional assessment and management in CLD patients remains unexplored. The aim of this study was to establish an NPI cutoff point for the identification of nutritional risk in advanced CLD (ACLD) patients, as well as to assess the NPI's ability to predict ACLD-associated mortality.

METHODS

This ethically approved prospective cohort study investigated malnutrition risk using both the NPI and the Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT) in patients hospitalized for ACLD. NPI reference values were determined using a receiver operating characteristic curve. Associations between nutritional risk identified by the RFH-NPT and the NPI were assessed using Fisher's exact test, and agreement between tools was assessed using the Kappa index. The association between NPI-defined nutritional risk and 12-mo mortality was examined using Pearson Chi-square test.

RESULTS

The sample population consisted of 120 adults, comprising 84 (70%) male and 57 (50.9%) of alcoholic etiology and presenting as Child-Pugh A, B, or C at admission. The identified cutoff point for NPI was <41, identifying nutritional risk in 82.5% of patients. The NPI presented a statistically significant association with the RFH-NPT, with a substantial agreement coefficient of 0.34. An association between NPI <41 cutoff and mortality were observed, with 82.1% of the sample below cutoff experiencing mortality within 12 mo.

CONCLUSIONS

The NPI is a valuable nutritional marker for the identification of nutritional risk in ACLD and is a simple and effective assessment tool that can aid in early CLD prognosis assessment. Validation, however, remains necessary in other CLD populations of different etiologies.

Initial participant perspectives about participating in an online, semi-supervised, cirrhosis-specific nutrition and exercise intervention

OBJECTIVES

In chronic diseases, there have been issues with low levels of participant adherence and retention during well-supported lifestyle behaviour change interventional studies. Theoretically informed, the objective was to explore the types of challenges participants are experiencing to inform future designs.

DESIGN

We conducted an exploratory descriptive study in an adult cirrhosis population after the first 4-6 weeks of a 12-week semi-supervised nutrition and exercise online program.

METHODS

Participants in the parent feasibility study, assessing the nutrition and exercise intervention (Heal-Me), were eligible for this nested study. Heal-Me is a multimodal program that is tailorable to a participant's abilities through regular interaction with the study's registered dietician and exercise specialist. Interviews (~60 min) with participants were recorded then analysed descriptively, guided by the capability, opportunity and motivational behaviour change model.

RESULTS

The 20 participants preferred the expert-led group online nutrition and exercise classes over independent activities such as protein tracking and the exercise videos. Social gamification (e.g., weekly polls on favourite things like movies or sports teams) contributed to the group experience. All except one person required program tailoring to address preferences, abilities and new onset health events. Findings led to the inclusion of 4 behaviour change techniques to the initial 17, whereas 2 others were expanded.

CONCLUSIONS

While program tailoring, awareness of cirrhosis nutrition and regular interactions with staff influenced participant retention and adherence in the first 4-6 weeks of the online program.

Management of Chronic Liver Disease in Patients with Hepatocellular Carcinoma

Management of cirrhosis sequelae is critical in providing the most options for patients with hepatocellular carcinoma (HCC). Compensated liver disease is the ideal state for HCC patients who may require resection, locoregional therapies, or liver transplantation. Portal hypertension complications, suboptimal nutrition, and frailty are common barriers to various HCC treatments. For patients with advanced HCC, systemic therapies are altering the approach to multifocal, unresectable HCC, but similar barriers exist related to managing cirrhosis complications. Frequently, managing the underlying liver disease etiology is a key component to enabling HCC treatment.

How different body compositions affect the prognosis of HCC undergoing immunotherapy: the paradoxical phenomenon of BMI

PURPOSE

Body mass index (BMI) is associated with the prognosis of hepatocellular carcinoma (HCC) receiving immunotherapy. Body compositions are considered to account for this association, but this hypothesis has yet to be verified conclusively.

MATERIAL AND METHODS

Our study included 305 patients received immunotherapy at 3 centers between August 2018 and February 2022. We calculated skeletal muscle index (SMI), mean skeletal muscle density (SMD), subcutaneous adipose tissue index (SATI), visceral adipose tissue index (VATI), and visceral to subcutaneous adipose tissue area ratio (VSR) at lumbar 3 level. The influences of BMI and body compositions on overall survival (OS) were comprehensively described.

RESULTS

Sarcopenia (Low SMI, HR = 2.203, 95% CI:1.425-3.405, P < 0.001), myosteatosis (low SMD, HR = 2.013, 95% CI:1.246-3.252, P = 0.004) and visceral adipose deposition (high VATI, HR = 0.658, 95% CI:0.453-0.957, P = 0.028) were independent predictors of OS, while BMI was not. The prognosis of underweight (BMI < 20.0 kg/m2, P = 0.009) and obesity (BMI ≥ 25.0 kg/m2, P = 0.003) were significantly worse than normal weight (20.0 ≤ BMI ≤ 24.9 kg/m2), which might attribute to the differences in body compositions. High VATI had significantly improved OS than low VATI (P = 0.002), and the difference remained significant after propensity score matching (P = 0.017).

CONCLUSION

In HCC receiving immunotherapy, sarcopenia, myosteatosis, and visceral adipose deposition independently predicted OS, and visceral adipose was protective in OS. The effects of BMI on OS depended on body compositions.

Semiquantitative muscle parameters derived from FAPI and FDG PET/CT in evaluating sarcopenia among patients with malignant tumors

BACKGROUND

The objective of this study is to explore and compare the potential utility of fibroblast activation protein inhibitor (FAPI) and fluorodeoxyglucose PET/computed tomography (CT) in assessing sarcopenia among patients with malignant tumors.

METHODS

A retrospective analysis was conducted on 127 patients with histologically confirmed malignant tumors who underwent both 18F/68Ga-FAPI and fluorine-18-fluorodeoxyglucose (18F-FDG) PET/CT scans. Clinical characteristics and PET/CT parameters of maximum and mean standard uptake value (SUVmax and SUVmean) of muscle at the 3rd lumbar (L3) level were reviewed. Skeletal muscle area at the L3 level was measured, and skeletal muscle index was calculated to determine sarcopenia. The association between sarcopenia and PET/CT parameters was analyzed.

RESULTS

The incidence of sarcopenia was 41.7% among these 127 patients. Higher age, male, lower BMI, lower SUVmax and SUVmean of muscle from 18F/68Ga-FAPI PET/CT, and lower SUVmax of muscle from 18F-FDG PET/CT were correlated with a higher prevalence of sarcopenia (P < 0.05). Besides, no significant differences in SUVmax and SUVmean of muscle were noted between 18F-FAPI and 68Ga-FAPI groups. The best cutoff value of SUVmax of muscle from 18F/68Ga-FAPI PET/CT was 1.17, yielding the area under the curve (AUC) of 0.764 and sensitivity and specificity of 74.3% and 71.7%, while the optimal cutoff value of SUVmax of muscle from 18F-FDG PET/CT was 0.76, with an AUC of 0.642 and sensitivity and specificity of 36.5% and 86.8%, respectively.

CONCLUSION

Patients with sarcopenia exhibit decreased muscle uptake of FAPI and fluorodeoxyglucose. FAPI PET/CT emerges as a more valuable tool for sarcopenia assessment in patients with malignant tumors compared to fluorodeoxyglucose PET/CT.

Efficacy and safety of individual nutrition support in patients with hepatitis B virus-related acute-on-chronic liver failure at nutrition risk: a study protocol for a randomised controlled clinical trial

INTRODUCTION

Malnutrition is a common complication of hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF) typically associated with poor prognosis. Despite nutritional treatment, the outcomes for these patients are limited by the symptoms and complications associated with ACLF. So far, the benefits of nutritional interventions in these populations have not been proven. This study aims to explore a new nutritional intervention method for patients with HBV-ACLF and evaluate its safety and efficacy.

METHODS AND ANALYSIS

This study is an investigator-initiated, nonblind, randomised controlled clinical trial. We will recruit 60 patients with HBV-ACLF according to the Chinese Group on the Study of Severe Hepatitis B criteria hospitalised in the Infectious Diseases Department of the Third Affiliated Hospital of Sun Yat-Sen University. Eligible patients will be randomly allocated to the nutrition support group (intervention group) and the control group in a 1:1 ratio. Patients in the nutrition support group will receive 10 days of tailor-made nutrition therapy consisting of oral nutritional supplements and supplementary parenteral nutrition. Patients in the control group will receive standard nutrition with dietary advice. All assessments will be conducted at baseline, 30 days and 90 days. The primary outcome measure is the liver transplant-free mortality rate. The secondary indicators include the incidence of clinical adverse outcomes and changes in indicators such as muscle mass, muscle strength, physical function and quality of life (EQ-5D scale).

ETHICS AND DISSEMINATION

This study has been approved by the Medical Ethics Committee of the Third Affiliated Hospital of Sun Yat-Sen University (approval number: II2023-242-03). The results and conclusions of the clinical trial will be published in academic conferences or journals.

TRIAL REGISTRATION NUMBER

NCT06128421.

EASL Clinical Practice Guidelines on liver transplantation

Liver transplantation (LT) is an established life-saving procedure. The field of LT has changed in the past 10 years from several perspectives, with the expansion of indications, transplantation of patients with acute-on-chronic liver failure, evolution of transplant oncology, the use of donations after cardiac death, new surgical techniques, and prioritisation of recipients on the waiting list. In addition, the advent of organ perfusion machines, the recognition of new forms of rejection, and the attention paid to the transition from paediatric to adult patients, have all improved the management of LT recipients. The purpose of the EASL guidelines presented here is not to cover all aspects of LT but to focus on developments since the previous EASL guidelines published in 2016.

Resting energy expenditure in patients with liver cirrhosis: Indirect calorimetry vs. predictive equations

BACKGROUND AND OBJECTIVES

The objective of our study was to explore the accuracy of previously published prediction equations in predicting resting energy expenditure (REE) in patients with liver cirrhosis (LC). We also aimed to develop a novel equation to estimate REE for Chinese patients with LC.

METHODS AND STUDY DESIGN

In 90 patients with LC, the agreement between REE measured by Indirect calorimetry (IC) and predictive equations was quantified using paired T-test and visualized using a Bland-Altman Plot. Pearson correlation coefficient (R) was used to measure a linear correlation between REE measured by IC and different predictive equations. Stepwise multiple regression analysis was used to create a new REE equation.

RESULTS

The estimated REEs of previous equations were underestimated against REE measured by IC (1610 ± 334 kcal). Lean body mass (LBM) was positively correlated with REE measured by IC (r = 0.723, p < 0.01). The newly derived estimation equation for REE (kcal) was 1274.3 - 209.0 * sex - 5.73 * age + 3.69 * waist circumference + 22.89 * LBM. The newly derived estimation equation was found to have a Pearson-r value of 0.765 compared with REE measured by IC.

CONCLUSIONS

REE in liver cirrhosis was underestimated by using predictive equations. The new predictive equation developed by using age, sex, waist circumference, and LBM may help estimate REE in Chinese patients with LC accurately and easily.

Multimedia-Based Education Led to Improvement in Disease Knowledge Among Patients with Cirrhosis

BACKGROUND

Current evidence shows limited patient understanding of liver disease, coupled with no standard guidelines or methods to offer patient education in a busy clinical environment. We developed multimedia-based education (MBE) for those with cirrhosis & tested its effectiveness in improving patient knowledge from baseline to 1 month.

METHODS

This prospective study enrolled cirrhotic patients who had a scheduled visit with a hepatologist at an ambulatory academic practice or were admitted to the liver inpatient service. Once consented, patients completed a baseline knowledge questionnaire, and were given a link to watch the videos (text or email). Four videos were developed by the study team with input from clinicians and patients (liver function, symptoms and complications, medical management and preventive actions & nutrition). At month 1, the study coordinator confirmed with the patient that they had watched the videos at least once, and patients completed the same knowledge questionnaire. The scores between pre- and post-intervention were compared using the Wilcoxon signed rank test.

RESULTS

Of the 120 enrolled, 113 completed baseline and 75 completed follow-up. 48% had alcohol-related liver disease as the underlying cause of cirrhosis. Mean MELD score at enrollment was 14.7 ± 8.14. There was a statistically significant improvement in knowledge scores across all domains from baseline to month 1 (p < 0.05). The overall knowledge score improved from 65 to 83% (p < 0.001), with highest improvement by 40% in the domain of liver function and causes of cirrhosis.

CONCLUSIONS

MBE can help improve patients' knowledge about liver function, management, and prevention and can be used in both ambulatory and inpatient hepatology practice.

IMPACT OF SARCOPENIA ON THE PROGNOSIS OF PATIENTS WITH CIRRHOSIS HOSPITALIZED FOR ACUTE DECOMPENSATION OR ACUTE-ON-CHRONIC LIVER FAILURE

BACKGROUND

Cirrhosis is a prevalent disease and ranks among the leading causes of death worldwide. Sarcopenia is believed to be associated with a poorer prognosis in patients with cirrhosis.

OBJECTIVE

To evaluate the impact of sarcopenia on the prognosis of patients hospitalized for acute decompensation of cirrhosis, with or without acute-on-chronic liver failure.

METHODS

This prospective cohort study evaluated patients hospitalized for acute decompensation of cirrhosis, with or without acute-on-chronic liver failure. Sarcopenia was assessed according to the European Working Group on Sarcopenia in Older People, using skeletal muscle mass analysis by bioelectrical impedance and handgrip strength testing. The data was collected between March-2019 and April-2020. Qualitative variables were presented as frequencies and percentages, and quantitative variables as means and standard deviations when symmetrical, or medians and 25th and 75th percentiles when asymmetrical. The association of sarcopenia and mortality with quantitative variables was tested using Student's t-test or the Mann-Whitney test, while associations with qualitative variables were tested using the Chi-square test or Fisher's Exact test. For significant associations, crude and adjusted (multivariate analysis) relative risk estimates with a 95% confidence interval were calculated using Poisson regression analysis. Results with P<0.05 were considered significant.

RESULTS

Fifty patients were included, with a mean age of 60.5 years (±10.4) and a slight predominance of men (56%). The main causes of cirrhosis were alcohol use disorder (28%) and hepatitis C (24%). The median Child-Pugh score was 8 points (7-10), and the median Model for End-stage Liver Disease score was 15 points (12.5-21). Ten patients were diagnosed with acute-on-chronic liver failure. Sarcopenia was present in 50% of the sample. Sarcopenia was present in 70.0% of patients with acute-on-chronic liver failure and in 43.2% of those without acute-on-chronic liver failure (P=0.168). Overall mortality was 48% in patients with sarcopenia and 44% in those without sarcopenia (P=1.000). In multivariate analysis, overall mortality was associated only with leukocyte count (relative risk=1.01, 95% confidence interval=1.01-1.01) and Model for End-stage Liver Disease score (relative risk=1.07, 95% confidence interval =1.03-1.10).

CONCLUSION

In this study, sarcopenia was not associated with mortality in patients hospitalized for acute decompensation of cirrhosis, with or without acute-on-chronic liver failure. There was a non-significant trend towards a higher prevalence of sarcopenia among individuals with acute-on-chronic liver failure.

Medically Tailored Meals for Patients With Cirrhosis and Hepatic Encephalopathy: The BRAINFOOD Proof-of-concept Trial

Background and aims

Guidelines recommend that patients with hepatic encephalopathy (HE) receive a high-protein diet (roughly 1 g/kg actual body weight). Concommitant sodium restriction, low health literacy, and food insecurity limit patients' ability to meet this goal. We aimed to determine the feasibility of home-delivered high-protein medically tailored meals (MTMs) for patients with a recent episode of overt HE.

Methods

We enrolled patients with prior overt HE on active HE therapy in a 6-month trial of MTM. All received 21 home-delivered meals/week with protein snacks (mid-day and bedtime) for 12 weeks. Patients completed follow-up at week 24. The primary outcome was feasibility. Additional outcomes included change in protein and micronutrient intake (measured using 24 h dietary recalls performed by dieticians), cognitive function (Animal Naming Test [ANT]; EncephalApp Stroop), physical function (Liver Frailty Index [LFI]), and quality of life (Short Form-8 Health Survey [SF-8]). Healthcare utilization was also assessed.

Results

Ten patients competed the study with >90% of MTM consumed. Protein intake rose from 74.6 ± 25.1 g at baseline to 93.8 ± 24.3 g on MTM (P = 0.04). Branched-chain amino acids also increased-valine 3.73 ± 1.26 g to 5.17 ± 1.28 g, isoleucine 3.32 ± 1.18 to 4.69 ± 1.55, leucine 5.83 ± 2.00 to 7.49 ± 2.07, all P < 0.001. The LFI score improved from 4.42 ± 0.32 to 3.96 ± 0.82 by the end of the MTM phase (P = 0.03). SF-8 quality-of-life scores improved from 55.5 ± 15.5 at baseline to 64.7 ± 18.3 after the MTM phase, to 64.4 ± 19.1 at the end of the study (P = 0.1). EncephalApp Stroop time improved from 227 ± 94 to 194 ± 58s by the end of the MTM phase (P = 0.08). ANT scores were similarly non-significantly improved.

Conclusion

Home-delivered MTMs are feasible, increase protein consumption, and may improve patient wellbeing. A randomized trial is needed.

Beyond the Liver: Neurologic Manifestations of Alcohol Use

Alcohol use, while commonly associated with liver damage, also has significant neurologic implications, which often mimic hepatic encephalopathy and complicate diagnosis and management. Alcohol mediates its acute central nervous system effects by altering neurotransmitter balance, notably between gamma-aminobutyric acid and glutamate. Its chronic neurotoxicity, compounded by thiamine deficiency, results in chronic neurologic complications. Clinically, alcohol-related neurologic disorders present a spectrum from acute intoxication and withdrawal to chronic conditions like Korsakoff syndrome, dementia, cerebellar degeneration, and peripheral neuropathy. This review underscores differentiating these conditions from hepatic encephalopathy and highlights the importance of history-taking and physical examination in clinical practice.

Reversing malnutrition and low muscle strength with targeted enteral feeding in patients awaiting liver transplant: A randomized controlled trial

BACKGROUND AND AIMS

Most patients with decompensated cirrhosis fail to meet their nutrition targets. The impact of nasogastric feeding (NGF) on malnutrition in cirrhosis remains unknown. This study aims to assess the impact of pretransplant NGF on pre-liver transplant and post-liver transplant outcomes.

APPROACH AND RESULTS

This single-center, prospective randomized controlled trial of 55 patients with severe malnutrition and low handgrip strength (HGS) compared a standard high-energy high-protein diet to diet plus supplemental nocturnal NGF while awaiting transplant. The primary outcome was a change in HGS. The median age was 58.5 years (IQR: 51.1-64), median MELD was 24 (20-28.5), and 32 (58%) patients were male. The median duration of NGF was 63.0 days (34.5-127), following which time the median between-group difference in HGS was 3.6 kg (95% CI: 1.7-5.2, p <0.001), an increase of 20% from baseline. Mid-upper-arm circumference, triceps skinfold, and immune function all increased significantly with NGF. Muscle and nutritional parameters continued to improve with increasing duration of feeding. NGF significantly increased daily energy intake between groups by 1285 kcal (95% CI: 860-1677) and protein intake by 51 g (95% CI: 32-71) (both p <0.001). All NGF patients met >100% of their measured nutritional requirements. Posttransplant clinical outcomes were similar between groups.

CONCLUSIONS

Targeted enteral feeding before liver transplant improves HGS, anthropometry, and immune function in severely malnourished patients with cirrhosis. These findings provide a strong rationale for early consideration of NGF to reverse malnutrition and improve muscle strength. Appropriately powered studies should explore whether NGF can also impact clinically relevant outcomes including pretransplant and posttransplant mortality.

Textbook outcome and nomogram-guided approaches for enhancing surgical success in elderly HCC patients: Deciphering the influence of sarcopenia

Sarcopenia, serving as a surrogate for frailty, is clinically significant in liver resection (LR) for elderly hepatocellular carcinoma (HCC) patients. Our study aims to assess sarcopenia's impact, measured by Psoas Muscle Index (PMI), on postoperative outcomes. We retrospectively studied patients aged ≥ 60 years who underwent LR for HCC between 2014 and 2018. PMI, derived from preoperative CT scans, and Textbook Outcome (TO) for LR were assessed. A nomogram predicting overall survival (OS) was developed via multivariable analysis. Of the 149 eligible HCC patients, the median PMI was 7.225 cm2/m2 in males and 4.882 cm2/m2 in females, with 37 (24.8%) patients identified as sarcopenic. Mortality was significantly associated with sarcopenia (HR 2.15; p = 0.032), MELD ≥ 10 (HR 3.13; p = 0.001), > 3 HCC nodules (HR 4.97; p = 0.001), and Clavien-Dindo ≥ 3 complications (HR 3.38; p < 0.001). Sarcopenic patients had a 5-year OS of 38.8% compared to 61% for non-sarcopenic individuals (p = 0.085). Achieving TO correlated with higher OS (p = 0.01). In sarcopenic cases, the absence of postoperative complications emerged as a limiting factor. Sarcopenic patients failing to achieve TO had worse OS compared to non-sarcopenic and TO-achieving counterparts (5-year OS 18.5%; p = 0.00039). Sarcopenia emerges as a prognostic factor for LR outcomes in elderly HCC patients. Postoperative complications in sarcopenic patients may compromise oncological outcomes.

Current challenges and future perspectives in treating patients with NAFLD-related cirrhosis

Despite the slow, progressive nature of NAFLD, the number of patients with NAFLD-related cirrhosis has significantly increased. Although the management of patients with cirrhosis is constantly evolving, improving the prognosis of patients with NAFLD-related cirrhosis is a challenge because it is situated at the crossroads between the liver, the metabolic, and the cardiovascular diseases. Therefore, the therapeutic interventions should not only target the liver but also the associated cardiometabolic conditions and should be adapted accordingly. The objective of the current review is to critically discuss the particularities in the management of patients with NAFLD-related cirrhosis. We relied on the recommendations of scientific societies and discussed them in the specific context of NAFLD cirrhosis and the surrounding cardiometabolic milieu. Herein, we covered the following aspects: (1) the weight loss strategies through lifestyle interventions to avoid sarcopenia and improve portal hypertension; (2) the optimal control of metabolic comorbidities in particular type 2 diabetes aimed not only to improve cardiovascular morbidity/mortality but also to lower the incidence of cirrhosis-related complications (we discussed various aspects related to the safety of oral antidiabetic drugs in cirrhosis); (3) the challenges in performing bariatric surgery in patients with cirrhosis related to the portal hypertension and the risk of cirrhosis decompensation; (4) the particularities in the diagnosis and management of the portal hypertension and the difficulties in managing patients awaiting for liver transplantation; and (5) the difficulties in developing drugs and conducting clinical trials in patients with NAFLD-related cirrhosis. Moreover, we discussed the emerging options to overcome these obstacles.

Nutrition in pediatric end-stage liver disease

PURPOSE OF REVIEW

The aim of this review is to outline recent studies relating to nutritional status and outcomes in pediatric end-stage liver disease.

MAIN FINDINGS

Pediatric patients with chronic and end-stage liver disease are at high risk of malnutrition. Given additional growth demands in children and the inherent complications of chronic liver disease, achieving adequate nutrition in these patients remains a challenge. In addition, while guidelines on nutrition in chronic liver disease exist, global approaches and definitions of malnutrition vary. Recent literature has focused on sarcopenia and nutrition-related transplant outcomes, with some studies exploring nutritional assessment and management. Pediatric studies however continue to lag adult research, with limited prospective and interventional studies.

SUMMARY

Optimizing nutrition in pediatric end-stage liver disease remains a challenge, however understanding of the mechanisms and clinical manifestations of malnutrition in this population is improving. Despite these efforts, high quality studies to determine optimal nutrition strategies and interventions are lacking behind adult evidence and should be the focus of future research.

Akkermansia muciniphila is associated with normal muscle mass and Eggerthella is related with sarcopenia in cirrhosis

Background

Sarcopenia and gut dysbiosis are common in cirrhosis. The aim is to study the correlations between the gut microbiota taxa and muscle mass level in cirrhosis.

Methods

The study included 40 cirrhosis patients including 18 patients with sarcopenia. The gut microbiota composition was assessed using amplicon sequencing of the hypervariable V3-V4 regions of the 16S rRNA gene. The skeletal muscle mass, subcutaneous and visceral fat levels were assessed with abdominal computed tomography as skeletal muscle, subcutaneous and visceral fat indices (SMI, SFI and VFI).

Results

Patients with sarcopenia had more relative abundance (RA) of Agathobacter, Anaerostipes, Butyricicoccus, Dorea, Eggerthella, Microbacteriaceae, Veillonella and less RA of Akkermansiaceae, Akkermansia muciniphila, Verrucomicrobiae and Bilophila compared to patients with normal muscle mass. SMI directly correlated with RA of Akkermansia, Alistipes indistinctus, Anaerotruncus, Atopobiaceae, Bacteroides clarus, Bacteroides salyersiae, Barnesiellaceae, Bilophila wadsworthia, Pseudomonadota, Olsenella, and Parabacteroides distasonis, and negatively correlated with RA of Anaerostipes and Eggerthella. Sarcopenia was detected in 20.0% patients whose gut microbiota had Akkermansia but not Eggerthella, and in all the patients, whose gut microbiota had Eggerthella but not Akkermansia. The Akkermansia and Eggerthella abundances were independent determinants of SMI. RA of Akkermansia, Akkermansia muciniphila, Akkermansiaceae, Bacteroides salyersiae, Barnesiella, Bilophila, Desulfobacterota, Verrucomicrobiota and other taxa correlated positively and RA of Anaerovoracaceae, Elusimicrobiaceae, Elusimicrobium, Kiritimatiellae, Spirochaetota, and other taxa correlated negatively with the SFI. RA of Alistripes, Romboutsia, Succinivibrio, and Succinivibrionaceae correlated positively and RA of Bacteroides thetaiotaomicron correlated negatively with VFI.

Conclusion

The muscle mass level in cirrhosis correlates with the abundance of several gut microbiota taxa, of which Akkermansia and Eggerthella seems to be the most important.

Low geriatric nutritional risk index is associated with osteoporosis and fracture risk in patients with chronic liver disease: a cross-sectional study

BACKGROUND

Patients with chronic liver disease (CLD) frequently suffer from malnutrition and bone diseases, both of which heighten the risk of poor clinical outcomes. This study investigated the relationship between geriatric nutritional risk index (GNRI) and osteoporosis or fracture risk using the fracture risk assessment tool (FRAX) in patients with CLD.

METHODS

This cross-sectional study included 209 consecutive patients with CLD. The participants were divided into two groups: the all-risk group (GNRI ≤ 98.0) with nutrition-related risk and the no-risk group (GNRI > 98.0) without nutrition-related risk. Osteoporosis was diagnosed according to the World Health Organization criteria. The FRAX was used to estimate the 10-year probabilities of hip fracture (FRAX-HF) and major osteoporotic fracture (FRAX-MOF).

RESULTS

Of the 209 patients, 72 (34.4%) had osteoporosis. The all-risk group had a significantly higher prevalence of osteoporosis than the no-risk group (p < 0.001). Conversely, patients with osteoporosis had significantly lower GNRI than those without osteoporosis (p < 0.001). Multivariate analysis found lower GNRI to be a significant and independent risk factor for osteoporosis (odds ratio [OR], 0.927; p < 0.001) and high fracture risk derived from FRAX (without BMD) (OR, 0.904; p = 0.009). GNRI had a positive correlation with bone mineral density (BMD) at the lumbar spine, femoral neck, and total hip, but a negative correlation with FRAX-HF and FRAX-MOF in the FRAX with and without BMD (p < 0.001 for all). The cutoff value of GNRI for predicting osteoporosis was 104.9, with sensitivity of 0.667 and specificity of 0.657.

CONCLUSIONS

The GNRI was significantly associated with osteoporosis and FRAX-derived fracture risk in patients with CLD, suggesting that it could be a simple and useful indicator for the management of bone diseases.

Reduced muscle mass is an important part of Global Leadership Initiative on Malnutrition criteria in nutritional diagnosis of hepatocellular carcinoma

BACKGROUND

The Global Leadership Initiative on Malnutrition criteria (GLIM) was established to build a global consensus on the diagnostic criteria for malnutrition. The study aimed to assess the prevalence of the malnutrition diagnosed by GLIM criteria for patients with hepatocellular carcinoma (HCC), and to determine the role of the reduced muscle mass defined by CT scans in the GLIM criteria.

METHODS

This cohort research was conducted on adult cirrhotic patients with HCC. The risk of malnutrition was screened by Nutritional Risk Screening 2002 (NRS-2002), and malnutrition was diagnosed by GLIM criteria. The third lumbar vertebrae (L3-SMI) were used to represent the muscle mass in GLIM criteria. The variables associated with overall mortality were assessed by multivariate Cox regression analyses.

RESULTS

The incidence of malnutrition diagnosed by GLIM criteria was 49.7% (179/360) in patients with HCC. If reduced muscle mass was not included in GLIM criteria, the prevalence of malnutrition was 31.7% (114/360). GLIM-defined malnutrition (HR = 1.979, 95%CI 1.019-3.841, P = 0.044) was independently associated with overall mortality in patients with HCC. However, the GLIM-defined malnutrition (without muscle mass) was not associated with overall mortality (HR = 0.863, 95%CI 0.399-1.867, P = 0.709).

CONCLUSIONS

Skeletal muscle mass is an integral component of the GLIM criteria for patients with HCC. The malnutrition is common in patients with HCC, and malnourishment is associated with higher overall mortality. GLIM criteria are recommended to assess the nutritional status of hospitalized patients with HCC, which is recommended and can be used as the basis for nutritional interventions.

Body composition and muscle composition phenotypes in patients on waitlist and shortly after liver transplant - results from a pilot study

BACKGROUND

Sarcopenia is common in end-stage liver disease and negatively impacts patients awaiting or undergoing liver transplantation (LT). Magnetic resonance imaging (MRI) may be used to measure body composition and sarcopenia. We aimed to evaluate the feasibility of MRI-based LT body composition profiling, describe waitlist body composition, and assess the natural rate of change in body composition while on the waitlist and post-LT.

METHODS

This prospective pilot study recruited adults listed for LT at an urban, tertiary care facility. Eighteen participants were scanned at time of waitlisting and 15 had follow-up MRIs (waitlist and/or post-LT). An 8-min MRI was used to measure body composition (AMRA® Researcher) including thigh fat-free muscle volume (FFMV) and fat infiltration (MFI), visceral (VAT) and abdominal subcutaneous (ASAT) adipose tissue volumes, and liver fat. A sex- and BMI invariant FFMV z-score (z-FFMV) was calculated, and muscle composition (MC) phenotypes were defined using the muscle assessment score (consisting of the FFMV z-score and sex-adjusted MFI). Rate of body composition change was calculated using mixed-effect modelling and is presented as rate per 30 days.

RESULTS

At time of waitlisting, 73% of the 18 participants had high MFI and 39% had the adverse MC (low FFMV z-score and high MFI) phenotype. Seven participants received an LT. Post-LT serial MRIs, at a median of 147 days apart within the first 200 days post-LT, demonstrated increased z-FFMV 0.22 SDs/(30 days) (p = 0.002), VAT 0.23 (p < 0.001), and ASAT 0.52 (p = 0.001) L/(30 days), but no change in MFI (p = 0.200) nor liver fat (p = 0.232).

CONCLUSION

MRI-based body composition profiling is feasible in LT patients and shortly after LT. This can be amended to routine clinical scans and may help in early identification of patients who may benefit from interventions to improve body composition. In addition, body composition changes significantly over time after LT.

Development and external validation of a machine-learning based model to predict pre-sarcopenia in MASLD population: Results from NHANES 2017-2018

INTRODUCTION AND OBJECTIVES

With rising prevalence of pre-sarcopenia in metabolic dysfunction-associated steatotic liver disease (MASLD), this study aimed to develop and validate machine learning-based model to identify pre-sarcopenia in MASLD population.

MATERIALS AND METHODS

A total of 571 MASLD subjects were screened from the National Health and Nutrition Examination Survey 2017-2018. This cohort was randomly divided into training set and internal testing set with a ratio of 7:3. Sixty-six MASLD subjects were collected from our institution as external validation set. Four binary classifiers, including Random Forest (RF), support vector machine, and extreme gradient boosting and logistic regression, were fitted to identify pre-sarcopenia. The best-performing model was further validated in external validation set. Model performance was assessed in terms of discrimination and calibration. Shapley Additive explanations were used for model interpretability.

RESULTS

The pre-sarcopenia rate was 17.51 % and 15.16 % in NHANES cohort and external validation set, respectively. RF outperformed other models with area under receiver operating characteristic curve (AUROC) of 0.819 (95 %CI: 0.749, 0.889). When six top-ranking features were retained as per variable importance, including weight-adjusted waist, sex, race, creatinine, education and alkaline phosphatase, a final RF model reached an AUROC being 0.824 (0.737, 0.910) and 0.732 (95 %CI: 0.529, 0.936) in internal and external validation sets, respectively. The model robustness was proved in sensitivity analysis. The calibration curve and decision curve analysis confirmed a good calibration capacity and good clinical usage.

CONCLUSIONS

This study proposed a user-friendly model using explainable machine learning algorithm to predict pre-sarcopenia in MASLD population. A web-based tool was provided to screening pre-sarcopenia in community and hospitalization settings.

Clinically relevant cut-points for changes in the Liver Frailty Index are associated with waitlist mortality in patients with cirrhosis

Physical frailty is a critical determinant of mortality in patients with cirrhosis and can be objectively measured using the Liver Frailty Index (LFI), which is potentially modifiable. We aimed to identify LFI cut-points associated with waitlist mortality. Ambulatory adults with cirrhosis without HCC awaiting liver transplantation from 9 centers from 2012 to 2021 for ≥3 months with ≥2 pre-liver transplantation LFI assessments were included. The primary explanatory variable was the change in LFI from first to second assessments per 3 months (∆LFI); we evaluated clinically relevant ∆LFI cut-points at 0.1, 0.2, 0.3, and 0.5. The primary outcome was waitlist mortality (death or delisting for being too sick), with transplant considered as a competing event. Among 1029 patients, the median (IQR) age was 58 (51-63) years; 42% were female; and the median lab Model for End-Stage Liver Disease-Sodium at first assessment was 18 (15-22). For each 0.1 improvement in ∆LFI, the risk of overall mortality decreased by 6% (cause-specific hazard ratio: 0.94, 95% CI: 0.92-0.97, p < 0.001). ∆LFI was associated with waitlist mortality at cut-points as low as 0.1 (cause-specific hazard ratio: 0.63, 95% CI: 0.46-0.87) and 0.2 (HR: 0.61, 95% CI: 0.42-0.87). An improvement in LFI per 3 months as small as 0.1 in the pre-liver transplantation period is associated with a clinically meaningful reduction in waitlist mortality. These data provide estimates of the reduction in mortality risk associated with improvements in LFI that can be used to assess the effectiveness of interventions targeting physical frailty in patients with cirrhosis.

Incorporation of quantitative imaging data using artificial intelligence improves risk prediction in veterans with liver disease

BACKGROUND AND AIMS

Utilization of electronic health records data to derive predictive indexes such as the electronic Child-Turcotte-Pugh (eCTP) Score can have significant utility in health care delivery. Within the records, CT scans contain phenotypic data which have significant prognostic value. However, data extractions have not traditionally been applied to imaging data. In this study, we used artificial intelligence to automate biomarker extraction from CT scans and examined the value of these features in improving risk prediction in patients with liver disease.

APPROACH AND RESULTS

Using a regional liver disease cohort from the Veterans Health System, we retrieved administrative, laboratory, and clinical data for Veterans who had CT scans performed for any clinical indication between 2008 and 2014. Imaging biomarkers were automatically derived using the analytic morphomics platform. In all, 4614 patients were included. We found that the eCTP Score had a Concordance index of 0.64 for the prediction of overall mortality while the imaging-based model alone or with eCTP Score performed significantly better [Concordance index of 0.72 and 0.73 ( p <0.001)]. For the subset of patients without hepatic decompensation at baseline (n=4452), the Concordance index for predicting future decompensation was 0.67, 0.79, and 0.80 for eCTP Score, imaging alone, or combined, respectively.

CONCLUSIONS

This proof of concept demonstrates that the potential of utilizing automated extraction of imaging features within CT scans either alone or in conjunction with classic health data can improve risk prediction in patients with chronic liver disease.

Alcohol-associated liver disease increases the risk of muscle loss and mortality in patients with cirrhosis

BACKGROUND

Rapid skeletal muscle loss adversely affects the clinical outcomes of liver cirrhosis. However, the relationships between the annual changes in skeletal muscle area (ΔSMA/year) and the etiology of cirrhosis, factors associated with muscle loss, and risk of mortality remains unclear.

METHODS

A total of 384 patients who underwent multiple computed tomography (CT) scans between March 2004 and June 2021 were enrolled in this study (median age, 67 years; 64% men; median model for end-stage liver disease score, 9). Body composition and ΔSMA/year were estimated using a 3D image analysis system and data from at least two distinct CT scans. Differences in ΔSMA/year among different etiologies of cirrhosis, factors associated with rapid muscle loss (defined as ΔSMA/year ≤  - 3.1%), and the association between ΔSMA/year and mortality were examined.

RESULTS

Patients with alcohol-associated liver disease (ALD) cirrhosis experienced more rapid muscle loss (ΔSMA/year, - 5.7%) than those with hepatitis B (ΔSMA/year, - 2.8%) and hepatitis C cirrhosis (ΔSMA/year, - 3.1%). ALD cirrhosis was independently associated with ΔSMA/year ≤  - 3.1% after adjusting for age, sex, and liver functional reserve. Over a median follow-up period of 3.8 years, ALD cirrhosis, ΔSMA/year ≤  - 3.1%, and low subcutaneous adipose tissue level were found to be significantly associated with reduced survival. ALD cirrhosis (hazard ratio [HR], 2.43; 95% confidence interval [CI] 1.12-5.28) and ΔSMA/year ≤  - 3.1% (HR, 3.68; 95% CI 2.46-5.52) were also predictive of mortality.

CONCLUSIONS

These results suggest that ALD cirrhosis increases the risk of rapid muscle loss and mortality in affected patients.

Key Insights and Clinical Pearls in the Identification and Management of Cirrhosis and Its Complications

Cirrhosis is a prevalent, chronic condition with an asymptomatic compensated phase, in which patients may feel well, and a decompensated phase that begins with the onset of complications (eg hepatic encephalopathy, ascites, and/or variceal bleeding). Because patients with cirrhosis may appear healthy with normal liver enzymes, alkaline phosphatase, and serum bilirubin levels, awareness of clinical signals is important. For example, patients with thrombocytopenia should be evaluated for chronic liver disease and cirrhosis. Early recognition and management of cirrhosis-related complications (eg hepatic encephalopathy, ascites, and/or variceal bleeding) are important, given their association with hospitalization and poor prognosis (eg increased odds of short-term mortality). Hepatic encephalopathy can be the most subtle cirrhosis-related complication and associated cognitive impairment may be misdiagnosed. Because hepatic encephalopathy can be associated with hospital readmissions, reducing readmission rates after hepatic encephalopathy-related hospitalizations is critical. This includes incorporating ongoing therapy (eg rifaximin plus lactulose) in postdischarge management plans to reduce the risk of hepatic encephalopathy recurrence. Strategies that mitigate cirrhosis progression and prevent the development of cirrhosis-related complications are key to improving patient outcomes.

Optimizing muscle preservation during weight loss in patients with cirrhosis: A pilot study comparing continuous energy restriction to alternate-day modified fasting for weight loss in patients with obesity and non-alcoholic cirrhosis of the liver

Introduction

Obesity is associated with increased morbidity in patients with advanced liver disease, but it is particularly challenging for these patients to preserve skeletal muscle mass during weight loss and accelerating sarcopenia is a concern. Alternate-day modified fasting (ADMF) may be particularly effective for weight loss in patients with concomitant cirrhosis and obesity due to preservation of fat-free mass (FFM).

Methods

A weight loss program featuring either ADMF or a continuous low-calorie diet (LCD) was evaluated in a 24-week randomized clinical trial in 20 adult patients with Child-Pugh Class A cirrhosis and obesity. Participants were randomized to either ADMF (n = 11) or LCD (n = 9). Both groups received a remotely delivered exercise program. Body composition, sarcopenia measures, and functional outcomes were assessed pre-post.

Results

Thirteen participants completed the intervention (Age = 57 ± 10; BMI = 37.7 ± 5.8 kg/m2). The median body weight lost in ADMF was 13.7 ± 4.8 kg (13.9% of initial body weight), while LCD lost 9.9 ± 6.9 kg (10.7% of initial body weight). Total body fat percentage decreased in both groups (ADMF: -4.1 ± 4.0%; LCD = -2.8 ± 1.4%). Fat-free mass accounted for 34 ± 20% of total weight loss in ADMF and 38 ± 10% in LCD. Functional measures, such as timed chair stands, improved in both groups.

Conclusion

This pilot study demonstrates the feasibility of the ADMF and LCD interventions to produce significant weight loss while improving body composition in patients with cirrhosis and obesity. Further research is needed to validate these findings in larger cohorts and to assess changes in muscle quality and visceral fat.

Trial Registration

ClinicalTrials.gov Identifier: NCT05367596.

Comparative analysis of Sarcopenia in hospitalized elderly: exploring the impact of liver cirrhosis

The progressive aging of the population has led to a rise in geriatric pathologies, with sarcopenia, characterized by muscle mass and function loss, becoming a crucial prognostic indicator. This study investigates sarcopenia in elderly hospitalized patients with advanced chronic liver disease (cirrhotic) and non-liver disease patients, comparing their prevalence and exploring correlations with anthropometric and biochemical factors. The cohort of 115 patients, including 50 cirrhotic and 65 non-cirrhotic individuals, exhibited significant comorbidities and a mean age of 78.4 years. Cirrhotic patients presented distinct laboratory parameters indicating liver damage. Applying European Working Group on Sarcopenia in Older People criteria, probable sarcopenia prevalence was similar in cirrhotic (62%) and non-cirrhotic (63%) patients. Stratifying probable sarcopenia into confirmed sarcopenia and dynapenia revealed no significant differences between populations. Correlation analyses demonstrated positive associations between Appendicular Skeletal Muscle Mass (ASM) and anthropometric parameters, malnutrition risk, and grip strength. In cirrhotic patients, muscle mass inversely correlated with liver damage. Odds ratio analysis highlighted the Mini Nutritional Assesment's (MNA) significant predictive capability for sarcopenia. ROC curve analysis affirmed MNA and biochemical markers' combined use, such as transferrin, albumin, total cholesterol, lymphocyte count and C-reactive protein as a strong predictor. Despite limitations, such as a small sample size, this study underscores the significance of thorough sarcopenia screening in elderly hospitalized patients, especially those with cirrhosis. Indeed, individuals with end-stage liver disease are particularly susceptible to sarcopenia. A more personalized approach utilizing tools like MNA and biochemical markers could prove beneficial. Further research is warranted to validate these findings and inform clinical interventions.

Falls and malnutrition are associated with in-hospital mortality in patients with cirrhosis

BACKGROUND

Hospitalized patients with end-stage liver disease are at risk of malnutrition, reduced body function, and cognitive impairment due to HE. This combination may have an impact on in-hospital falls and mortality. The purpose of this study was to identify factors associated with the risk of falls and to analyze the consequences regarding in-hospital mortality.

METHODS

We performed a retrospective analysis of patients hospitalized with liver cirrhosis between 2017 and 2019 at the Department of Gastroenterology at the University Hospital Frankfurt. Clinical data, laboratory work, and follow-up data were analyzed. Factors associated with the risk of falls and in-hospital mortality were calculated using a mixed effect poisson regression model and competing risk time-to-event analyses.

RESULTS

Falls occurred with an incidence of 4% (80/1985), including 44 injurious falls with an incidence rate of 0.00005/100 patient-days (95% CI: 0.00001-0.00022). In the multivariate analysis malnutrition (incidence risk ratio: 1.77, 95% CI: 1.04-3.04) and implanted TIPS (incidence risk ratio: 20.09, 95% CI: 10.1-40.1) were independently associated with the risk of falling. In a total of 21/80 (26.25%) hospitalizations, patients with a documented fall died during their hospital stay versus 160/1905 (8.4%) deaths in hospitalizations without in-hospital fall. Multivariable analysis revealed as significant clinical predictors for in-hospital mortality a Nutritional Risk Screening ≥2 (HR 1.79, 95% CI: 1.32-2.4), a falling incident during hospitalization (HR 3.50, 95% CI: 2.04-6.0), high MELD, and admission for infections.

CONCLUSIONS

Malnutrition and TIPS are associated with falls in hospitalized patients with liver cirrhosis. The in-hospital mortality rate of patients with cirrhosis with falls is high. Specific attention and measures to ameliorate these risks are warranted.

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

BACKGROUND & AIMS

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 sub-hazard 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 sub-hazard ratio 1.18, 95% CI 1.04-1.35). 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 of 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 cirrhosis. The novelty of this study is its multicentre, prospective nature and the fact that it distinguishes between the 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 play a dominant role in the prognosis of patients with cirrhosis.

Quantitative Assessment of Body Composition in Cirrhosis

Changes in body composition often accompany the progression of liver disease and seem to be an aggravating pathophysiological factor. Specifically, accelerated loss of skeletal muscle mass, lower muscle quality, and changes in body fat distribution have been shown to be associated with poor clinical outcomes. The aim of the present narrative review was to discuss the current status and relevance of commonly applied, advanced, non-invasive methods to quantify skeletal muscle mass, muscle fat infiltration-i.e., myosteatosis-and fat distribution. This review focuses in particular on Computed Tomography (CT), Dual-energy X-ray Absorptiometry (DXA), Bioelectrical Impedance Analysis (BIA), Magnetic Resonance Imaging (MRI), and Ultrasonography (US). We propose future directions to enhance the diagnostic and prognostic relevance of using these methods for quantitative body composition assessment in patients with cirrhosis.

Global Leadership Initiative on Malnutrition-defined malnutrition coexisting with visceral adiposity predicted worse long-term all-cause mortality among inpatients with decompensated cirrhosis

BACKGROUND/OBJECTIVES

Malnutrition coexisting with abdominal adipose tissue accumulation bring a double burden on prognosis. More recently, the Global Leadership Initiative on Malnutrition (GLIM) has reached a novel consensus concerning the diagnostic criteria, that is, a two-step modality combining nutritional risk screening and subsequent phenotypic/etiologic parameters for comprehensive evaluation in hopes of harmonizing the malnutrition diagnosis. We aimed to elucidate their synergistic impact among inpatients with decompensated cirrhosis concerning long-term mortality.

SUBJECTS/METHODS

Malnutrition, visceral obesity, and visceral adiposity were defined by the Global Leadership Initiative on Malnutrition (GLIM), visceral fat area (VFA), and visceral to subcutaneous adipose tissue area ratio (VSR) on computed tomography, respectively. Accordingly, the patients were categorized into different groups given their nutritional status and visceral obesity/adiposity. Multivariate Cox regression was performed to identify independent risk factors associated with 1-year all-cause mortality. Kaplan-Meier curves with log-rank tests were compared among distinct groups.

RESULTS

Totally, 295 patients were recruited. GLIM, VFA, and VSR identified 131 (44.4%), 158 (53.6%), and 59 (20%) patients with malnutrition, visceral obesity and visceral adiposity, respectively. Malnutrition coexisted with visceral obesity in 55 (MO group) relative to visceral adiposity in 40 patients (MA group). Multivariate Cox analysis showed that MA (hazard ratio: 2.48; 95% confidence interval: 1.06, 5.79; P = 0.036) was independently associated with dire outcome rather than MO. Moreover, patients with cirrhosis in the MA group had the worst survival status when compared with other groups (log-rank test: P < 0.001).

CONCLUSIONS

The current study indicated that coexisting GLIM-defined malnutrition and VSR-defined visceral adiposity were in relation to worse long-term mortality among inpatients. It is imperative to delicately manage nutritional status and provide personalized treatment in this vulnerable subgroup for achieving better prognosis.

Change of skeletal muscle mass in cirrhotic patients with hypersplenism after partial splenic artery embolization

PURPOSE

Partial splenic artery embolization (PSAE) is an effective procedure for cirrhotic patients with hypersplenism. The aim of our study is to evaluate the effect of PSAE on skeletal muscle, and to identify the predictor for an improvement in skeletal muscle index (SMI) in cirrhotic patients with hypersplenism after PSAE.

MATERIALS AND METHODS

466 cirrhotic patients with hypersplenism underwent PASE between Dec 2013 and Mar 2022. Medical records and CT images of enrolled patients were analyzed.

RESULTS

105 cirrhotic patients with hypersplenism were enrolled. Sarcopenia was observed in 60.00 % (63/105) of these patients, 68.25 % (43/63) of male patients, and 31.75 % (20/63) of female patients. In cirrhotic patients, no significant change in the mean SMI at the third lumbar vertebra (L3) level after PSAE. In patients with sarcopenia, the L3 SMI increased from 36.77 cm2/m2 (baseline) to 43.38 cm2/m2 (P < 0.01), the L3 subcutaneous fat area (SFA) increased from 79.16 cm2 (baseline) to 103.52 cm2 (P < 0.01) at 12-month follow-up after PSAE. In patients without sarcopenia, the L3 SMI decreased from 58.38 cm2/m2 (baseline) to 49.44 cm2/m2 (P < 0.05), the L3 SFA increased from 89.63 cm2 (baseline) to 94.77 cm2 (P > 0.05) at 12-month follow-up after PSAE. Univariate and multivariate analysis demonstrated splenic infarction rate (OR: 0.01, P = 0.0032) and SMI (OR: 0.84, P < 0.001) were independent predictors for an improvement in skeletal muscle in patients with sarcopenia.

CONCLUSIONS

In cirrhotic patients with sarcopenia, an improvement in skeletal muscle and fat mass was observed after PSAE; splenic infarction rate and the L3 SMI before PSAE predicted an improvement in skeletal muscle index in patients with sarcopenia after PSAE.

Development and validation of an explainable machine learning model for predicting multidimensional frailty in hospitalized patients with cirrhosis

We sought to develop and validate a machine learning (ML) model for predicting multidimensional frailty based on clinical and laboratory data. Moreover, an explainable ML model utilizing SHapley Additive exPlanations (SHAP) was constructed. This study enrolled 622 patients hospitalized due to decompensating episodes at a tertiary hospital. The cohort data were randomly divided into training and test sets. External validation was carried out using 131 patients from other tertiary hospitals. The frail phenotype was defined according to a self-reported questionnaire (Frailty Index). The area under the receiver operating characteristics curve was adopted to compare the performance of five ML models. The importance of the features and interpretation of the ML models were determined using the SHAP method. The proportions of cirrhotic patients with nonfrail and frail phenotypes in combined training and test sets were 87.8% and 12.2%, respectively, while they were 88.5% and 11.5% in the external validation dataset. Five ML algorithms were used, and the random forest (RF) model exhibited substantially predictive performance. Regarding the external validation, the RF algorithm outperformed other ML models. Moreover, the SHAP method demonstrated that neutrophil-to-lymphocyte ratio, age, lymphocyte-to-monocyte ratio, ascites, and albumin served as the most important predictors for frailty. At the patient level, the SHAP force plot and decision plot exhibited a clinically meaningful explanation of the RF algorithm. We constructed an ML model (RF) providing accurate prediction of frail phenotype in decompensated cirrhosis. The explainability and generalizability may foster clinicians to understand contributors to this physiologically vulnerable situation and tailor interventions.

A sex-oriented analysis concerning skeletal muscle quantity and quality and associations to quality of life in hospitalized patients with cirrhosis

BACKGROUND

There is a paucity of data regarding sex-oriented analyses of connection between muscle quantity and quality and health-related quality of life (HRQoL), taking into account the pathophysiological differences of sarcopenia/myosteatosis in males versus females. We sought to investigate the associations between skeletal muscle index (SMI)-defined sarcopenia and intramuscular adipose tissue content (IMAC)-defined myosteatosis and EuroQol-5D (EQ-5D)-defined HRQoL in patients with decompensated cirrhosis concerning sex disparities.

METHODS

Totally, 382 patients were enrolled. The relationship between SMI/IMAC and HRQoL was evaluated with restricted cubic spline and Pearson correlation analyses. Furthermore, association between SMI or sarcopenia and EQ-5D utility index was determined by multiple linear regression, adjusted for age, BMI and concurrent disease severity.

RESULTS

The study population comprised evenly distributed male and female patients (190: 192), mean age 61.9 years. The prevalence of sarcopenia (40.5 versus 9.9%, P < 0.001) and SMI (48.8 versus 42.2 cm2/m2, P < 0.001) were significantly higher in males relative to females, with comparable myosteatosis prevalence (15.3 versus 16.7%, P = 0.708). Self-care, usual activities and pain within EQ-5D scale were more prevalent in the sarcopenia compared with non-sarcopenia groups across entire population and stratified by sex. The SMI values exhibited a significantly linear correlation with EQ-5D utility index in male but not female patients (P for non-linearity = 0.281). In multiple analysis, SMI or the presence of sarcopenia was both significantly associated with EQ-5D utility index. Subgroup analyses unveiled no discernible interactions between sarcopenia and EQ-5D utility index.

CONCLUSIONS

Muscle quantity measured by SMI was associated with declined HRQoL in males rather than females, whereas no associations were found regarding muscle quality measured by IMAC in both sexes. It is tempting to manage sarcopenia by increasing SMI levels as high as possible in hopes of achieving better health consequence. Our findings represent the importance of connecting CT-demarcated body composition abnormalities to meaningful patient-centered outcomes. Future targeted studies with sizable multi-center populations are warranted to clarify this causality, and in consequence develop optimized intervention against sarcopenia/myosteatosis or key determinants concerning impaired HRQoL.

Visual Analysis of Hot Topics and Trends in Nutrition for Decompensated Cirrhosis Between 1994 and 2024

OBJECTIVE

An updated summary of the research profile of nutrition for the last 30 years for decompensated cirrhosis is lacking. This study aimed to explore the literature on nutrition for decompensated cirrhosis, draw a visual network map to investigate the research trends, and provide suggestions for future research. The Web of Science database retrieves the literature on nutrition for decompensated cirrhosis between 1994 and 2024.

METHODS

We used the cooperative, co-occurrence, and co-citation networks in the CiteSpace knowledge graph analysis tool to explore and visualize the relevant countries, institutions, authors, co-cited journals, keywords, and co-cited references.

RESULTS

We identified 741 articles on nutrition for decompensated cirrhosis. The number of publications and research interests has generally increased. The USA contributed the largest number of publications and had the highest centrality. The University of London ranked first in the number of articles issued, followed by the University of Alberta and Mayo Clinic. TANDON P, a "core strength" researcher, is a central hub in the collaborative network. Of the cited journals, HEPATOLOGY had the highest output (540, 15.3%).

CONCLUSIONS

Over the past three decades, the focus of research on nutrition in decompensated cirrhosis has shifted from "hepatic encephalopathy, intestinal failure, metabolic syndrome, and alcoholic hepatitis" to "sarcopenia and nutritional assessment." In the future, nutritional interventions for sarcopenia should be based on a multimodal approach to address various causative factors. Its targeted treatment is an emerging area that warrants further in-depth research.

Quality measures in pre-liver transplant care by the Practice Metrics Committee of the American Association for the Study of Liver Diseases

The liver transplantation (LT) evaluation and waitlisting process is subject to variations in care that can impede quality. The American Association for the Study of Liver Diseases (AASLD) Practice Metrics Committee (PMC) developed quality measures and patient-reported experience measures along the continuum of pre-LT care to reduce care variation and guide patient-centered care. Following a systematic literature review, candidate pre-LT measures were grouped into 4 phases of care: referral, evaluation and waitlisting, waitlist management, and organ acceptance. A modified Delphi panel with content expertise in hepatology, transplant surgery, psychiatry, transplant infectious disease, palliative care, and social work selected the final set. Candidate patient-reported experience measures spanned domains of cognitive health, emotional health, social well-being, and understanding the LT process. Of the 71 candidate measures, 41 were selected: 9 for referral; 20 for evaluation and waitlisting; 7 for waitlist management; and 5 for organ acceptance. A total of 14 were related to structure, 17 were process measures, and 10 were outcome measures that focused on elements not typically measured in routine care. Among the patient-reported experience measures, candidates of LT rated items from understanding the LT process domain as the most important. The proposed pre-LT measures provide a framework for quality improvement and care standardization among candidates of LT. Select measures apply to various stakeholders such as referring practitioners in the community and LT centers. Clinically meaningful measures that are distinct from those used for regulatory transplant reporting may facilitate local quality improvement initiatives to improve access and quality of care.

Frailty and sarcopenia in patients with acute-on-chronic liver failure: Assessment and risk in the liver transplant setting

Frailty and sarcopenia are well-recognized factors related to worse outcomes in patients with cirrhosis, including liver transplant (LT) candidates. Implications of pre-LT functional and muscle deterioration also affect post-LT outcomes. Patients with cirrhosis and acute-on-chronic liver failure (ACLF) have a lower survival rate, both before and after LT. There is a need to better identify those patients with ACLF who would benefit from LT. This review aims to present the available data about frailty and sarcopenia in patients with ACLF in the LT setting. An exhaustive review of the published literature was conducted. Data regarding frailty and sarcopenia in LT candidates with ACLF are scarce and heterogeneous. Studies evaluating frailty and sarcopenia in critically ill patients outside the liver literature are also presented in this review to enrich the knowledge of this field in expansion. Frailty and sarcopenia seem to contribute to worse outcomes in LT candidates with ACLF, both before and after LT. Sarcopenia evaluation may be the most prudent approach for those very sick patients. Skeletal muscle index assessed by computed tomography is recommended to evaluate sarcopenia. The role of muscle ultrasound and bioelectrical impedance analysis is to be determined. Frailty and sarcopenia are crucial factors to consider on a case-by-case basis in LT candidates with ACLF to improve patient outcomes.

Impact of Sarcopenia on Post-Liver Transplant Hospitalization: Insights From a South Asian Cohort

BACKGROUND

Sarcopenia's impact on post-liver transplant outcomes remains a subject of debate, with limited data from South Asia on its association with post-liver transplant hospital stays. This study aims to investigate sarcopenia's influence on post-transplant hospitalization duration in South Asians.

METHODS

In this retrospective study, patients with liver cirrhosis who underwent living-donor liver transplantation (LDLT) at Shifa International Hospital in Islamabad, Pakistan, between January 2022 and January 2023 were included. Computed tomography (CT) images were used to assess the skeletal muscle index (SMI). The areas of the psoas, erector spinae, multifidus, quadratus lumborum, rectus abdominis, transverse abdominis, and internal/external oblique muscles were quantified at the level of L3. The data were analyzed using SPSS version 29.0 (IBM).

RESULTS

There was a total of 84 patients. Mean age was 47.4 ± 12.0 years. There were 62 (73.8%) male patients and 22 (26.2%) female patients. Hepatitis C was noted in 36 (42.9%) patients. Twenty-two (26.2%) patients had hepatocellular carcinoma. Sarcopenia was identified in 58 (69.0%) patients. No significant association was observed between sarcopenia and intensive care unit (ICU) or general floor stays. Regression analysis identified pre-transplant model for end-stage liver disease-sodium (MELD-Na) score as the sole significant factor associated with both ICU and total length of stay (P value .002; P value .009).

CONCLUSION

In our population, sarcopenia did not correlate with post-transplant ICU or overall hospital stay. The pre-transplant MELD-Na score emerged as the most influential predictor of length of stay. Therefore, delaying liver transplant procedures based on muscle mass estimations may not be a practical clinical approach for South Asian patients.

Inadequate Dietary Education and Poor Adherence to a High Protein, Low Sodium Diet in Cirrhosis: Mixed Methods Approach

BACKGROUND

Malnutrition in cirrhosis is associated with poor outcomes, leading to guidelines for a high protein, low sodium diet; however, there is no guidance regarding the implementation of diet education in clinical practice.

METHODS

A mixed methods study enrolled 21 patients with cirrhosis and their caregivers. Semi-structured interviews on barriers and facilitators of dietary education and adherence were conducted. Demographic and clinical data were obtained, along with quantitative measures of dietary adherence, including 24-h food recall and spot urine sodium. Combined deductive and inductive coding was used to identify qualitative themes, along with a quantitative assessment of interviews. Quantitative data was reported using descriptive statistics with frequencies, mean and confidence intervals.

RESULTS

Participants were mostly male (16/21) with a mean age 57.8 years (SE 2.8) and MELD-Na 9 (SE 1.2). 4 themes emerged: 1. More than 50% of participants and caregivers endorsed no or inadequate diet education 2. They reported mostly negative experiences with dietary adherence with largest impact on social life 3. Facilitators of adherence included the presence of household support and fear of complications of cirrhosis 4. Overwhelmingly desired non-generic handouts and information. Dietary adherence was poor with only one participant meeting protein and sodium requirements based on food recall. Four participants who adhered to < 2000 mg sodium had inadequate daily caloric intake.

CONCLUSIONS

Dietary education is inadequate, and adherence to dietary recommendations is poor in patients with cirrhosis. Future studies should use these barriers and facilitators for intervention development.

Bisphosphonate effectiveness in patients with cirrhosis: An emulated clinical trial

BACKGROUND

Falls and fractures are common and morbid for patients with cirrhosis. Bisphosphonates are recommended for the prevention of fractures for people with osteoporosis cirrhosis; however, data supporting effectiveness in cirrhosis are lacking.

AIM

We sought to emulate a clinical trial of bisphosphonates in cirrhosis.

METHODS

We used national Medicare data (2008-2020) to examine the 5-year risk of fractures in patients who did or did not receive bisphosphonates with a new-user design among people diagnosed with cirrhosis and osteoporosis. We balanced treated and untreated with inverse probability of treatment weighting, evaluated intention-to-treat and as-treated effects, and examined both control exposures (statin use) and outcomes (decompensation) to test causal relationships.

RESULTS

There were 253 and 20,888 new users and non-users of bisphosphonates, respectively. The median age was 74 years. The most common bisphosphonate used was alendronate (73.6%). Bisphosphonates significantly reduced fractures overall (27.5% vs. 33.0%, p = 0.0004) in the intention-to-treat analysis, particularly for people <65 years (sHR 0.56) old, men (sHR 0.64) and those with non-alcohol related liver disease (sHR 0.85). Though there were fewer arm (20.7% vs. 26.4%, p < 0.0001) and femur (28.9% vs. 31.2%, p = 0.005), there were more spinal (25.8% vs. 19.0%), rib (40.0% vs. 32.2%) and skull (10.1% vs. 8.7%) fractures. In the as-treated analysis, cumulative bisphosphonate exposure significantly reduced fractures, sHR 0.95 95% CI (0.91, 0.98). Treatment was inconsistent; bisphosphonate users spent 29.9% person-years of follow-up on the drug.

CONCLUSION

In a nationally representative cohort of elderly patients with cirrhosis, bisphosphonates reduced fractures overall. Efforts to increase uptake and drug continuation are needed.

Frailty and sarcopenia in patients with cirrhosis awaiting liver transplantation: evidence from a single-centre, prospective cohort study

Sarcopenia and frailty are common complications in patients with cirrhosis evaluated for liver transplantation (LT). Although the negative impact of sarcopenia on patient's outcome has been well studied, the prognostic role of frailty is not as clear. We assessed the prevalence of sarcopenia and frailty and the clinical impact of frailty in a prospective cohort of cirrhosis patients with and without hepatocellular carcinoma (HCC) listed for LT. Patients with cirrhosis were prospectively recruited at the time of admission into the waiting list. Clinical and lab values were collected. Physical frailty was assessed by liver frailty index (LFI) and patients were categorized into robust (< 3.2); pre-frail (between 3.2 and 4.5), and frail (> 4.5). Skeletal muscle mass was evaluated via skeletal muscle index (SMI) obtained from last CT scan before LT; sarcopenia was defined by SMI < 50 cm2/m2 in males and < 39 cm2/m2 in females. 105 patients were included, of which 42 (40%) had hepatocellular carcinoma (HCC). In patients without HCC (63.5% males, median age 61 years), 36.5% were frail, 50.8% were pre-frail and 12.7% were robust. Frail patients were older than non-frail patients (63 vs. 56; p = 0.008) and had more severe liver disease (Child C: 65% vs. 37.5%; p = 0.02). Prevalence of sarcopenia in patients without HCC was 63%, with similar value of median SMI between frail and not frail patients (p = 0.454). Patients with HCC (78.6% males, 65 years old) were 21.4% frail, 61.9% pre-frail, and 16.7% robust. Frail patients had more severe liver disease (Child C: 77% vs. 18.2%; p = 0.004), whereas age was comparable to non-frail patients; among patients without HCC, during a median follow-up of 263 days, 17% died (of which 72% were frail) and 10 patients were delisted due to clinical improvement (none of whom were frail). Among those with HCC, during a median follow-up of 289 days, 4 (9%) patients died of which 50% were frail. Frailty and sarcopenia are common complications in patients with cirrhosis awaiting LT. Frailty appears to be associated with an increased risk of mortality during wait-list time especially in those with decompensated cirrhosis. At univariate analysis Meld score, Child score and presence of frailty were found to be associated with shorter survival, however, at multivariate analysis presence of frailty and Child C vs. A/B were the only independent predictor of death. Larger cohorts are required to confirm these results.

EASL-EASD-EASO Clinical Practice Guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD)

Metabolic dysfunction-associated steatotic liver disease (MASLD), previously termed non-alcoholic fatty liver disease (NAFLD), is defined as steatotic liver disease (SLD) in the presence of one or more cardiometabolic risk factor(s) and the absence of harmful alcohol intake. The spectrum of MASLD includes steatosis, metabolic dysfunction-associated steatohepatitis (MASH, previously NASH), fibrosis, cirrhosis and MASH-related hepatocellular carcinoma (HCC). This joint EASL-EASD-EASO guideline provides an update on definitions, prevention, screening, diagnosis and treatment for MASLD. Case-finding strategies for MASLD with liver fibrosis, using non-invasive tests, should be applied in individuals with cardiometabolic risk factors, abnormal liver enzymes, and/or radiological signs of hepatic steatosis, particularly in the presence of type 2 diabetes (T2D) or obesity with additional metabolic risk factor(s). A stepwise approach using blood-based scores (such as FIB-4) and, sequentially, imaging techniques (such as transient elastography) is suitable to rule-out/in advanced fibrosis, which is predictive of liver-related outcomes. In adults with MASLD, lifestyle modification - including weight loss, dietary changes, physical exercise and discouraging alcohol consumption - as well as optimal management of comorbidities - including use of incretin-based therapies (e.g. semaglutide, tirzepatide) for T2D or obesity, if indicated - is advised. Bariatric surgery is also an option in individuals with MASLD and obesity. If locally approved and dependent on the label, adults with non-cirrhotic MASH and significant liver fibrosis (stage ≥2) should be considered for a MASH-targeted treatment with resmetirom, which demonstrated histological effectiveness on steatohepatitis and fibrosis with an acceptable safety and tolerability profile. No MASH-targeted pharmacotherapy can currently be recommended for the cirrhotic stage. Management of MASH-related cirrhosis includes adaptations of metabolic drugs, nutritional counselling, surveillance for portal hypertension and HCC, as well as liver transplantation in decompensated cirrhosis.

Evaluation of Five Screening Tools in Detecting Physical Frailty in Cirrhosis and Their Prognostic Role

Background: Physical frailty (PF) is a syndrome of decreased physical function and reserves, preventing patients from coping with stressful events. PF screening tools in patients with liver cirrhosis (LC) can help evaluate the risk of complications and death. The aim of this study was to assess the performance of five screening tools in detecting PF and their ability to predict 18-month mortality in LC. Methods: The Short Physical Performance Battery (SPPB), Fried frailty phenotype (FFP), Clinical Frailty Scale (CFS) and 6-Minute Walk Test (6MWT) were compared with the Liver Frailty Index (LFI) as the method of reference. Patients with an LFI ≥ 4.5, SPPB ≤ 8, FFP ≥ 3, CFS ≥ 6 points, and those walking <250 m, were considered frail. Results: A total of 109 consecutive patients with stable LC were included [63.3% male, median age 62 years, (IQR 52-70), MELD 9 (7-14.5), 46.8% with decompensated LC (DC)]. PF was present in 23.9%, 27.5%, 41.3%, 13.8%, and 28.4% as assessed by the LFI, SPPB, FFP, CFS, and 6MWT, respectively. Cohen's kappa measurement of agreement of four of the tools with LFI was 0.568, 0.334, 0.439, and 0.502, respectively (p < 0.001 for each). Kaplan-Meier survival curves at 18 months showed higher mortality in frail patients compared to non-frail patients by any method (log rank p < 0.05). In the multivariate models, PF defined by any method emerged as an independent prognostic factor of 18-month mortality after adjustment for age, gender, and MELD-score. Conclusions: Patients characterized as frail by five screening tools were not identical. However, PF defined by either method was proven to be an independent poor prognostic factor for long-term mortality after adjustment for covariates.

Muscle mass dynamics is independently associated with long-term liver-related mortality in patients with cirrhosis

Objectives

Sarcopenia has a detrimental impact on the prognosis of individuals with liver cirrhosis, however, the clinical significance of alterations in muscle mass remains uncertain. This study aims to investigate the influence of loss of skeletal muscle mass (LSMM) on the prognostic outcomes among patients diagnosed with cirrhosis.

Methods

In this retrospective analysis, a total of 158 individuals with cirrhosis who visited our hospital during the period from January 2018 to August 2023 were included. Computed tomography was utilized to measure the cross-sectional area of the skeletal muscles at the level of the third lumbar vertebra. This measurement enabled the determination of the skeletal muscle index for the purpose of diagnosing sarcopenia. The annual relative change in skeletal muscle area (ΔSMA/y) was calculated for each patient, and LSMM was defined as ΔSMA/y < 0. To assess the risk factors associated with liver-related mortality, a competing risk model was applied.

Results

Of the 158 cirrhotic patients, 95 (60.1 %) patients were identified as LSMM. The median of ΔSMA/y% was -0.9 (interquartile range [IQR], -3.8, 1.6) in all patients. Chronic kidney disease (CKD) was confirmed as a risk factor of LSMM. During a median follow-up period of 68.1 (IQR, 43.5, 105.0) months, 57 patients (36.1 %) died due to the liver-related diseases. The competing risk model found that LSMM was significantly associated with liver-related mortality in cirrhotic patients (hazard ratio [HR], 1.86; 95 % CI, 1.01-3.44, p = 0.047). Cumulative survival was significantly higher in patients without LSMM than in those with LSMM (p = 0.004). Survival rates at 1-, 3-, and 5-years were 96.8 %, 81.0 %, and 65.1 %, respectively, in patients without LSMM, and 97.9 %, 80.0 %, and 56.8 %, respectively, in patients with LSMM.

Conclusion

The utilization of LSMM can be valuable in the prediction of liver-related mortality among individuals diagnosed with liver cirrhosis. Paying attention to the management of skeletal muscle might play a role in enhancing the prognosis of patients with cirrhosis.

Clinical relevance statement

This study provides an additional indicator-LSMM for clinicians to help predict the liver-related mortality in patients diagnosed with cirrhosis.

Advances in the management of complications from cirrhosis

Cirrhosis with complications of liver decompensation and hepatocellular carcinoma (HCC) constitute a leading cause of morbidity and mortality worldwide. Portal hypertension is central to the progression of liver disease and decompensation. The most recent Baveno VII guidance included revision of the nomenclature for chronic liver disease, termed compensated advanced chronic liver disease, and leveraged the use of liver stiffness measurement to categorize the degree of portal hypertension. Additionally, non-selective beta blockers, especially carvedilol, can improve portal hypertension and may even have a survival benefit. Procedural techniques with interventional radiology have become more advanced in the management of refractory ascites and variceal bleeding, leading to improved prognosis in patients with decompensated liver disease. While lactulose and rifaximin are the preferred treatments for hepatic encephalopathy, many alternative treatment options may be used in refractory cases and even procedural interventions such as shunt embolization may be of benefit. The approval of terlipressin for the treatment of hepatorenal syndrome (HRS) in the USA has improved the way in which HRS is managed and will be discussed in detail. Malnutrition, frailty, and sarcopenia lead to poorer outcomes in patients with decompensated liver disease and should be addressed in this patient population. Palliative care interventions can lead to improved quality of life and clinical outcomes. Lastly, the investigation of systemic therapies, in particular immunotherapy, has revolutionized the management of HCC. These topics will be discussed in detail in this review.

Dysphagia risk evaluated by the Eating Assessment Tool-10 is associated with health-related quality of life in patients with chronic liver disease

OBJECTIVE

This study aimed to reveal the prevalence and characteristics of individuals at risk of dysphagia in patients with chronic liver disease (CLD) and its association with health-related quality of life (HRQOL).

METHODS

This cross-sectional study included 335 outpatients with CLD. Dysphagia risk, sarcopenia risk, malnutrition risk, and HRQOL were assessed using the Eating Assessment tool-10 (EAT-10), SARC-F, Royal Free Hospital-Nutrition Prioritizing Tool (RFH-NPT), and Chronic Liver Disease Questionnaire (CLDQ), respectively. Dysphagia risk and low HRQOL were based on EAT-10 ≥3 and CLDQ overall score <5, respectively. Factors associated with dysphagia risk and low HRQOL were assessed using the logistic regression model.

RESULTS

Dysphagia risk and lower HRQOL were observed in 10% and 31% of the patients, respectively. Patients with dysphagia risk were older, had lower liver functional reserve, were at higher risk for sarcopenia and malnutrition, and showed lower CLDQ overall score (median, 4.41 vs. 5.69; P < 0.001) than those without. After adjustment, SARC-F (odds ratio [OR], 1.24; 95% confidence interval [CI], 1.02-1.50; P = 0.029) and RFH-NPT (OR, 1.71; 95% CI, 1.04-2.81; P = 0.034) scores were independently associated with dysphagia risk. EAT-10 (OR, 1.17; 95% CI, 1.04-1.30; P = 0.008) and SARC-F (OR, 1.37; 95% CI, 1.18-1.59; P < 0.001) scores were also independently associated with low HRQOL.

CONCLUSIONS

Dysphagia risk was prevalent in approximately 10% of patients with CLD and was associated with a risk of sarcopenia and malnutrition. Furthermore, dysphagia risk was related to HRQOL in patients with CLD.

Sarcopenia evaluated by EASL/AASLD computed tomography-based criteria predicts mortality in patients with cirrhosis: A systematic review and meta-analysis

Background & Aims

Sarcopenia is associated with increased morbidity and mortality in patients with cirrhosis, but its definition in current literature is very heterogeneous. We performed a systematic review and meta-analysis to assess the association between mortality and sarcopenia evaluated by computed tomography (CT) in patients with cirrhosis, both overall and stratified for the criteria used to define sarcopenia.

Methods

Medline, Embase, Scopus, and Cochrane Library were searched up to January 2023. We included studies assessing sarcopenia presence with CT scans and providing data on the risk of mortality. Adjusted hazard ratios (HRs) and 95% CIs were pooled using a random-effects model.

Results

Thirty-nine studies comprising 12,827 patients were included in the meta-analysis. The summary prevalence of sarcopenia was 44% (95% CI 38-50%). The presence of sarcopenia (any definition) was an independent predictor of mortality with an adjusted HR of 2.07 (95% CI 1.81-2.36), and the result was consistent in all subgroup analyses. The prognostic role of the EASL/AASLD criteria was confirmed for the first time with an HR of 1.86 (95% CI 1.53-2.26) (n = 14 studies). The cut-offs used to define sarcopenia based on psoas muscle parameters varied among studies, thus, a subgroup analysis was not feasible. There was no substantial heterogeneity for the main estimates and no significant risk of publication bias.

Conclusions

Sarcopenia on CT is associated with a 2-fold higher risk of mortality in patients with cirrhosis. The cut-offs proposed by EASL/AASLD are prognostically relevant and should be the recommended criteria used to define sarcopenia in clinical practice.

Impact and implications

Sarcopenia assessed by the reference standard (computed tomography scan) is an independent predictor of mortality in patients with cirrhosis, with a 2-fold increase in the risk of death in all sensitivity analyses. This finding is particularly valid in patients from Europe and North America, and in transplant candidates. Stratifying for the parameters and cut-offs used, we confirmed for the first time the prognostic impact of the definition proposed by EASL/AASLD, supporting their use in clinical practice. Psoas muscle assessment is promising, but data are still limited and too heterogeneous to recommend its routine use at present.