Sarcopenia as a prognostic predictor of liver cirrhosis: a multicentre study in China

Impact of sarcopenia on variceal rebleeding in patients after endoscopic therapy: a multicenter retrospective cohort study based on propensity score matching

BACKGROUND

Sarcopenia is a common complication of liver cirrhosis and can be used for predicting dismal prognostic outcomes. This study aimed to evaluate the role of sarcopenia in rebleeding and mortality of liver cirrhosis patients after endoscopic therapy.

METHODS

The liver cirrhosis patients who received endoscopic treatment were enrolled. Propensity score matching (PSM) was used to overcome selection bias. Two-year rebleeding episodes and mortality after endoscopic therapy were recorded.

RESULTS

A total of 109 (32.4%) sarcopenia patients were reported. Before PSM, the frequency of rebleeding was significantly higher in the sarcopenia group relative to the non-sarcopenia group (41.3% vs. 15.9%, p < 0.001). Moreover, the multivariable analysis revealed that sarcopenia (p < 0.001, HR:2.596, 95% CI 1.591-4.237) was independently associated with a 2-year rebleeding episode. After PSM, the sarcopenia group exhibited an increased rebleeding rate as compared with non-sarcopenia group (44.4% vs. 15.3%, p < 0.001). According to multivariable analysis, sarcopenia (p < 0.001, HR:3.490, 95% CI 1.756-6.938) was identified as a significant predictor for 2-year rebleeding.

CONCLUSION

Sarcopenia was significantly associated with a high 2-year rebleeding rate in liver cirrhosis patients after endoscopic treatment. Therefore, the precise evaluation of a patient's nutritional status, including sarcopenia becomes mandatory before endoscopic treatment.

The relationship between imaging-based body composition abnormalities and long-term mortality in patients with liver cirrhosis

BACKGROUND

Emerging evidence on cirrhosis suggests a close correlation between abnormality in body composition characteristics and poor prognosis. This study aimed to evaluate the impact of dynamic changes in body composition on the prognostic outcomes in patients with cirrhosis.

METHODS

This retrospective analysis included 158 patients diagnosed as cirrhosis from January 2018 to August 2023. Skeletal muscle mass, muscle quality, visceral and subcutaneous adiposity were evaluated using computed tomography (CT) imaging at the third lumbar vertebra level. Competing risk model was performed four different body composition status (i.e., normal, only sarcopenia, only myosteatosis, and combined status) for liver-related mortality. We also explored the relationship between the dynamic change in body composition and long-term prognosis by applying Gray's test.

RESULTS

Of the 158 cirrhotic patients (mean [SD] age, 57.1 [12.6] years), sarcopenia was present in 85 (60.1 %) patients, while 22 (13.9 %) patients had sarcopenic obesity and 68 (43.0 %) had myosteatosis. Patients solely diagnosed with sarcopenia exhibited a higher mortality rate compared to those with normal body composition (Gray's test, P=0.006), while patients solely diagnosed with myosteatosis or with a combination of sarcopenia and myosteatosis did not reach statistical significance (Gray's test, P=0.076; P=0.140). Multivariable analysis also revealed that VSR (HR=1.10 [1.01∼1.20]; P=0.028), sarcopenia (HR=2.73 [1.20∼6.22], P=0.017) and myosteatosis (HR=2.39 [1.10∼5.18], P=0.028) were significant independent predictors of liver-related deaths. Otherwise, patients exhibiting aggravating body composition during follow-up period were associated with a significantly higher mortality risk compared to those with normal or remission body composition status (HR=7.63 [1.12∼51.14]; P=0.036).

CONCLUSION

Progressive alterations in body composition status appears to be associated with liver-related mortality in individuals with liver cirrhosis. Focusing on the management of skeletal muscle, along with visceral and subcutaneous adiposity, may contribute to improving the prognosis of cirrhotic patients.

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.

Evaluating the role of sarcopenia and [18F]FDG PET/CT parameters in prognosis of pancreatic ductal adenocarcinoma

This study investigates the relationship between 18F-fluorodeoxyglucose ([18F]FDG) positron emission tomography/computed tomography (PET/CT) metabolic parameters, clinicopathological characteristics, and sarcopenia in patients with pancreatic ductal adenocarcinoma (PDAC) and evaluates their prognostic roles.

MATERIAL AND METHODS

The primary tumor's maximum standard uptake (SUVmax), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) values, as well as clinicopathological factors, were evaluated retrospectively. Computed tomography (CT) was used to assess the skeletal muscle index (SMI). Sarcopenia was defined based on SMI calculated at the third lumbar vertebra (L3). SMI cut-off values ​​for sarcopenia were accepted as 44.77 cm2/m2 for men and 32.50 cm2/m2 for women. The primary endpoint was the overall survival (OS). OS data were analyzed by the Kaplan-Meier method and compared using the log-rank test. To identify predictive factors for sarcopenia, multivariable logistic regression was used following univariable logistic regression. Cox proportional hazards regression analyses were used to find predictors of OS.

RESULTS

Of the 86 patients included in the study, 37 (43%) were diagnosed with sarcopenia. Compared with non-sarcopenic patients, sarcopenia was observed in older patients (P=0,028) and patients with lower body mass index (BMI) (p=0,001). Age and BMI independently predicted sarcopenia. Univariate analysis identified sarcopenia, advanced stage, and higher primary tumor TLG as significant predictors of overall survival. Multivariate Cox regression analysis revealed that the advanced tumor stage (p=0.017) and higher TLG (p=0,042) independently predicted OS. The median OS was 9.4 months in non-sarcopenic patients and 5.0 months in sarcopenic patients (p=0,021).

CONCLUSION

In this study cohort, advanced-stage disease and higher primary tumor TLG were identified as independent predictors of OS in patients with PDAC. Additionally, we emphasize the importance of incorporating [18F]FDG PET/CT-derived sarcopenia assessments into the prognostic evaluation and clinical management of PDAC patients. While sarcopenia was associated with shorter OS in univariate analysis, it was not an independent predictor in multivariate analysis.

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.

A clinical-radiomics nomogram for the prediction of the risk of upper gastrointestinal bleeding in patients with decompensated cirrhosis

Objective

To develop a model that integrates radiomics features and clinical factors to predict upper gastrointestinal bleeding (UGIB) in patients with decompensated cirrhosis.

Methods

104 decompensated cirrhosis patients with UGIB and 104 decompensated cirrhosis patients without UGIB were randomized according to a 7:3 ratio into a training cohort (n = 145) and a validation cohort (n = 63). Radiomics features of the abdominal skeletal muscle area (SMA) were extracted from the cross-sectional image at the largest level of the third lumbar vertebrae (L3) on the abdominal unenhanced multi-detector computer tomography (MDCT) images. Clinical-radiomics nomogram were constructed by combining a radiomics signature (Rad score) with clinical independent risk factors associated with UGIB. Nomogram performance was evaluated in calibration, discrimination, and clinical utility.

Results

The radiomics signature was built using 11 features. Plasma prothrombin time (PT), sarcopenia, and Rad score were independent predictors of the risk of UGIB in patients with decompensated cirrhosis. The clinical-radiomics nomogram performed well in both the training cohort (AUC, 0.902; 95% CI, 0.850-0.954) and the validation cohort (AUC, 0.858; 95% CI, 0.762-0.953) compared with the clinical factor model and the radiomics model and displayed excellent calibration in the training cohort. Decision curve analysis (DCA) demonstrated that the predictive efficacy of the clinical-radiomics nomogram model was superior to that of the clinical and radiomics model.

Conclusion

Clinical-radiomics nomogram that combines clinical factors and radiomics features has demonstrated favorable predictive effects in predicting the occurrence of UGIB in patients with decompensated cirrhosis. This helps in early diagnosis and treatment of the disease, warranting further exploration and research.

Chinese consensus on the management of liver cirrhosis

Liver cirrhosis, characterized by diffuse necrosis, insufficient regeneration of hepatocytes, angiogenesis, severe fibrosis, and the formation of pseudolobules, is a progressive, chronic liver disease induced by a variety of causes. It is clinically characterized by liver function damage and portal hypertension, and many complications may occur in its late stage. Based on the updated practice guidelines, expert consensuses, and research advances on the diagnosis and treatment of cirrhosis, the Chinese Society of Gastroenterology of Chinese Medical Association established the current consensus to standardize the clinical diagnosis and management of liver cirrhosis and guide clinical practice. This consensus contains 43 statements on the etiology, pathology and pathogenesis, clinical manifestations, major complications, diagnosis, treatment, prognosis, and chronic disease control of liver cirrhosis. Since several practice guidelines and expert consensuses on the complications of liver cirrhosis have been published, this consensus emphasizes the research progress of liver cirrhosis itself.

Screening and assessment of malnutrition in patients with liver cirrhosis

The development and advancement of malnutrition is associated not only with the progression of hepatic dysfunction, but also with cirrhosis-related complications. However, the prevalence of malnutrition reported in different studies varies widely due to differences in diagnostic methods and patient investigation settings. Therefore, we need to identify malnourished patients promptly and accurately. The purpose of this review was to compare the validity and reliability of nutritional screening tools and to select the most appropriate nutritional risk screening for patients with cirrhosis. We compared nutritional risk screening tools such as the Nutritional Risk Screening 2002 (NRS-2002), Malnutrition Universal Screening Tool (MUST), Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT) and Liver Disease Undernutrition Screening Tool (LDUST). Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT) is more feasible to screen cirrhotic patients for nutritional risk, and is highly reproducible, considering the impact of sodium and water retention; so it is practical to screen cirrhotic patients via RFH-NPT for nutritional risk, subsequently, to evaluate the nutritional status of patients with nutritional risk via the Global Leadership Initiative on Malnutrition (GLIM) diagnostic criteria. L3-SMI (third lumbar-skeletal muscle index) can accurately define sarcopenia in cirrhotic patients and also be used for clinical nutritional status assessment.

Ct-based diagnosis of sarcopenia as a prognostic factor for postoperative mortality after elective open-heart surgery in older patients: a cohort-based systematic review and meta-analysis

Background

Cardiac open-heart surgery, which usually involves thoracotomy and cardiopulmonary bypass, is associated with a high incidence of postoperative mortality and adverse events. In recent years, sarcopenia, as a common condition in older patients, has been associated with an increased incidence of adverse prognosis.

Methods

We conducted a search of databases including PubMed, Embase, and Cochrane, with the search date up to January 1, 2024, to identify all studies related to elective cardiac open-heart surgery in older patients. We used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence.

Results

A total of 12 cohort studies were included in this meta-analysis for analysis. This meta-analysis revealed that patients with sarcopenia had a higher risk of postoperative mortality. Furthermore, the total length of hospital stay and ICU stay were longer after surgery. Moreover, there was a higher number of patients requiring further healthcare after discharge. Regarding postoperative complications, sarcopenia patients had an increased risk of developing renal failure and stroke.

Conclusion

Sarcopenia served as a tool to identify high-risk older patients undergoing elective cardiac open-heart surgery. By identifying this risk factor early on, healthcare professionals took targeted steps to improve perioperative function and made informed clinical decisions.Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42023426026.

Prognostic value of 18F-FDG PET radiomics and sarcopenia in patients with oral squamous cell carcinoma

BACKGROUND

Oral cancer is one of the most common malignancies in the head and neck region. Approximately 90% of oral cancers are oral squamous cell carcinomas (OSCC). 18F-FDG PET/CT has been used in OSCC patients for its high value in detecting metastatic lymph nodes and distant metastases. PET radiomics and sarcopenia can be measured on the PET and CT components of 18F-FDG PET/CT.

PURPOSE

This study aimed to investigate the prognostic value of radiomics and sarcopenia measured on the PET and CT components of pre-operation 18F-FDG PET/CT in OSCC.

METHODS

A total of 116 patients eventually enrolled in our study were randomly divided into two cohorts: training cohort (n = 58) and validation cohort (n = 58). The Cox model combined with the least absolute shrinkage and selection operator (LASSO) algorithm was applied to construct the radiomics score (Rad_score). The third lumber skeletal muscle index (L3 SMI) was calculated to identify sarcopenia. Univariate and multivariate Cox regression analyses were performed to identify the independent prognostic factors. Based on the clinical factors, the clinical model was constructed, and the combined model was developed through the combination of the clinical model and Rad_score. C index, time-dependent C-index curves, receiver operating characteristic (ROC) curve, calibration curves, and decision curve analysis were used to evaluate the performance of prediction models.

RESULTS

Three radiomics features constitute the Rad_score for overall survival (OS) and progression-free survival (PFS), respectively. Multivariate Cox regression analysis revealed that Rad_score was an independent prognostic factor, whereas sarcopenia was not. The combined models showed satisfactory performance in both the training cohort (C-index: OS:0.836, PFS:0.776) and the validation cohort (C-index: OS:0.744, PFS:0.712). The combined models were visualized as nomograms. Nomogram scores can realize the risk stratification of OSCC patients. Lower nomogram score is significantly related to the poorer OS (training cohort: p < 0.0001, validation cohort: p < 0.0001, overall cohort: p < 0.0001) and PFS (training cohort: p < 0.0001, validation cohort: p = 0.00017, overall cohort: p < 0.0001).

CONCLUSIONS

Rad_score, but not sarcopenia, was an independent prognostic factor for patients with OSCC. The nomograms had a satisfactory performance, which might be helpful for OSCC patients and clinicians in personalized prognostic prediction and treatment decision-making.

Longitudinal changes in sarcopenia was associated with survival among cirrhotic patients

Background

Sarcopenia is common in patients with liver cirrhosis and is an independent predictor of multiple clinical outcomes. Most studies to date have used a static assessment of sarcopenia. However, there is very limited data evaluating the temporal course of muscle area in cirrhosis. To bridge this gap in clinical studies, we performed a longitudinal analysis to evaluate the impact of changes in sarcopenia for cirrhotic patients.

Methods

Adult patients with clinically diagnosed liver cirrhosis who underwent at least 2 abdominal computed tomography (CT) scans in the hospital were enrolled. The interval between the two abdominal scans was 6 ± 1 months. Patients were categorized into persistent non-sarcopenia, new-onset sarcopenia, sarcopenia to non-sarcopenia, and persistent sarcopenia based on changes in sarcopenia. Kaplan-Meier method and Log-rank tests were used to separately compare unadjusted survival curves by different statuses of sarcopenia. Cox regression analysis was performed to assess the associations between different states of sarcopenia and overall mortality. The association between persistent non-sarcopenia and new-onset sarcopenia was analyzed by multivariate logistic regression analysis.

Results

A total of 307 patients were included for analysis. At the second assessment, 10.10% (31/307) patients were new-onset sarcopenia, 27.69% (85/307) with persistent sarcopenia status, while 13.03% (40/307) patients with sarcopenia developed non-sarcopenia and 49.19% (151/307) with persistent non-sarcopenia status. The overall survival rate was significantly lower in the persistent sarcopenia and new-onset sarcopenia than in the non-sarcopenia group and sarcopenia to non-sarcopenia group (p < 0.001). Persistent sarcopenia (HR 5.799, 95%CI 1.563-21.521, p = 0.009) and new onset sarcopenia (HR 5.205, 95%CI 1.482-18.282, p = 0.010) were identified as poor prognostic factors for cirrhotic patients. The etiology of cirrhosis and the initial skeletal muscle mass were independent risk factors for new-onset sarcopenia.

Conclusion

Sarcopenia is a dynamically changing process in patients with cirrhosis. Persistent and new-onset sarcopenia were independently and robustly associated with overall survival.

Skeletal muscle alterations indicate poor prognosis in cirrhotic patients: a multicenter cohort study in China

INTRODUCTION

We aimed to determine the diagnostic criteria of myosteatosis in a Chinese population and investigate the effect of skeletal muscle abnormalities on the outcomes of cirrhotic patients.

METHODS

Totally 911 volunteers were recruited to determine the diagnostic criteria and impact factors of myosteatosis, and 480 cirrhotic patients were enrolled to verify the value of muscle alterations for prognosis prediction and establish new noninvasive prognostic strategies.

RESULTS

Multivariate analysis showed age, sex, weight, waist circumference, and biceps circumference had a remarkable influence on the L3 skeletal muscle density (L3-SMD). Based on the cut-off of a mean - 1.28 × SD among adults aged < 60 years, the diagnostic criteria for myosteatosis was L3-SMD < 38.93 Hu in males and L3-SMD < 32.82 Hu in females. Myosteatosis rather than sarcopenia has a close correlation with portal hypertension. The concurrence of sarcopenia and myosteatosis not only is associated with poor liver function but also evidently reduced the overall and liver transplantation-free survival of cirrhotic patients (p < 0.001). According to the stepwise Cox regression hazard model analysis, we established nomograms including TBil, albumin, history of HE, ascites grade, sarcopenia, and myosteatosis for easily determining survival probabilities in cirrhotic patients. The AUC is 0.874 (95% CI 0.800-0.949) for 6-month survival, 0.831 (95% CI 0.764-0.898) for 1-year survival, and 0.813 (95% CI 0.756-0.871) for 2-year survival prediction, respectively.

CONCLUSIONS

This study provides evidence of the significant correlation between skeletal muscle alterations and poor outcomes of cirrhosis, and establishes valid and convenient nomograms incorporating musculoskeletal disorders for the prognostic prediction of liver cirrhosis. Further large-scale prospective studies are necessary to verify the value of the nomograms.

Nutritional screening and assessment tools for patients with cirrhosis based on the Global Leadership Initiative on Malnutrition criteria

BACKGROUND

Malnutrition is highly prevalent and associated with complications and mortality in patients with cirrhosis.

METHODS

This was a prospective observational study. Patients with cirrhosis were screened using the Nutritional Risk Screening 2002, the Royal Free Hospital-Nutritional Prioritizing Tool and the Skeletal Muscle Index. Then, the sensitivity, specificity, positive and negative predictive values, and consistency with the Global Leadership Initiative on Malnutrition criteria results were calculated. We also analysed the association between nutritional status and short-term prognosis.

RESULTS

We enrolled 125 patients with cirrhosis, of whom 59.20% and 60.00% were malnourished based on the Global Leadership Initiative on Malnutrition criteria and Skeletal Muscle Index. Some 53.60% and 65.60%, respectively, were classified medium-to-high nutritional risk by Nutritional Risk Screening 2002 and the Royal Free Hospital-Nutritional Prioritizing Tool. The Royal Free Hospital-Nutritional Prioritizing Tool had the best predictive value, and it was more sensitive and had a better negative predictive value than the Nutritional Risk Screening 2002 Tool. The Skeletal Muscle Index also had good sensitivity and predictive value. The Royal Free Hospital-Nutritional Prioritizing Tool, Skeletal Muscle Index and Global Leadership Initiative on Malnutrition criteria showed high concordance. The 3- and 6-month mortality rates were significantly higher for patients with moderate-to-high nutritional risk or malnutrition, regardless of the tool.

CONCLUSIONS

When assessing cirrhosis with the Global Leadership Initiative on Malnutrition criteria, the Royal Free Hospital-Nutritional Prioritizing Tool is best for nutritional screening and the Skeletal Muscle Index is also a good nutritional assessment tool.

The association between hemoglobin level and sarcopenia in Chinese patients with Crohn's disease

Sarcopenia and anemia are common complications in patients with Crohn's Disease (CD). However, few studies have shown the association between sarcopenia and hemoglobin levels in CD patients. This retrospective study aimed to explore such association in Chinese patients with CD. Two hundred and twelve adult CD inpatients who underwent computed tomography (CT) or magnetic resonance imaging (MRI) examinations from July 2019 to December 2021 were included in the study. Sarcopenia was defined according to the cutoff value of skeletal muscle index of lumbar spine 3 (SMI-L3) (< 44.77cm2/m2 for males and < 32.5cm2/m2 for females). The CD patients were divided into two groups based on the presence or absence of sarcopenia. Clinical data, hemoglobin levels, and other laboratory data were retrospectively collected. The association between hemoglobin levels and sarcopenia was analyzed by univariable and multivariable logistic regression analysis. Sarcopenia occurred in 114 CD patients (53.8%). Compared to patients without sarcopenia, patients with sarcopenia had a lower proportion of L1 (30.7% vs. 45.8%, p = 0.032) and B1 classification (58.8% vs. 72.4%, p = 0.037). Patients with sarcopenia had significantly lower levels of hemoglobin (Hb) (116.5 ± 22.8 vs. 128.1 ± 21.0, p < 0.001). The prevalence of sarcopenia increased with the decrease in hemoglobin level (p for trend < 0.05). Linear regression analysis showed that hemoglobin levels were associated with SMI-L3 (β = 0.091, p = 0.001). Multivariable logistic regression analysis found that higher hemoglobin levels (OR:0.944; 95% CI: 0.947,0.998; p = 0.036) were independent protective factors for sarcopenia. Lower hemoglobin levels are independently associated factors of sarcopenia in adult Chinese patients with CD.

Implications of Sarcopenia and Glucometabolism Parameters of Muscle Derived From Baseline and End-of-Treatment 18F-FDG PET/CT in Diffuse Large B-Cell Lymphoma

OBJECTIVE

We previously found that the incidence of sarcopenia increased with declining glucose metabolism of muscle in patients with treatment-naïve diffuse large B-cell lymphoma (DLBCL). This study aimed to investigate the relationship between sarcopenia and muscle glucometabolism using 18F-FDG PET/CT at baseline and end-of-treatment, analyze the changes in these parameters through treatment, and assess their prognostic values.

MATERIALS AND METHODS

The records of 103 patients with DLBCL (median 54 years [range, 21-76]; male:female, 50:53) were retrospectively reviewed. Skeletal muscle area at the third lumbar vertebral (L3) level was measured, and skeletal muscle index (SMI) was calculated to determine sarcopenia, defined as SMI < 44.77 cm²/m² and < 32.50 cm²/m² for male and female, respectively. Glucometabolic parameters of the psoas major muscle, including maximum standardized uptake value (SUVmax) and mean standardized uptake value (SUVmean), were measured at L3 as well. Their changes across treatment were also calculated as ΔSMI, ΔSUVmax, and ΔSUVmean; Δbody mass index was also calculated. Associations between SMI and the metabolic parameters were analyzed, and their associations with progression-free survival (PFS) and overall survival (OS) were identified.

RESULTS

The incidence of sarcopenia was 29.1% and 36.9% before and after treatment, respectively. SMI (P = 0.004) was lower, and sarcopenia was more frequent (P = 0.011) at end-of-treatment than at baseline. The SUVmax and SUVmean of muscle were lower (P < 0.001) in sarcopenia than in non-sarcopenia at both baseline and end-of-treatment. ΔSMI was positively correlated with ΔSUVmax of muscle (P = 0.022). Multivariable Cox regression analysis showed that sarcopenia at end-of-treatment was independently negatively associated with PFS (adjusted hazard ratio [95% confidence interval], 2.469 [1.022-5.965]), while sarcopenia at baseline was independently negatively associated with OS (5.051 [1.453-17.562]).

CONCLUSION

Sarcopenic patients had lower muscle glucometabolism, and the muscular and metabolic changes across treatment were positively correlated. Sarcopenia at baseline and end-of-treatment was negatively associated with the prognosis of DLBCL.

Prevalence and effect on prognosis of sarcopenia in patients with primary biliary cholangitis

Background

Sarcopenia adversely affects the treatment outcomes in Cirrhosis and NAFLD. However, such research is limited in primary biliary cholangitis (PBC) patients. This study was performed to examine the prevalence of sarcopenia and its impact on PBC patients' prognoses.

Methods

This study enrolled confirmed PBC patients who had an abdominal CT scan. Sarcopenia was determined by the L3-skeletal muscle index with a Chinese population-based cut-off value. Laboratory test values and liver stiffness measurements values were obtained from the electronic medical records.

Results

In total, 174 PBC patients with a median age of 54 (IQR, 48, 62) years old, were enrolled. 45 (25.9%) patients among them were diagnosed with sarcopenia. Univariate and multivariate logistic regression results illustrated that male gender (OR = 9.152, 95%CI = 3.131-26.751, p < 0.001) and LSM ≥ 12.8 kPa (OR = 4.539, 95%CI = 1.651, 12.478, p = 0.003) were the independent risk factors of sarcopenia in PBC patients. In the prognosis analysis, sarcopenia was determined as a risk factor for indicating adverse events in PBC patients (HR = 4.058, 95%CI = 1.955-8.424, p < 0.001) by Cox proportional hazards regression.

Conclusion

The current findings illustrate that comprehensive evaluation and management of sarcopenia may contribute to the improvement of treatment outcomes and life quality of PBC patients.

Prevalence and clinical impact of sarcopenia in liver transplant recipients: A meta-analysis

BACKGROUND

The prevalence of sarcopenia in patients undergoing liver transplantation (LT) remains to be determined partly because of different diagnostic criteria. Sarcopenia has recently been recognized as a new prognostic factor for predicting outcomes in LT candidates.

AIM

To estimate the prevalence of sarcopenia and evaluate its clinical effect on LT candidates.

METHODS

This systematic search was conducted in PubMed, Web of Science, Embase, and Cochrane Library for original English-language articles that investigated the prevalence and influence of sarcopenia in patients undergoing LT from database inception to November 30, 2022. Cohort studies of the definition of sarcopenia that estimate sarcopenia prevalence and evaluate its effect on clinical outcomes and the risk of mortality were included.

RESULTS

Twenty-five studies involving 7760 patients undergoing LT were included. The pooled prevalence of sarcopenia in patients undergoing LT was 40.7% [95% confidence intervals (95%CI): 32.1-49.6]. The 1-, 3-, and 5-year cumulative probabilities of post-LT survival in patients with preoperative sarcopenia were all lower than those without sarcopenia (P < 0.05). Sarcopenia was associated with an increased risk of post-LT mortality in patients undergoing LT (adjusted hazard ratio: 1.58; 95%CI: 1.21-2.07). Patients with preoperative sarcopenia had a longer intensive care unit stay, a high risk ratio of sepsis, and serious post-LT complications than those without sarcopenia.

CONCLUSION

Sarcopenia is prevalent in a substantial proportion of patients undergoing LT and is strongly and independently associated with higher a risk of mortality risk.

Association of chronic liver disease with bone diseases and muscle weakness

The liver is a vital organ involved in nutrient metabolism, hormone regulation, immunity, cytokine production, and gut homeostasis. Impairment in liver function can result in malnutrition, chronic inflammation, decreased anabolic hormone levels, and dysbiosis. These conditions eventually cause an imbalance in osteoblast and osteoclast activities, resulting in bone loss. Osteoporosis is a frequent complication of chronic liver disease (CLD) that adversely affects quality of life and increases early mortality. Sarcopenia is another common complication of CLD characterized by progressive loss of skeletal muscle mass and function. Assessment criteria for sarcopenia specific to liver disease have been established, and sarcopenia has been reported to be associated with an increase in the risk of liver disease-related events and mortality in patients with CLD. Owing to their similar risk factors and underlying pathophysiological mechanisms, osteoporosis and sarcopenia often coexist (termed osteosarcopenia), progress in parallel, and further exacerbate the conditions mentioned above. Therefore, comprehensive management of these musculoskeletal disorders is imperative. This review summarizes the clinical implications and characteristics of osteoporosis, extending to sarcopenia and osteosarcopenia, in patients with CLD caused by different etiologies.

Correlation between sarcopenia and cirrhosis: a meta-analysis

Background

The relationship between sarcopenia and cirrhosis is unclear. In this research, our aim is to evaluate the prevalence of sarcopenia among individuals with liver cirrhosis and its correlation with survival and mortality risks.

Methods

We conducted searches on PubMed, Web of Science, EMBASE, and Cochrane for English articles published up to July 10, 2023, and additionally manually searched the bibliography of relevant articles. We incorporated research on sarcopenia in patients with cirrhosis to examine the connection between sarcopenia and the likelihood of survival and mortality. Statistical analyses were carried out utilizing the Stata version 15.1 software. Depending on the heterogeneity of the results, we employed either fixed-effects models or random-effects models for data synthesis. To assess publication bias, we employed funnel plots and conducted Egger's test.

Results

We included 40 studies involving 8,945 patients with cirrhosis. The overall prevalence of cirrhosis was 41% (95% CI 34%-48%). Male patients and those with liver cirrhosis and hepatic encephalopathy had a higher prevalence of sarcopenia (44% for male patients and 48% for hepatic encephalopathy patients). Sarcopenia emerged as a risk factor for both survival (HR = 2.57, 95% CI 2.02-3.27, p < 0.001) and mortality (HR = 2.13, 95% CI 1.86-2.44, p < 0.001) in patients with cirrhosis. Subgroup analyses consistently yielded the same results for study sites, whether HCC patients were excluded from the cohort, whether patients were from the liver transplant cohort or had undergone tips surgery, the definition of sarcopenia (L3-SMI or other methods), and the diagnostic criteria used by patients. The presence of sarcopenia was also a significant risk factor for hepatic encephalopathy [HR = 2.27, 95% CI (1.76-2.94), p < 0.001].

Conclusion

This systematic review and meta-analysis reveal that patients with cirrhosis have a prevalence of sarcopenia of 41% and is associated with survival rate and mortality rate. Therefore, we should attach importance to the screening of sarcopenia in patients with cirrhosis, early detection of susceptible populations, and appropriate measures to reduce the occurrence and adverse outcomes.Systematic review registration:https://www.crd.york.ac.uk/PROSPERO/#recordDetails.

Influence of subcutaneous adipose tissue index on prognosis in cirrhotic patients following endoscopic therapy: a retrospective cohort study

BACKGROUND

The relation of adipose tissue depletion with prognostic outcome of variceal bleeding among cirrhotic patients is still inconclusive. The present work explored whether adipose tissue, which was measured based on computed tomography (CT), was valuable for analyzing rebleeding and mortality among patients with variceal bleeding who had undergone endoscopic therapy.

METHODS

The study encompassed cirrhotic patients who underwent endoscopic therapy to prevent variceal rebleeding between January 2016 and October 2022. The L3-level CT images were obtained. Besides, impacts of subcutaneous adipose tissue index (SATI), visceral adipose tissue index (VATI), as well as total adipose tissue index (TATI) on rebleeding and mortality among cirrhotic patients following endoscopic therapy were examined.

RESULTS

In this work, our median follow-up period was 31 months. Among those adipose tissue indexes, only SATI exhibited an independent relation to higher rebleeding (HR 0.981, 95% CI, 0.971-0.991, p < 0.001) and mortality (HR 0.965, 95% CI, 0.944-0.986, p = 0.001) risks. Upon multivariate Cox regression, low SATI (male < 30.15 cm2/m2, female < 39.82 cm2/m2) was independently linked to higher rebleeding risk (HR 2.511, 95% CI, 1.604-3.932, p < 0.001) and increased mortality risk (HR 3.422, 95% CI, 1.489-7.864, p = 0.004) after adjusting for other predictors. Furthermore, subgroups were created based on using nonselective β-blockers (NSBBs), demonstrating that quantitatively assessing SATI exerts a vital role in evaluating rebleeding incidence in patients with or without NSBB therapy.

CONCLUSION

This study underscores the potential of quantifying SATI as a means for achieving a more accurate risk classification for individual patients and identifying patients that can gain more benefits from nutritional intervention.

Application of Global Leadership Initiative on Malnutrition criteria in patients with liver cirrhosis

BACKGROUND

The Global Leadership Initiative on Malnutrition (GLIM) criteria were published to build a global consensus on nutritional diagnosis. Reduced muscle mass is a phenotypic criterion with strong evidence to support its inclusion in the GLIM consensus criteria. However, there is no consensus regarding how to accurately measure and define reduced muscle mass in clinical settings. This study aimed to investigate the optimal reference values of skeletal muscle mass index for diagnosing sarcopenia and GLIM-defined malnutrition, as well as the prevalence of GLIM-defined malnutrition in hospitalized cirrhotic patients.

METHODS

This retrospective study was conducted on 1002 adult patients with liver cirrhosis between January 1, 2018, and February 28, 2022, at Beijing You-An Hospital, Capital Medical University. Adult patients with a clinical diagnosis of liver cirrhosis and who underwent an abdominal computed tomography (CT) examination during hospitalization were included in the study. These patients were randomly divided into a modeling group (cohort 1, 667 patients) and a validation group (cohort 2, 335 patients). In cohort 1, optimal cut-off values of skeletal muscle index at the third lumbar skeletal muscle index (L3-SMI) were determined using receiver operating characteristic analyses against in-hospital mortality in different gender groups. Next, patients in cohort 2 were screened for nutritional risk using the Nutritional Risk Screening 2002 (NRS-2002), and malnutrition was diagnosed by GLIM criteria. Additionally, the reference values of reduced muscle mass in GLIM criteria were derived from the L3-SMI values from cohort 1. Multivariate logistic regression analysis was used to analyze the association between GLIM-defined malnutrition and clinical outcomes.

RESULTS

The optimal cut-off values of L3-SMI were 39.50 cm 2 /m 2 for male patients and 33.06 cm 2 /m 2 for female patients. Based on the cut-off values, 31.63% (68/215) of the male patients and 23.3% (28/120) of the female patients had CT-determined sarcopenia in cohort 2. The prevalence of GLIM-defined malnutrition in cirrhotic patients was 34.3% (115/335) and GLIM-defined malnutrition was an independent risk factor for in-hospital mortality in patients with liver cirrhosis ( Wald = 6.347, P  = 0.012).

CONCLUSIONS

This study provided reference values for skeletal muscle mass index and the prevalence of GLIM-defined malnutrition in hospitalized patients with liver cirrhosis. These reference values will contribute to applying the GLIM criteria in cirrhotic patients.

Prevalence of and associated factors for sarcopenia in patients with liver cirrhosis: A systematic review and meta-analysis

BACKGROUND

Sarcopenia is associated with poor outcomes in patients with cirrhosis. However, the prevalence of and associated factors for developing sarcopenia in this population remain to be determined.

OBJECTIVES

This study aimed to summarize the prevalence, characteristics, and associated factors of sarcopenia in patients with cirrhosis.

METHODS

Electronic searches were performed from inception to June 9, 2022 to identify the eligible studies. We meta-analyzed the prevalence of sarcopenia in overall patients with cirrhosis and subgroups. Both crude and adjusted odds ratios (ORs) were pooled using the random effects model.

RESULTS

A total of 55 studies involving 13,158 patients from 17 countries were included. The overall prevalence of sarcopenia was 40.1 % (95 % CI 35.4%-44.9 %) in patients with cirrhosis. The pooled prevalence was higher in males, Child-Pugh class C cirrhosis, decompensated stage, ascites, subjective global assessment class C cirrhosis, and when sarcopenia was defined by L3-SMI (third lumbar-skeletal muscle index) at a higher cutoff. In multivariate analysis, older age (adjusted OR 1.04, 95 % CI 1.00-1.07), male (adjusted OR 4.75, 95 % CI 2.72-8.28), lower body mass index (BMI) (adjusted OR 0.78, 95 % CI 0.73-0.83), alcoholic liver disease (ALD) (adjusted OR 1.43, 95 % CI 1.19-1.72), but not ascites and hepatic encephalopathy, were significantly associated with an increased risk of sarcopenia in patients with cirrhosis.

CONCLUSION

Sarcopenia is a prevalent complication, and older age, male patients, lower BMI, and patients with ALD are associated with an increased risk of sarcopenia in patients with cirrhosis.

Portal Hypertension in Malnutrition and Sarcopenia in Decompensated Cirrhosis-Pathogenesis, Implications and Therapeutic Opportunities

Malnutrition and sarcopenia are highly prevalent in patients with decompensated cirrhosis and are associated with poorer clinical outcomes. Their pathophysiology is complex and multifactorial, with protein-calorie malnutrition, systemic inflammation, reduced glycogen stores and hormonal imbalances all well reported. The direct contribution of portal hypertension to these driving factors is however not widely documented in the literature. This review details the specific mechanisms by which portal hypertension directly contributes to the development of malnutrition and sarcopenia in cirrhosis. We summarise the existing literature describing treatment strategies that specifically aim to reduce portal pressures and their impact on nutritional and muscle outcomes, which is particularly relevant to those with end-stage disease awaiting liver transplantation.

Feasibility of using chest computed tomography (CT) imaging at the first lumbar vertebra (L1) level to assess skeletal muscle mass: a retrospective study

Background

Skeletal muscle mass is an essential parameter for diagnosing sarcopenia. The gold standard for assessing skeletal muscle mass is using computed tomography (CT) to measure skeletal muscle area at the third lumbar vertebra (L3) level. This study aims to investigate whether skeletal muscle mass could be evaluated at the first lumbar vertebra (L1) level using images obtained from routine chest CT scans.

Methods

Skeletal muscle index (SMI, cm2/m2) and skeletal muscle density (SMD, HU) are commonly used to measure relative muscle mass and the degree of fat infiltration. This study used CT images at the L1 level to measure the skeletal muscle area (SMA, cm2) in 815 subjects from the health examination center. Linear regression analysis was used to explore the association between L1 and L3 measurements. The receiver operating characteristic (ROC) analysis was used to assess the predictive performance of L1 SMI for sarcopenia. The sex-specific cut-off values for low skeletal muscle mass in patients under the age of 60 were determined using the following formula: "mean - 1.28 × standard deviation." A multivariate linear regression model was established.

Results

A significantly higher SMI at the L1 level was found in males than in females (43.88 ± 6.33 cm2/m2 vs 33.68 ± 5.03 cm2/m2; P < 0.001). There were strong correlations between measures at the L1 and L3 levels in both the total subject and sex-specific analyses. A negative association was found between age and L3 SMI in males (r = -0.231, P = 0.038). Both body mass index (BMI) and body surface area (BSA) were positively associated with L1 SMI in both males and females. A multivariate analysis was used to establish a prediction rule to predict SMI at the L3 level. The assessment of consistency and interchangeability between predicted and actual SMI at the L3 level yielded moderately good results. Considering the significant differences observed between male and female participants, the sex-specific cut-off values of the L1 SMI for defining low skeletal muscle mass were 36.52 cm2/m2 in males and 27.29 cm2/m2 in females.

Conclusions

Based on a population from central China, the correlated indicators obtained at the L1 level from routine chest CT scans may serve as effective surrogate markers for those at the L3 level in assessing overall skeletal muscle mass.

Sarcopenia assessed by computed tomography or magnetic resonance imaging is associated with the loss of response to biologic therapies in adult patients with Crohn's disease

Sarcopenia occurs in patients with Crohn's disease (CD). However, the association between sarcopenia and loss of response (LOR) to biologic agents remains unclear. This study explored such an association in CD patients. This retrospective study included 94 CD patients who received biologic therapy. The skeletal muscle cross-sectional area at the third lumbar was assessed by computed tomography or magnetic resonance imaging for sarcopenia evaluation. A LOR was defined by fecal calprotectin (FC) < 250 μg/g or >50% reduction from baseline levels or other factors, such as the used agent being replaced by other biologic agents. The association between sarcopenia and LOR was assessed by logistic regression analysis. LOR was observed in 54 patients (57.4%). The prevalence of sarcopenia in the LOR group was higher than that in response group (70.4% vs. 40.0%, p = 0.003). Sarcopenia (odds ratio [OR] = 3.89, 95% confidence interval [CI]: 1.31-11.54), Montreal L1 type (OR = 0.20, 95% CI: 0.06-0.60), perianal lesions (OR = 4.08, 95% CI: 1.31-12.70), and monocytes percentage (OR = 1.27, 95% CI: 1.02-1.57) at baseline were independent associated factors for LOR. Sarcopenia was also associated with LOR in patients who received infliximab (OR = 3.31, 95% CI: 1.11-9.87). Montreal L1 type, perianal lesions, and monocytes percentage (Model 1), and with additional consideration of sarcopenia (Model 2), were developed to predict LOR. Model 2 showed better performance than Model 1 (area under the curve [AUC] 0.82 vs. 0.75). Sarcopenia was associated with the LOR to biological agents or infliximab in adult patients with CD.

A prospective study on the differential association of sarcopenia and frailty with health outcomes in cirrhotic patients

BACKGROUND

To investigate the joint impact of sarcopenia and frailty on mortality and the development of decompensation in cirrhosis.

METHODS

Sarcopenia was assessed using the skeletal muscle mass index (SMI) by computed tomography, whereas frailty was measured using the Fried Frailty Phenotype (FFP). Cox proportional hazard regression and competing risks analysis were used to evaluate their association with adverse outcomes.

RESULTS

The prevalence of sarcopenia and frailty was 29.6% and 37.2%, respectively. Sarcopenia and frailty separately increased more than two times higher risk of all-cause mortality after adjustment for age, gender, Child-Turcotte-Pugh, and comorbidities. Co-occurrence of sarcopenia and frailty was associated with a higher incremental risk of mortality in patients with cirrhosis (HR = 4.16, 95% CI: 1.64-10.58, P = 0.003), but these two conditions didn't have significant interaction. Frailty, but not sarcopenia, was significantly associated with an increased cumulative incidence of liver-related mortality and decompensation after adjusting covariates. Subgroup analysis revealed that frailty shortened the liver-related survival of cirrhosis patients with male or higher liver severity based on MELD.

CONCLUSIONS

Co-occurrence of sarcopenia and frailty increased the risk of death in cirrhosis, but these two conditions didn't have a significant interaction association. Frailty, but not sarcopenia, was associated with more adverse outcomes in cirrhotic patients.

Impact of sarcopenia and sarcopenic obesity on survival in patients with primary liver cancer: a systematic review and meta-analysis

Background

Sarcopenia and sarcopenic obesity are associated with an increased possibility of adverse clinical outcomes; however, the effects of sarcopenia and sarcopenic obesity on patients with primary liver cancer remain controversial. Therefore, the present study aimed to determine the impact of sarcopenia and sarcopenic obesity on survival in patients with primary liver cancer.

Methods

We searched studies published in English in PubMed, Embase, Web of Science, and Cochrane Library databases up to 13 November 2022. Cohort studies that reported the association among sarcopenia, sarcopenic obesity, and patient survival were included.

Results

A total of 64 cohort studies with data on 11,970 patients with primary liver cancer were included in the meta-analysis. Sarcopenia was associated with poor overall survival in patients with primary liver cancer [adjusted hazard ratio (HR) 2.11, 95% confidence interval (CI): 1.89-2.36, P < 0.0001], with similar findings for sarcopenic obesity (adjusted HR: 2.87, 95% CI: 2.23-3.70, P < 0.0001). Sarcopenia was also associated with poor overall survival across the subgroups analyzed by ethnicity, type of liver cancer, treatment modalities, method used to define sarcopenia, and etiology of liver cancer. We also found a negative correlation among sarcopenia, sarcopenic obesity, and recurrence-free/disease-free survival (adjusted HR: 1.73, 95% CI: 1.50-1.99, P < 0.001; adjusted HR: 2.28, 95% CI: 1.54-3.35, P < 0.001, respectively).

Conclusion

Sarcopenia and sarcopenic obesity were significantly associated with poor overall survival and recurrence-free/disease-free survival in patients with primary liver cancer.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=378433, PROSPERO [42022378433].

Body composition predicts prognosis of hepatocellular carcinoma patients undergoing immune checkpoint inhibitors

PURPOSE

Immune checkpoint inhibitors (ICIs) with anti-PD-1/PD-L1 antibody are promising treatments for hepatocellular carcinoma (HCC), but lack reliable biomarkers of response. In the present study, we aimed to investigate the correlation between pre-treatment body composition measures (muscle, adipose, etc.) and the prognosis of patients with HCC treated with ICIs.

METHODS

We measured the total area of all skeletal muscles, total adipose tissue area, subcutaneous adipose tissue area, and visceral adipose tissue area at the level of the third lumbar vertebra using quantitative CT. Then, we calculated the skeletal muscle index, visceral adipose tissue index, subcutaneous adipose tissue index (SATI), and total adipose tissue index. The Cox regression model was used to determine the independent factors of the patient prognosis and construct a nomogram to predict survival. The consistency index (C-index) and calibration curve were used to determine the predictive accuracy and discrimination ability of the nomogram.

RESULTS

Multivariate analysis revealed that the SATI (high- vs. low SATI; HR 0.251; 95% CI 0.109-0.577; P = 0.001), sarcopenia (sarcopenia vs. no sarcopenia; HR 2.171; 95% CI 1.100-4.284; P = 0.026), and portal vein tumor thrombus (PVTT) (PVTT vs. No PVTT; HR 2.429; 95% CI 1. 197-4. 929; P = 0.014) were indicated as independent prognostic factors for OS in multivariate analysis. Multivariate analysis indicated that Child-Pugh class (HR 0.477, 95% CI 0.257-0.885, P = 0.019) and sarcopenia (HR 2.376, 95% CI 1.335-4.230, P = 0.003) were independent prognostic factors of PFS. We established a nomogram using SATI, SA, and PVTT to predict the 12-month and 18-month survival probability of HCC patients treated with ICIs. The C-index of the nomogram was 0.754 (95% CI 0.686-0.823), and the calibration curve confirmed that the predicted results were in good agreement with the actual observations.

CONCLUSION

Subcutaneous adipose and sarcopenia are significant prognostic factors of patients with HCC receiving ICIs. A nomogram based on body composition parameters and clinical factors could well predict survival in HCC patients treated with ICIs.

Role of body composition and metabolic parameters extracted from baseline 18F-FDG PET/CT in patients with diffuse large B-cell lymphoma

This study aimed to clarify the clinical and prognostic role of body composition and metabolic parameters extracted from baseline 18F-FDG PET/CT in patients with diffuse large B-cell lymphoma (DLBCL). We retrospectively collected the clinicopathological and 18F-FDG PET/CT parameters of 181 DLBCL patients. The indexes of skeletal muscle, subcutaneous adipose tissue, and visceral adipose tissue were calculated using the area measured at the 3rd lumbar level normalized for height. Additionally, the metabolic activity of corresponding muscle and adipose tissue, and maximum standardized uptake value (SUVmax), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) of all lesions were measured. Survival endpoints included progression-free survival (PFS) and overall survival (OS). We identified 75 (41.4%) patients with low skeletal muscle index (sarcopenia), presenting risk factors including male, high β2-microglobulin, low BMI, high visceral adipose tissue index, low SUVmax of skeletal muscle, and high SUVmax of visceral adipose tissue. Male, low BMI, low visceral adipose tissue index, and high SUVmax of subcutaneous adipose tissue were risk factors for low subcutaneous adipose tissue index diagnosed in 105 (58.0%) patients. In total, 132 (79.2%) patients represented low visceral adipose tissue index, associated with younger age, B symptoms, and low BMI. Eastern Cooperative Oncology Group (ECOG) status, sarcopenia, and visceral adipose tissue index were found independently predictive of PFS and OS, while β2-microglobulin was independently predictive of OS. In conclusion, body composition indexes were correlated with both clinical characteristics and 18F-FDG PET/CT metabolic parameters, significantly impacting survival, such that sarcopenia and high visceral adipose tissue index were powerful predictors of poor DLBCL outcomes.

Sarcopenia defined with L3-SMI is an independent predictor of survival in male patients with ARLD in mainland China

Background

The burden of alcohol-related liver disease (ARLD) is increasing in China. Patients with ARLD are more likely to have comorbid sarcopenia, which may impair their survival. This study aimed to evaluate the relationship between the prognoses of patients with ARLD and sarcopenia, identified using the skeletal muscle index at the third lumbar vertebra level (L3-SMI).

Methods

Hospitalized patients with ARLD were retrospectively enrolled between 2015 and 2018 and followed up for 24 months to evaluate their survival profiles. Cox proportional hazards regression models were used to estimate patient survival factors. A receiver operating characteristic curve was created to identify the cut-off point of the L3-SMI for predicting the prognoses of Chinese patients with ARLD.

Results

The study enrolled 168 male patients with ARLD who were followed-up for 24 months or until a study endpoint was met. The overall L3-SMI in patients with ARLD was 42.61 ± 9.15 cm2/m2, and 42.86% (72/168) of patients with ARLD were comorbid with sarcopenia. The overall survival in patients with ARLD was 77.38% at 24 months. The survival rate of patients with sarcopenia was lower than that of patients without sarcopenia (66.67% vs. 85.42%, p = 0.004). Multiple Cox regression analysis showed that sarcopenia, abstinence, and baseline creatinine level were independent prognostic factors of 24-month survival with hazard ratios (95% confidence intervals) of 2.022 (1.025-3.991), 0.275 (0.122-0.617), and 1.018 (1.008-1.027), respectively. The cut-off value of the L3-SMI for predicting 24-month survival was 40.0 cm2/m2 for male patients with ARLD.

Conclusion

Sarcopenia is an independent mortality risk factor in male patients with ARLD in mainland China. Early diagnosis and intervention of sarcopenia are important for optimizing the management of patients with ARLD.

Plasma pentosidine as a useful biomarker of sarcopenia, low gait speed, and mortality in patients with cirrhosis

Purpose

The accumulation of advanced glycation end products (AGEs) is associated with various diseases and age-related impairments, including loss of muscle mass and function. We investigated the association between plasma pentosidine, which is one of the AGEs, and sarcopenia, low gait speed, and mortality in patients with cirrhosis.

Methods

This retrospective study divided 128 patients with cirrhosis into three groups by 25th and 75th quartiles of baseline plasma pentosidine levels: low (L)-, intermediate (I)-, and high (H)-pentosidine (Pen) groups. Sarcopenia was diagnosed following the Japan Society of Hepatology criteria. Low gait speed was defined as <0.8 m/s. The cumulative survival rates were compared between the three groups. Cox proportional hazards regression analysis was performed to identify independent factors associated with mortality.

Results

Of the 128 patients, 40 (31.3%) and 34 (26.6%) had sarcopenia and low gait speed, respectively. The prevalence of sarcopenia and low gait speed significantly increased stepwise with increasing plasma pentosidine levels, with the highest in the H-Pen group (59.4% [19/32] and 56.3% [18/32], respectively) and lowest in the L-Pen group (18.8% [6/32] and 6.3% [2/32], respectively). Multivariate analysis identified plasma pentosidine levels as a significant and independent factor associated with sarcopenia (odds ratio [OR], 1.07; p = 0.036) and low gait speed (OR, 1.06; p = 0.036), with the cutoff levels of 0.0792 μg/mL (sensitivity/specificity, 0.600/0.773) and 0.0745 μg/mL (sensitivity/specificity, 0.735/0.691), respectively. The cumulative survival rates were significantly lower in the H-Pen group than in the L-Pen (hazard ratio [HR], 11.7; p = 0.001) and I-Pen (HR, 4.03; p < 0.001) groups. Plasma pentosidine levels were identified as a significant and independent prognostic factor (HR, 1.07; p < 0.001).

Conclusion

Plasma pentosidine levels are associated with sarcopenia, low gait speed, and mortality and may serve as a useful surrogate biomarker for these clinical events in patients with cirrhosis.

The Added Value of Sarcopenia on Existing Risk Scores to Predict Mortality after TIPS Placement: A Multicenter Study

RATIONALE AND OBJECTIVES

Multiple prognostic scores have been applied for predicting survival after TIPS placement. The aim was to evaluate the added value of sarcopenia on existing risk scores and develop a sarcopenia-based scoring system for survival prediction and risk stratification.

MATERIALS AND METHODS

In the derivation cohort of 386 cirrhotic patients undergoing TIPS, five risk scores (Child-Pugh, MELD, MELD-Na, MELD 3.0, and FIPS) were compared for prediction of short- and long-term mortality after TIPS. Sarcopenia was diagnosed based on the L3 skeletal muscle index and was incorporated into existing scores to assess its added value. A novel sarcopenia-based score was developed and externally validated in an independent cohort of 198 patients undergoing TIPS.

RESULTS

Among existing scores, the FIPS score showed the highest discrimination (c-index: 0.756-0.783) and calibration (Brier score: 0.059-0.127). Besides, the FIPS score was significantly associated with the severity of baseline sarcopenia and reversal of sarcopenia after TIPS. The inclusion of sarcopenia improved discrimination of existing scores in different degrees and sarcopenia could stratify the low-risk categories deemed by these scores. A FIPS-sarcopenia score was developed, showing superior discrimination over existing scores (c-index: 0.777-0.804 in the derivation cohort, 0.738-0.788 in the validation cohort). With a determined cutoff of 0.8, this score allowed for the identification of two prognostic subgroups with distinct prognoses.

CONCLUSION

FIPS score was highly correlated with the severity of sarcopenia and sarcopenia reversal after TIPS, and sarcopenia could improve the prognostic ability of existing scores. A FIPS-sarcopenia score was developed and validated, showing improved survival prediction and risk stratification.

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.

Sarcopenia in cirrhosis: Prospects for therapy targeted to gut microbiota

Decreased muscle mass and function, also known as sarcopenia, is common in patients with cirrhosis and is associated with a poor prognosis. Although the pathogenesis of this disorder has not been fully elucidated, a disordered gut-muscle axis probably plays an important role. Decreased barrier function of the gut and liver, gut dysbiosis, and small intestinal bacterial overgrowth (SIBO) can lead to increased blood levels of ammonia, lipopolysaccharides, pro-inflammatory mediators, and myostatin. These factors have complex negative effects on muscle mass and function. Drug interventions that target the gut microbiota (long-term use of rifaximin, lactulose, lactitol, or probiotics) positively affect most links of the compromised gut-muscle axis in patients with cirrhosis by decreasing the levels of hyperammonemia, bacterial translocation, and systemic inflammation and correcting gut dysbiosis and SIBO. However, although these drugs are promising, they have not yet been investigated in randomized controlled trials specifically for the treatment and prevention of sarcopenia in patients with cirrhosis. No data exist on the effects of fecal transplantation on most links of gut-muscle axis in cirrhosis; however, the results of animal experimental studies are promising.

Neutrophil gelatinase-associated lipocalin predicts the efficacy of tolvaptan for ascites in patients with liver cirrhosis

BACKGROUND

Acute kidney injury (AKI) is associated with liver cirrhosis (LC), water retention, diuretics to treat water retention, and a poor prognosis. Urinary neutrophil gelatinase-associated lipocalin (uNGAL) reportedly predicts a poor prognosis in decompensated LC. This study investigated the usefulness of uNGAL in predicting the short- and long-term effects of tolvaptan (TVP) and the incidence of AKI post-TVP administration.

METHODS

Of the LC cases with water retention, 86 with available pre-treatment uNGAL were analyzed. A short-term response was defined as weight loss of ≥ 1.5 kg within the first week; a long-term response was defined as a short-term response without early recurrence. The uNGAL usefulness in predicting the short- and long-term effects of TVP and AKI incidence post-TVP administration was investigated.

RESULTS

Short-term effects of TVP were observed in 52 patients. Of these, 15 patients had an early recurrence. In multivariate analysis, significant short-term predictive factors were C-reactive protein (CRP) < 1.4 mg/dl, uNa/K ratio ≥ 3.51, and uNGAL < 50.2 ng/ml. Patients were classified according to these three cut-off values, with short-term response rates of 92.9%, 68.8%, 26.7%, and 0% for 0, 1, 2, and 3 points, respectively. CRP < 0.94 mg/dl and uNGAL < 50.2 ng/ml were significant factors for predicting the long-term response of TVP. The AKI incidence post-TVP was 8.1% (n = 7) and was significantly higher among those with uNGAL ≥ 38.1 ng/mL.

CONCLUSION

uNGAL is a useful predictor of the short- and long-term efficacy of TVP and can be useful in predicting AKI incidence post-TVP administration.

Osteosarcopenia predicts poor survival in patients with cirrhosis: a retrospective study

BACKGROUND

Osteosarcopenia, defined as the coexistence of sarcopenia and osteoporosis, is associated with adverse clinical outcomes. The present study investigated the prognostic significance of osteosarcopenia in patients with cirrhosis.

METHODS

This retrospective study evaluated 126 patients with cirrhosis. Participants were classified into three groups based on the presence or absence of (1) sarcopenia and/or osteoporosis; and (2) Child-Pugh (CP) class B/C cirrhosis and/or osteosarcopenia, and the cumulative survival rates were compared between the groups. Cox proportional hazards model was used to identify independent factors associated with mortality. Sarcopenia and osteoporosis were diagnosed according to the Japan Society of Hepatology and the World Health Organization criteria, respectively.

RESULTS

Among the 126 patients, 24 (19.0%) had osteosarcopenia. Multivariate analysis identified osteosarcopenia as a significant and independent prognostic factor. The cumulative survival rates were significantly lower in patients with osteosarcopenia than in those without (1/3/5-year survival rates = 95.8%/73.7%/68.0% vs. 100%/93.6%/86.5%, respectively; p = 0.020). Patients with osteosarcopenia, but not sarcopenia or osteoporosis alone, had significantly lower cumulative survival rates than those without both conditions (p = 0.019). Furthermore, patients with both CP class B/C and osteosarcopenia had significantly lower cumulative survival rates than those without both (p < 0.001) and with either condition (p < 0.001).

CONCLUSIONS

Osteosarcopenia was significantly associated with mortality in patients with cirrhosis. The cumulative survival rates were lower in patients with osteosarcopenia than in those without both conditions. Additionally, comorbid osteosarcopenia worsened the prognosis of patients with CP class B/C. Therefore, simultaneous evaluation of both sarcopenia and osteoporosis is crucial to better predict the prognosis.

Sarcopenia in chronic viral hepatitis: From concept to clinical relevance

Although the frequency of metabolic risk factors for cirrhosis and hepatocellular carcinoma (HCC) is increasing, chronic hepatitis B (CHB) and chronic hepatitis C (CHC) remain the most relevant risk factors for advanced liver disease worldwide. In addition to liver damage, hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are associated with a myriad of extrahepatic manifestations including mixed cryoglobulinaemia, lymphoproliferative disorders, renal disease, insulin resistance, type 2 diabetes, sicca syndrome, rheumatoid arthritis-like polyarthritis, and autoantibody production. Recently, the list has grown to include sarcopenia. Loss of muscle mass or muscle function is a critical feature of malnutrition in cirrhotic patients and has been found in approximately 23.0%-60.0% of patients with advanced liver disease. Nonetheless, among published studies, there is significant heterogeneity in the aetiologies of hepatic diseases and measurement methods used to determine sarcopenia. In particular, the interaction between sarcopenia, CHB and CHC has not been completely clarified in a real-world setting. Sarcopenia can result from a complex and multifaceted virus-host-environment interplay in individuals chronically infected with HBV or HCV. Thus, in the present review, we provide an overview of the concept, prevalence, clinical relevance, and potential mechanisms of sarcopenia in patients with chronic viral hepatitis, with an emphasis on clinical outcomes, which have been associated with skeletal muscle loss in these patients. A comprehensive overview of sarcopenia in individuals chronically infected with HBV or HCV, independent of the stage of the liver disease, will reinforce the necessity of an integrated medical/nutritional/physical education approach in the daily clinical care of patients with CHB and CHC.

Sarcopenia in cirrhosis: epidemiology, diagnosis, management and prognosis

PURPOSE OF REVIEW

With the development of many international guidelines, research on sarcopenia has increased rapidly, showing that sarcopenia is predictive of adverse outcomes, including increased mortality and impaired mobility, in patients with cirrhosis. The purpose of this article is to review the current evidence concerning the epidemiology, diagnosis, management and predictive value of sarcopenia on the prognosis of patients with cirrhosis.

RECENT FINDINGS

Sarcopenia is a frequent and lethal complication of cirrhosis. Currently, abdominal computed tomography imaging is the most commonly used method to diagnose sarcopenia. In clinical practice, assessing muscle strength and physical performance, such as by measuring handgrip strength and gait speed, is of increasing interest. In addition to the necessary pharmacological therapy, adequate intake of protein, energy and micronutrients, as well as regular moderate-intensity exercise, can help to minimize sarcopenia. Sarcopenia has been shown to be a strong predictor of prognosis in patients with severe liver disease.

SUMMARY

A global consensus is needed on the definition and operational parameters for the diagnosis of sarcopenia. Further research should focus on developing standardized screening, management and treatment protocols for sarcopenia. Adding sarcopenia to existing models may better exploit the effect of sarcopenia on prognosis in patients with cirrhosis, which should be investigated further.

Prognostic significance of sarcopenia and severe vitamin D deficiency in patients with cirrhosis

Background and Aim

Sarcopenia and severe vitamin D deficiency are associated with malnutrition and poor prognosis. We investigated the impact of the comorbidity of Child-Pugh (CP) class B/C cirrhosis and the aforementioned complications on the prognosis of patients with cirrhosis.

Methods

We retrospectively evaluated 104 patients with cirrhosis. The cumulative survival rates were compared between patients with and without both or either of these disease conditions: CP class B/C and complications (sarcopenia or severe vitamin D deficiency). Sarcopenia was diagnosed according to the Japan Society of Hepatology criteria. Severe vitamin D deficiency was defined as levels of 25-hydroxyvitamin D <10 ng/mL in serum.

Results

The prevalence of CP class B/C, sarcopenia, and severe vitamin D deficiency was 26.9%, 38.5%, and 24.0%, respectively. Patients with both CP class B/C and sarcopenia had significantly lower survival rates than those without both (hazard ratio [HR] = 6.101; P < 0.001) and with either condition (HR = 6.137; P = 0.001). Similarly, patients with both CP class B/C and severe vitamin D deficiency or with either condition had significantly lower survival rates than those without both conditions (HR = 8.135 or 3.189; P < 0.001 or =0.025, respectively). CP class B/C (HR = 3.354; P = 0.006) and severe vitamin D deficiency (HR = 2.445; P = 0.044) were independent prognostic factors.

Conclusions

The coexistence of CP class B/C and sarcopenia or severe vitamin D deficiency worsened the prognosis of patients with cirrhosis. Nutritional assessments such as sarcopenia and vitamin D status should be considered to better evaluate disease conditions and patient prognosis.

Osteosarcopenia in NAFLD/MAFLD: An Underappreciated Clinical Problem in Chronic Liver Disease

Chronic liver disease (CLD), including non-alcoholic fatty liver disease (NAFLD) and its advanced form, non-alcoholic steatohepatitis (NASH), affects a significant portion of the population worldwide. NAFLD is characterised by fat accumulation in the liver, while NASH is associated with inflammation and liver damage. Osteosarcopenia, which combines muscle and bone mass loss, is an emerging clinical problem in chronic liver disease that is often underappreciated. The reductions in muscle and bone mass share several common pathophysiological pathways; insulin resistance and chronic systemic inflammation are the most crucial predisposing factors and are related to the presence and gravity of NAFLD and to the worsening of the outcome of liver disease. This article explores the relationship between osteosarcopenia and NAFLD/MAFLD, focusing on the diagnosis, prevention and treatment of this condition in patients with CLD.

Usefulness of 18 F-FDG PET/computed tomography metabolic parameters in predicting sarcopenia and prognosis of treatment-naive patients with non-small cell lung cancer

PURPOSE

Sarcopenia tremendously impacts the quality of life but remains debatable in prognostication in treatment-naive patients with non-small cell lung cancer (NSCLC). Hence, this study aimed to find a clinically feasible approach using 18 F-FDG PET/computed tomography (CT) imaging parameters and clinical characteristics to predict sarcopenia and determine independent prognostic factors.

METHODS

Clinical characteristics and 18 F-FDG PET/CT metabolic parameters, including maximum standard uptake value, metabolic tumor volume, and total lesion glycolysis of primary tumor (SUVmax_P, MTV_P, and TLG_P) and combination of whole-body lesions (MTV_C and TLG_C) were collected in 344 treatment-naive patients with NSCLC. Skeletal muscle index at the third lumbar vertebra was calculated to determine sarcopenia. SUVmax of the psoas major muscle (SUVmax_M) was measured at the third lumbar vertebra as well. The diagnostic endpoint is the probability of sarcopenia, and the survival endpoints include progression-free survival (PFS) and overall survival (OS).

RESULTS

Among 344 patients with NSCLC there were 271 patients with adenocarcinoma and 73 with squamous cell carcinoma (SCC). One hundred forty-seven patients (42.7%) were diagnosed with sarcopenia. Higher age, male, lower BMI, SCC, and lower SUVmax_M were correlated with a higher incidence of sarcopenia ( P  < 0.05), while age, sex and SUVmax_M were independently predictive of sarcopenia. Multivariate Cox-regression analysis revealed that BMI, advanced stage and TLG_C were independent predictors of PFS and OS, while sex was independently predictive of OS.

CONCLUSIONS

The incidence of sarcopenia increased with declining SUVmax of muscle. BMI, tumor stage, and TLG_C, but not sarcopenia, were found independently predictive of both PFS and OS.

Prognostic value of liver damage assessed through direct bilirubin levels and skeletal muscle weakness in patients with heart failure

BACKGROUND

Patients with heart failure (HF) often exhibit signs of liver dysfunction such as high bilirubin concentrations, leading to physical dysfunction and poor prognosis. Nevertheless, the relationship between direct bilirubin (DB), a fractionated form of total bilirubin, and dynapenia remains unclear, as does their effect on prognosis.

OBJECTIVES

This study investigated the association between DB concentrations and dynapenia in patients with HF.

METHODS

This retrospective study included patients with HF who underwent assessments for DB concentration, and handgrip and leg strengths to evaluate dynapenia and muscle weakness, respectively. Multiple logistic regression analyses examined the associations of DB with muscle strength and dynapenia. Additionally, we examined the prognostic value of comorbid high DB concentrations (≥0.5 mg/dL) and dynapenia. The endpoint was all-cause mortality.

RESULTS

Of 853 inpatients, high DB was identified in 147 and dynapenia in 377 (44.2%). Multiple regression analysis revealed that high DB was independently associated with decreased muscle strength (handgrip strength, P = 0.027; leg strength, P = 0.002). After adjusting for covariates, the high DB group (odds ratio: 1.800, 95% confidence interval [CI]: 1.203-2.695, P = 0.004) had a significantly higher risk of dynapenia than the low DB group. During the follow-up period, 189 patients died (median, 1.77 years; interquartile range, 0.64-3.81 years). The risk of death was significantly higher in the high DB and dynapenia group, even after adjusting for HF severity (hazard ratio: 2.610, 95% CI: 1.680-4.051, P<0.001).

CONCLUSIONS

High DB is associated with muscle weakness, and when combined with dynapenia, DB predicts a poorer prognosis in patients with HF.

Albumin–Globulin Score Combined with Skeletal Muscle Index as a Novel Prognostic Marker for Hepatocellular Carcinoma Patients Undergoing Liver Transplantation

Background: Sarcopenia was recently identified as a poor prognostic factor in patients with malignant tumors. The present study investigated the effect of the preoperative albumin–globulin score (AGS), skeletal muscle index (SMI), and combination of AGS and SMI (CAS) on short- and long-term survival outcomes following deceased donor liver transplantation (DDLT) for hepatocellular carcinoma (HCC) and aimed to identify prognostic factors. Methods: A total of 221 consecutive patients who underwent DDLT for HCC were enrolled in this retrospective study between January 2015 and December 2019. The skeletal muscle cross-sectional area was measured by CT (computed tomography). Clinical cutoffs of albumin (ALB), globulin (GLB), and sarcopenia were defined by receiver operating curve (ROC). The effects of the AGS, SMI, and CAS grade on the preoperative characteristics and long-term outcomes of the included patients were analyzed. Results: Patients who had low AGS and high SMI were associated with better overall survival (OS) and recurrence-free survival (RFS), shorter intensive care unit (ICU) stay, and fewer postoperative complications (grade ≥ 3, Clavien–Dindo classification). Stratified by CAS grade, 46 (20.8%) patients in grade 1 were associated with the best postoperative prognosis, whereas 79 (35.7%) patients in grade 3 were linked to the worst OS and RFS. The CAS grade showed promising accuracy in predicting the OS and RFS of HCC patients [areas under the curve (AUCs) were 0.710 and 0.700, respectively]. Male recipient, Child–Pugh C, model for end-stage liver disease (MELD) score > 20, and elevated CAS grade were identified as independent risk factors for OS and RFS of HCC patients after DDLT. Conclusion: CAS grade, a novel prognostic index combining preoperative AGS and SMI, was closely related to postoperative short-term and long-term outcomes for HCC patients who underwent DDLT. Graft allocation and clinical decision making may be referred to CAS grade evaluation.

Low adipose tissue index as an indicator of hepatic encephalopathy in cirrhotic patients following transjugular intrahepatic portosystemic shunt

PURPOSE

We aimed to investigate the predictive value of body compositions measured by CT, including skeletal muscle and adipose tissue, for hepatic encephalopathy (HE) in cirrhotic patients following transjugular intrahepatic portosystemic shunt (TIPS).

METHODS

Patients who underwent TIPS between November 2015 and April 2021 were included in this retrospective study. CT images taken at L3 were quantified for three body composition indexes (cm²/m²), visceral fat area index (VFAI), subcutaneous fat area index (SFAI), and skeletal muscle index (SMI) at baseline. Multivariable logistic regression models were conducted to assess associations between post-TIPS HE and body compositions. Nomograms based on the multivariable logistic regression models were developed and were evaluated from Calibration curves.

RESULTS

Male patients had greater SMI, whereas SFAI and VFAI were higher in females (p < 0.001 for each). In sex stratified multivariate analyses after adjustment for other confounding variables, VFAI in males (p = 0.033) and SFAI in females (p = 0.003) were significant predictors of post-TIPS HE. Male patients with low VFAI (< 53.52 cm²/m²) (OR 6.44; 95% CI 1.72-23.59; p = 0.006) and female patients with low SFAI (< 70.05 cm²/m²) (OR 10.55; 95% CI 2.36-46.23; p = 0.002) had a higher risk of post-TIPS HE. Risk factors in the nomogram contributing to the male model included age, height, Child-Pugh score, and low VFAI; pre-albumin and low SFAI were contributed to female model.

CONCLUSION

Body compositions could not only be noninvasively used for nutritional assessment, but also be utilized to predict HE risk of cirrhotic patients after TIPS.

Comparison of the GLIM criteria with specific screening tool for diagnosing malnutrition in hospitalized patients with cirrhosis: A descriptive cross-sectional study

BACKGROUND

The Global Leadership Initiative on Malnutrition (GLIM) has been built to diagnose malnutrition; however, its validity among patients with cirrhosis remains enigmatic. We aimed to investigate the prevalence of malnutrition according to GLIM criteria and compare the differences by using a specific screening tool.

METHODS

We conducted a descriptive cross-sectional study analyzing hospitalized patients. The Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT) was chosen as the screening tool. Estimated prevalence was shown with and without the initial screening process. Diverse combinations of phenotypic and etiologic criteria and distinct body mass index (BMI) cutoffs were applied to detect frequency of malnourished patients with cirrhosis.

RESULTS

Overall, 363 patients were recruited (median age, 64 years; 51.2% female). The prevalence of malnutrition according to GLIM criteria with and without RFH-NPT screening was 33.3% and 36.4%, respectively. Low BMI and inflammation represented the most prevalent combination resulting in a malnutrition diagnosis (42.4%), followed by low BMI and reduced food intake (39.4%). By contrast, the least prevalence was found when combining reduced muscle mass with inflammation to diagnose malnutrition. Furthermore, the frequency of malnourished and well-nourished participants was not statistically different when using divergent BMI reference values across the study population.

CONCLUSIONS

GLIM criteria may serve a specific proxy to diagnose malnutrition, along with RFH-NPT screening. Relevant investigation is required to report on the applied combination of phenotypic/etiologic criteria, taking into consideration the marked impact of different models. More attempts are warranted to delineate the prognostic role of GLIM criteria in the context of cirrhosis.

Risk factors in nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) is the most common liver disease, with a global prevalence estimated at approximately 25%. NAFLD is also the leading cause of liver cirrhosis, hepatocellular carcinoma, and death. Additionally, the risk of cardiovascular disease increases with greater NAFLD severity. The liver- and cardiovascular disease-related mortality incident rate ratios among the NAFLD population were 0.77 and 4.79 per 1,000 person-years, respectively. We intend to discuss the risk factors associated with NAFLD in terms of development and progression. Obesity or higher body mass index is closely associated with NAFLD in a dose-dependent manner, but growing evidence suggests that central obesity plays a more important role in the development of NAFLD. Saturated fat and fructose have been reported to be closely related to NAFLD. Fructose intake promotes lipogenesis and impairs mitochondria fat oxidation. The presence of type 2 diabetes is the most powerful predictive risk factor for hepatic fibrosis in patients with NAFLD. Single nucleotide polymorphism is not only associated with the prevalence of NAFLD but also associated with increased liver disease mortality. Obstructive sleep apnea, intestinal dysbiosis, and sarcopenia are associated with the development of NAFLD.

TIPS placement as the first-line therapy to prevent variceal rebleeding in patients with cirrhosis and sarcopenia

PURPOSE

Sarcopenia increases the risk of mortality and hepatic encephalopathy (HE) in cirrhosis, and is a potential indication for transjugular intrahepatic portosystemic shunt (TIPS). The aim was to investigate the prognostic effect of sarcopenia in patients with cirrhosis who received TIPS for prevention of variceal rebleeding.

METHOD

We retrospectively included 262 patients with cirrhosis receiving TIPS as the first-line treatment for prevention of rebleeding. L3 skeletal muscle index (SMI) was measured and sarcopenia was defined using sex-specific cutoffs. Incidence of post-TIPS mortality and overt HE, and changes of L3-SMI before and after TIPS were compared between the non-sarcopenia and sarcopenia group. Moreover, 21 patients with sarcopenia who received TIPS as the second-line treatment were included for additional comparison.

RESULTS

At admission, 99 (37.8 %) and 163 (62.2 %) patients were diagnosed as sarcopenia and non-sarcopenia, respectively. Compared with the non-sarcopenia group, the sarcopenia group had a similar risk of mortality (adjusted hazard ratio [HR] 1.04, 95 % confidence interval [CI]: 0.55-1.96, p = 0.900) and overt HE (adjusted HR 1.20, 95 %CI 0.72-2.00, p = 0.479). The sarcopenia group achieved higher extent of L3-SMI improvement after TIPS than the non-sarcopenia group (7.0 vs 2.4 cm²/m² in males; 4.2 vs 3.3 cm²/m² in females). For patients with sarcopenia, TIPS as the second-line treatment significantly increased mortality risk compared with TIPS as the first-line treatment (adjusted HR 2.68, 95 %CI 1.05-6.87, p = 0.04).

CONCLUSIONS

For patients treated with TIPS as the first-line treatment for prevention of rebleeding, baseline sarcopenia did not increase the risk of post-TIPS mortality and overt HE.

Malnutrition according to the Global Leadership Initiative on Malnutrition criteria is associated with in-hospital mortality and prolonged length of stay in patients with cirrhosis

OBJECTIVES

Malnutrition is prevalent and negatively affects patients with cirrhosis, but a generally accepted consensus pertaining to its diagnosis is lacking. Recently, a framework called the Global Leadership Initiative on Malnutrition (GLIM) has been proposed to diagnose malnutrition, but there is scant evidence regarding its validity. We aimed to investigate associations of malnutrition according to the GLIM criteria, as well as its individual indicator with in-hospital adverse outcomes.

METHODS

This was a prospective, observational study of consecutively hospitalized patients with cirrhosis. The malnutrition diagnosis was built on a stepwise GLIM process with initial screening, followed by fulfillment of at least one phenotypic and one etiologic criterion. Patients were followed up for a combined endpoint of in-hospital mortality and prolonged length of stay (LOS). Covariates compromise malnutrition according to the GLIM criteria and its indicators in separation. Logistic regression analyses were implemented to determine predictive validity.

RESULTS

A total of 387 cirrhotic patients were assessed. Malnutrition was diagnosed in 28.7% of patients according to the GLIM criteria, and increased the risk of in-hospital mortality and prolonged LOS by 2.166 and 1.767 times, respectively, adjusting for age, sex, biochemical parameters, and clinical scores of disease severity. When analyzing separate criteria, all constituents were independently associated with in-hospital adverse outcomes, adjusting for model for end-stage liver disease sodium score.

CONCLUSIONS

Malnutrition according to the GLIM criteria was considerably prevalent among hospitalized patients with cirrhosis, and associated with approximately two times greater probability of in-hospital mortality and prolonged LOS. These diagnostic criteria may be implemented and disseminated during daily practice considering their predictive validity.

Sarcopenia Defined by Psoas Muscle Thickness Predicts Mortality After Transjugular Intrahepatic Portosystemic Shunt

PURPOSE

To assess and compare the value of psoas muscle thickness at the level of the third lumbar (L3) vertebra (TPML) or umbilicus (TPMU) and skeletal muscle index (SMI) for diagnosing sarcopenia and predicting mortality in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS).

MATERIALS AND METHODS

Two hundred forty-nine patients undergoing TIPS were included in this retrospective study. The cut-offs of L3-SMI for sarcopenia were 42.0 cm²/m² in men and 38.0 cm²/m² in women. The cut-offs for TPML/height and TPMU/height to predict mortality was established using a receiver-operating characteristic analysis. The Kaplan-Meier and Cox regression were used for survival analyses.

RESULTS

Compared with TPMU/height, TPML/height was more consistent with L3-SM for the diagnosis of sarcopenia (Kappa coefficient: 0.63 vs. 0.36 in men; 0.61 vs. 0.45 in women). The Cox analysis showed that both TPML/height and TPMU/height were independent risk factors for mortality. The optimal cut-off values of TPML/height and TPMU/height for mortality in men and women were 11.2 mm/m, 9.4 mm/m, 18.4 mm/m, 15.1 mm/m, respectively. There were 119 (47.8%), 87 (34.9%), and 82 (32.9%) patients diagnosed with sarcopenia in the TPMU/height, TPML/height, and L3-SMI models, respectively. Kaplan-Meier analysis showed that the overall survival was significantly lower in the sarcopenia group in all three models.

CONCLUSION

TPMU/height and TPML/height have a similar survival prognostic value as L3-SMI. TPML/height has better consistency with L3-SMI in diagnosing sarcopenia and is a more stable alternative to L3-SMI for diagnosing sarcopenia in patients undergoing TIPS.

Role of 18F-FDG PET/CT and sarcopenia in untreated non-small cell lung cancer with advanced stage

BACKGROUND

Sarcopenia is essential in managing advanced stage (III-IV) non-small cell lung cancer (NSCLC) but is laborious to diagnose using currently available method. This study aimed to establish a simple approach to predict sarcopenia using ¹⁸F-FDG PET/CT parameters and clinical characteristics and determine their roles in prognostication in advanced stage NSCLC.

METHODS

Untreated 202 NSCLC patients with stage III-IV were retrospectively reviewed. Sarcopenia was defined using the skeletal muscle index (SMI) measured at the third lumbar vertebra (L3). ¹⁸F-FDG PET/CT metabolic parameters of maximum standard uptake value, metabolic tumor volume, and total lesion glycolysis of the primary tumor (SUVmax_T, MTV_T, and TLG_T) and of whole-body lesions (MTV_WB and TLG_WB) were measured. Besides, SUVmax of the psoas major muscle (SUVmax_Muscle) was measured at the L3 level. The diagnostic endpoint was the probability of sarcopenia, and the survival endpoints included progression-free survival (PFS) and overall survival (OS).

RESULTS

Among the enrolled 202 patients, 82 (40.6%) were diagnosed with sarcopenia. Higher age, male, lower BMI, and lower SUVmax_Muscle were correlated with a higher incidence of sarcopenia (P < 0.05), while age, sex, BMI, and SUVmax_Muscle were independently predictive of sarcopenia, and thus were utilized to construct a nomogram model. Multivariate Cox regression analysis revealed that sarcopenia score derived from the nomogram model, sarcopenia, stage, and TLG_WB were independently predictive of both PFS and OS.

CONCLUSION

The incidence of sarcopenia increased with declining SUVmax_Muscle in advanced stage NSCLC. Our model using age, sex, BMI, and SUVmax_Muscle might be substituted for the complicated measurement of SMI. After adjustment by stage and TLG_WB, both sarcopenia score and sarcopenia were found to be independently predictive of PFS and OS.