The sex-specific prognostic utility of sarcopenia in cirrhosis

The prevalence and effects of sarcopenia in patients with metabolic dysfunction-associated steatotic liver disease (MASLD): A systematic review and meta-analysis

BACKGROUND AND AIMS

Sarcopenia is a common complication in patients with metabolic dysfunction-associated steatotic liver disease (MASLD). However, the prevalence and its impact on the survival of sarcopenia in patients with MASLD is unknown. In this study, we aimed to assess the prevalence and effects of sarcopenia in patients with MASLD.

METHODS

Systematic review and meta-analysis of full texts of relevant studies were searched from inception until June 12, 2024 in five databases (PubMed, Cochrane Library, Embase, Web of Science, and the China National Knowledge Infrastructure). Next, we assessed the prevalence of sarcopenia in MASLD, and calculated the ORs and HRs between sarcopenia and MASLD based on the adjusted data from individual studies. Statistical analyses were performed using Stata 11.0.

RESULTS

Of the 2984 records considered, 29 studies recruiting 63,330 patients were included. The pooled prevalence of sarcopenia in patients with MASLD was 23.5% overall (95% CI; 19.1%-27.9%, I2 = 99.6%), and was higher in Asian patients, male, cross-sectional studies, when BIA were employed to measure muscle mass, one criterion of diagnosis sarcopenia, MASLD was diagnosed employing MRI, and moderate-quality studies. Sarcopenia was associated with MASLD patients (adjusted odds ratio [aOR] 2.08, 95% CI 1.58-2.74, I2 = 93.6%) with similar findings in subgroups stratified by age, study design, methods for measuring muscle mass, assessment method to detect sarcopenia, and study quality. The association between all-cause mortality further supports the association between sarcopenia and poor prognosis with MASLD (aHR 1.59, 95% CI 1.33-1.91, I2 = 0%).

CONCLUSIONS

Sarcopenia was strongly associated with MASLD progression and was a risk factor not only for MASLD pathogenesis but was also markedly correlated with MASLD-associated mortality.

Shining a spotlight on sarcopenia and myosteatosis in liver disease and liver transplantation: Potentially modifiable risk factors with major clinical impact

Muscle-wasting and disease-related malnutrition are highly prevalent in patients with chronic liver diseases (CLD) as well as in liver transplant (LT) candidates. Alterations of body composition (BC) such as sarcopenia, myosteatosis and sarcopenic obesity and associated clinical frailty were tied to inferior clinical outcomes including hospital admissions, length of stay, complications, mortality and healthcare costs in various patient cohorts and clinical scenarios. In contrast to other inherent detrimental individual characteristics often observed in these complex patients, such as comorbidities or genetic risk, alterations of the skeletal muscle and malnutrition are considered as potentially modifiable risk factors with a major clinical impact. Even so, there is only limited high-level evidence to show how these pathologies should be addressed in the clinical setting. This review discusses the current state-of-the-art on the role of BC assessment in clinical outcomes in the setting of CLD and LT focusing mainly on sarcopenia and myosteatosis. We focus on the disease-related pathophysiology of BC alterations. Based on these, we address potential therapeutic interventions including nutritional regimens, physical activity, hormone and targeted therapies. In addition to summarizing existing knowledge, this review highlights novel trends, and future perspectives and identifies persisting challenges in addressing BC pathologies in a holistic way, aiming to improve outcomes and quality of life of patients with CLD awaiting or undergoing LT.

Reduced bone mineral density is associated to post-TIPS survival of female patients with decompensated cirrhosis

BACKGROUND

Malnutrition is common in patients with cirrhosis, eventually leading to sarcopenia and loss of bone mass.

AIMS

The aims of this study was the assessment of body composition (BC) and bone mineral density (BMD) in patients with decompensated cirrhosis and the prognostic impact on survival after transjugular intrahepatic portosystemic shunt (TIPS) implantation.

METHODS

BMD and BC of 107 patients with cirrhosis undergoing TIPS implantation were prospectively analyzed by dual-energy X-ray absorptiometry. The prevalence and predisposing risk factors for reduced BMD and sarcopenia were assessed. Impact on 12-month survival after TIPS implantation was evaluated.

RESULTS

Sarcopenia was diagnosed in 48.6 % of the patients with a predominance of male patients (58.7% vs. 25.0 %, p = 0.001). 67.2 % had reduced BMD. Low BMI was independently associated with sarcopenia (OR 0.751 (95 % CI: 0.662;0.852), p < 0.001) and reduced BMD (OR 0.851 (0.773;0.937), p = 0.001). Patients with reduced BMD, but not sarcopenia, had impaired 12-month survival after TIPS-implantation (61.2% vs. 82.9 %, p = 0.030). Subgroup analysis showed that this was especially valid for female patients.

CONCLUSIONS

Sarcopenia and reduced BMD are frequently observed in patients with decompensated cirrhosis. Reduced BMD negatively affects post-TIPS survival. Since malnutrition is a leading cause, assessment of nutritional status and specific treatment should be included in clinical practice.

Branched-chain amino acid supplementation does not improve measures of sarcopenia in cirrhosis: results of a randomised controlled trial

BACKGROUND

Sarcopenia is associated with adverse outcomes in cirrhosis. Branched-chain amino acids (BCAA) target several pathways that lead to muscle loss in this population.

AIMS

We aimed to evaluate the impact of BCAA supplementation on sarcopenia measures in patients with cirrhosis.

METHODS

We conducted a 12-month double-blinded, randomised, controlled trial of BCAA supplementation (30 g daily) compared to an equicaloric, equi-nitrogenous whey protein in volunteers with cirrhosis and reduced muscle strength. The primary endpoint was an increase in grip strength and upper limb lean mass measured on DEXA. Mean-adjusted differences (MAD, 95% CI) between groups at 6 and 12 months are reported as treatment effect using a linear mixed model for repeated measures.

RESULTS

A total of 150 volunteers entered the trial (74 BCAA, 76 control), with a median age of 58 years [IQR 48; 63] and MELD of 14 [12; 17]. At 12 months, 57% in the BCAA arm and 61% in the control arm met the primary endpoint (p = 0.80). No significant between-group difference was found in grip strength (MAD -0.15 kg [-0.37; 0.06], p = 0.29) or upper limb lean mass (1.7 kg [-0.2; 3.6], p = 0.22) at 12 months. No significant differences in other body composition parameters, physical performance, frailty, rates of hospitalisation or mortality were found between the BCAA and the control group. Fatigue improved across the entire cohort, without significant between-group differences. 15% of volunteers reported side effects, with distaste higher in the BCAA arm (p = 0.045).

CONCLUSION

BCAA supplementation did not improve measures of muscle strength, mass or performance or physical frailty compared to a whey protein supplement in a randomised controlled setting. ACTRN12618000802202.

Transjugular intrahepatic portosystemic shunt insertion improves muscle mass but not muscle function or frailty measures

INTRODUCTION

Sarcopenia in cirrhosis is associated with poor outcomes. While transjugular intrahepatic portosystemic shunt (TIPS) insertion improves radiological measures of muscle mass, its impact on muscle function, performance and frailty has not been evaluated.

METHODS

Patients with cirrhosis referred for TIPS were prospectively recruited and followed for 6 months. L3 CT scans were used to calculate skeletal muscle and adipose tissue parameters. Handgrip strength, Liver Frailty Index and short physical performance battery were serially monitored. Dietary intake, insulin resistance, insulin-like growth factor (IGF)-1, and immune function using QuantiFERON Monitor (QFM) were measured.

RESULTS

Twelve patients completed the study with a mean age of 58 ± 9 years and model for end-stage liver disease score of 16 ± 5. At 6 months post-TIPS, skeletal muscle area increased from 139.33 cm 2  ± 22.72 to 154.64 ± 27.42 ( P  = 0.012). Significant increases were observed in the subcutaneous fat area ( P  = 0.0076) and intermuscular adipose tissue ( P  = 0.041), but not muscle attenuation or visceral fat. Despite marked changes in muscle mass, no improvements were observed in handgrip strength, frailty, or physical performance. At 6 months post-TIPS, IGF-1 ( P  = 0.0076) and QFM ( P  = 0.006) increased compared to baseline. Nutritional intake, hepatic encephalopathy measures, insulin resistance and liver biochemistry were not significantly impacted.

CONCLUSION

Muscle mass increased following TIPS insertion as did IGF-1, a known driver of muscle anabolism. The lack of improvement in muscle function was unexpected and may relate to impairment in muscle quality and the effects of hyperammonaemia on muscle contractile function. Improvements in QFM, a marker of immune function, may suggest a reduction in infection susceptibility in this at-risk population and requires further evaluation.